T-47 Minutes to Antibiotics Administration

8:24 a.m.

Patient arrived in ED

A 67-year-old male with a history of arthritis presents with a chief complaint: severe pain that radiates from his left hip down to his knee — worse than his chronic arthritic pain.

The night prior, the patient had an acute onset of his pain when he tried to get up from his recliner. The pain worsened and the patient was taken to the ED the following morning.

8:29 a.m.

Initial Assessment: Tachycardia and limited range of motion of left hip due to pain.

The vitals assessed were normal except for an elevated pulse rate of 122 BPM, which was potentially attributed to the patient's pain.

T: 37.8 | BP: 114/59 | P: 122 | RR: 18 | SpO2: 98% (RA)

Considering the patient's age and exhibited tachycardia, complete blood count (CBC) differential and basic metabolic panel (BMP) labs were ordered.

9:13 a.m.

CBC with Differential is Returned from the Lab: severe infection and risk of sepsis added to differential diagnosis.

The white blood cell (WBC) results come back elevated at 22.6, which could be attributed to the vomiting and stress due to significant pain. The monocyte distribution width (MDW) results come back at 30.1.

Due to the abnormal WBC and MDW results, the physicians deduced there might be an underlying infectious etiology. Reconsidering the vital signs abnormality, temperature of 37.8°C and elevated pulse rate of 122 BPM, lactate and blood cultures were ordered. 

9:18 a.m.

Head to Toe Exam Reveals Erythema

With no skin changes, ecchymosis, bruising or swelling to the left extremities where the patient felt pain, the doctors were left pondering what they may be missing.

After a comprehensive exam, it was revealed that there was significant erythema of the right lower extremity that was tender and warm to palpation – this was suggestive of cellulitis.

Total Time: 47 Minutes from Presentation to ER

The goal of the Surviving Sepsis Campaign is to administer antibiotics from the time of detection of severe sepsis or septic shock. In this case, the goal was met in less than one hour.

The abnormal MDW levels, coupled with the early signs and symptoms raised the doctors’ suspicions, prompted consideration of infection or sepsis. This led to the comprehensive examination of the patient, which wouldn’t otherwise be conducted in a busy ED environment. The assessment led to the discovery of skin cellulitis.

Without this discovery, the patient may have spent up to five hours in the ED or admitted to the hospital. Subsequentially, the patient would likely develop a fever at that time and likely receive the comprehensive assessment, which would reveal skin cellulitis at that time. 

Watch Dr. Sarani present this specific emergency department case study demonstrating the clinical utility of MDW in an acute care setting. Download video transcript here.