A 43-year-old man presents to the emergency department acutely with altered mental status. He uses intravenous drugs and is unable to offer a history. He was found unconscious in a park. His temperature is 99.0°F (37.2°C), blood pressure is 80/40 mmHg, pulse is 156/min, and respirations are 26/min. Physical exam reveals an obtunded man covered in vomit, with track marks on his arm and several skin abscesses. The patient is given 4 liters of Ringer lactate and intravenous antibiotics. As the fourth liter of fluids is finishing, the patient is noted to have jugular venous distension and an oxygen saturation of 92% on nonrebreather. He is subsequently intubated. An ECG is obtained as seen in Figure A. The patient is started on norepinephrine, and his blood pressure is subsequently found to be 85/44 mmHg. Which of the following is the most appropriate next step in management?
Cardioversion
Epinephrine
Phenylephrine
Hydrocortisone
Epinephrine
This patient who uses intravenous drugs with skin abscesses (the likely source of his infection) is hypotensive and tachycardic, with a blood pressure that is not responding to IV fluids; this is concerning for septic shock. Given his persistent hypotension, he should be started on vasopressors of which norepinephrine is first line and epinephrine is second line.

Septic shock is a life-threatening, systemic bacterial infection that leads to vasodilation and endothelial dysfunction. Early management is centered on IV fluids, blood cultures, broad-spectrum antibiotics, and workup to uncover the source. If the patient's blood pressure does not respond to IV fluids (by definition, their blood pressure will not respond to fluids in septic shock), vasopressors should be started with a goal mean arterial pressure > 65 mmHg. The first line vasopressor is norepinephrine, which can be titrated up for maximal effect. If this vasopressor fails to reach blood pressure goals, then the next vasopressor is either vasopressin or epinephrine (either is acceptable). If the second line vasopressor fails to increase blood pressure, then the third line vasopressor is vasopressin or epinephrine (whichever was not used as the second line pressor). Finally, the fourth line vasopressor for septic shock is phenylephrine.

Levy et al. review sepsis. They update the Surviving Sepsis campaign which gives the most up to date management guidelines of sepsis including adequate fluid resuscitation, broad-spectrum antibiotics, and vasopressors. They recommend early antibiotics and resuscitation to minimize morbidity and mortality.

Figure/Illustration A is an ECG demonstrating sinus tachycardia. Note the presence of P waves (red arrows highlighting several examples) that are present throughout all leads.

Incorrect Answers:
Answer A: Cardioversion would be appropriate in an unstable patient with unstable vital signs in the setting of atrial fibrillation with rapid ventricular response to convert the patient to normal sinus rhythm. Atrial fibrillation would present with an irregularly irregular rhythm without P waves. Cardioversion would not be indicated in sinus tachycardia.

Answer C: Hydrocortisone is a potent glucocorticoid that also has mineralocorticoid properties. While giving an IV steroid may have a permissive effect on blood pressure (via upregulating alpha-1 receptors on the vasculature) there is no reason that this patient would have a low cortisol level (such as in chronic steroid use). Epinephrine is a better answer in this case, though steroids can be considered. Steroids are typically reserved for patients failing at least 2 vasopressors (unless they have a known cortisol-deficient state).

Answer D: Normal saline is unlikely to benefit this patient as he has already been sufficiently fluid resuscitated. Moreover, it seems the patient may be developing pulmonary edema (hypoxia, jugular venous distension), a sign of fluid overload.

Answer E: Phenylephrine is the fourth line vasopressor and is an alpha-1 agonist. It is much less potent than norepinephrine and epinephrine, and would not be started in the management of septic shock until the patient has received epinephrine, norepinephrine, and vasopressin.

Bullet Summary:
In septic shock, the vasopressors given (in order) are norepinephrine, epinephrine/vasopressin, then phenylephrine.