This chapter explores sepsis in the context of the pregnant, or postpartum, woman. Including national tools for the recognition, investigation and management of sepsis. Common causes of maternal sepsis are explored as well as considerations for the baby. Key learning points: Understand the difference between infection and sepsis. Perform a full set of observations, including respiratory rate and temperature, in any woman feeling unwell in pregnancy or the postpartum period. Highlight the use of early warning score charts, e.g. maternity early warning score (MEWS) or modified obstetric early warning score (MOEWS), to document observations and aid the early detection of sepsis. Involve senior clinicians and the multi-professional team early. Early recognition and treatment of sepsis and septic shock improves outcomes. Effective treatment with the Sepsis Six includes early administration of intravenous antibiotics and fluid therapy.

The chapter describes a case of a 24-year-old female with abdominal pain, nausea, and vomiting. The patient is uncomfortable and lying still on a stretcher. The primary survey shows no apparent respiratory distress and regular rate and rhythm. The abdomen is tender to palpation in the right lower quadrant with guarding, and there is no rebound tenderness. The patient undergoes several tests, including CBC, BMP, pregnancy test, T&S, and UA, and is placed on a monitor. The CT abdomen/pelvis with oral contrast confirms the diagnosis of acute appendicitis, and the patient is taken to the OR for appendectomy. The chapter highlights the importance of early actions, including pain management, obtaining an appropriate imaging study, and performing a pelvic examination in women of child-bearing age with lower abdominal pain. It also provides several pearls related to appendicitis diagnosis and management.

The chapter describes a case of a 28-year-old male with pain in the anal region, a history of Crohn’s disease, and a prior similar episode requiring surgery in the ED. The patient is examined, and it is found that he has an uncomplicated perianal abscess. The chapter details the primary and secondary surveys, history, action taken, results, diagnosis, critical actions, and pearls associated with perirectal abscesses. The critical actions include thorough examination, incision and drainage, and follow-up management. The chapter concludes by stating that antibiotics are not necessary unless the patient exhibits systemic involvement.

The chapter describes a case of a 45-year-old female with type I diabetes who presented with severe diffuse abdominal pain for a day, fevers on and off since yesterday, and persistent nausea with vomiting. The physical exam revealed a mildly distended, diffusely tender abdomen, decreased bowel sounds, and rebound and guarding. The patient was diagnosed with diabetic ketoacidosis and urinary tract infection and was treated with IV fluid bolus, insulin drip, antibiotics, and ICU admission. The chapter provides pearls on the diagnosis and management of abdominal pain, including the importance of early blood glucose assessment, fluid replacement, insulin drip, and ICU admission for DKA, and early antibiotics, fluids, and surgical consultation for peritoneal signs.

The chapter discusses the diagnosis and critical actions for acute chest syndrome in patients. For acute chest syndrome, administration of oxygen, IV pain medications, and antibiotics are critical actions. Obtaining a CXR is key in this case, and albuterol should be given in patients with bronchospasm. Painful crises that are not typical of the patient’s usual symptoms should elicit a search for more serious complications of sickle cell disease.

This is an emergency medicine oral board-style case of a transplant patient with a fever. A patient with a history of a renal transplant presents to the emergency department with fever and is found to have sepsis secondary to cellulitis. As transplant patients are immunosuppressed and susceptible to septic shock, successful completion of the case requires the administration of IV fluid bolus, broad-spectrum antibiotics, obtaining blood and urine cultures, consulting the transplant specialist, and appropriately admitting the patient to the ICU.

Sepsis in infants can present in a variety of ways, including but not limited to fever, lethargy, altered mental status, respiratory distress and poor feeding. An ill-appearing infant should be considered septic until proven otherwise, by obtaining blood, urine, and cerebrospinal fluid samples to be sent for analysis. Broad-spectrum antibiotics should be provided early, and IV fluids should be given, especially if there is concern for septic shock. Infants with sepsis should be admitted to the hospital for monitoring and continued management.

The chapter describes the case of a 45-year-old male with stage 3 HIV who presents to the ED with fever, shortness of breath, pleuritic chest pain, and nonbloody diarrhea. The patient exhibits tachycardia, hypoxia, and a warm, diaphoretic appearance. Initial actions include oxygen supplementation, IV fluids, and labs. The patient is diagnosed with HIV pneumonia, likely Pneumocystis jirovecipneumonia (PCP), and is treated with antibiotics and steroids. Early recognition of fever and hypoxia, along with respiratory isolation, is critical to prevent sepsis. Tests ordered should include CBC, electrolytes, liver function tests, urinalysis and culture, blood cultures, and CXR. Focal infiltrates suggest bacterial pneumonia, while a diffuse interstitial or perihilar, granular pattern on CXR is associated with PCP. Steroids should be given to patients with a partial pressure of arterial oxygen <70 mmHg or an alveolar–arterial gradient of >35 mmHg.

This chapter describes a case of a 45-year-old male with stage 3 HIV who presented to the ED with fever, shortness of breath, pleuritic chest pain, and nonbloody diarrhea. The patient was diagnosed with HIV pneumonia, likely Pneumocystis jiroveci pneumonia(PCP), and was treated with antibiotics, steroids, oxygen supplementation, and IV fluids. The chapter emphasizes the importance of recognizing the symptoms of pneumonia in HIV patients and providing early treatment to prevent sepsis. The chapter also provides guidelines for diagnostic tests and highlights the significance of CD4 counts in the development of pulmonary disorders in HIV patients.

The chapter describes the case of a 10-day-old male with shortness of breath, poor feeding, and lethargy. The patient exhibits respiratory distress, intercostal and subcostal retractions, and a systolic murmur. Initial actions include oxygen supplementation, IV placement, and labs. The patient is diagnosed with critical aortic coarctation, which is dependent upon a patent ductus arteriosus to maintain blood flow to the body. Prostaglandin E1 administration and cardiology consultation are critical actions. Congenital heart disease should be considered in any newborn in shock or severe distress, and early recognition and intervention are important. Differential blood pressure and oxygen saturation can be clues to congenital heart disease.

Pneumonia and septic shock are common illnesses treated in the emergency department. This case reflects a patient with septic shock presenting to the emergency department from the community. The case progresses quickly from simple cough to septic shock with multiorgan failure. As the case progresses, the physician must quickly recognize the signs of severe sepsis and septic shock, which require immediate treatment with appropriate fluids, vasopressors, and antibiotics.

The chapter presents a case of a 34-year-old man with persistent diarrhea and abdominal pain. The patient had no significant past medical history and had traveled outside the country six weeks ago. The diagnosis was traveler’s diarrhea, likely caused by Giardia lambliainfection. The patient was prescribed antibiotics and rehydrated with oral or IV fluids. The chapter emphasizes the importance of eliciting a travel history and sending stool samples for laboratory analysis to identify the cause of diarrhea. It also provides information on the most common causes of traveler’s diarrhea, including protozoan infections like Giardiaand Entamoeba histolytica amebiasis, and bacterial infections like E. coli, Salmonella, and Vibrio cholera. The chapter discourages the use of loperamide in moderate to severe acute infectious diarrhea.