ETD: Septic shock secondary to infected scalded wound

This is definitely one of the most bizarre case I have seen in ETD so far.

This patient was referred from private hospital to us after some alleged mismanagement that caused harm to patient.

55 years old uncle, underlying hypertension, diabetes mellitus, history of ischaemic stroke in 2018 without residual weakness, and chronic kidney disease not on dialysis, apparently very bad DM control on OHA and insulin, initially was presented to private hospital late April with bilateral lower limb scalded wound after he soaked his legs into hot water.

Bedside debridement was done in private hospital and patient was treated as infected bilateral lower limb scalded wound, because wound swab C+S noted growth of 2 notorious organisms, which are Staph aureus sensitive to cloxacillin and cefepime, and Enterococcus faecalis sensitive to augmentin but resistant to cefepime. He was then started on IV cloxacillin and IV cefepime.

However he developed reduced consciousness after started on treatment for 5 days, while still admitted in the private hospital. CT brain done and it was normal. The physician consulted nephrologist and they thought it could be cefepime neurotoxicity. Thus they stopped the cefepime and changed to augmentin while the cloxacillin was continued. 

Unfortunately they did not investigate further, nor escalated antibiotics, patient eventually developed anuria with hypotension, then was started on norad and sent to my hospital for further management. 

Upon arrival at ETD, patient GCS was E1V1M4. The vitals were otherwise stable. We intubated the patient because of low GCS level. Upon examination noted multiple scalded wound with necrotic patches over bilateral heels and lateral shins, the wound appeared to be clean, underlying tissue not fluctuant and no crepitus. 

TWC of this patient is 39. The urea/creat is 17/500, compared to baseline upon arrival at private hospital 1 week ago was 13/350. Chest xray looks clear, and urine dipstick no UTI picture.

Our impression was septic shock secondary to the infected scalded wound, even though the wound somehow look clean. But we also covered for HAI, escalated antibiotics to tazocin for this patient. For the low GCS, we would like to rule out cefepime neurotoxicity, but it could be attributed to the sepsis as well. Whereas the anuric AKI on CKD, most likely due to end organ failure secondary to ?HAI or infected scalded wound.

Case was referred to surgical and ortho side, however both teams did not plan to go in OT for wound debridement, as the patient is unstable and wound doesn't look bad. We also referred the case to medical for AKI and covering for HAI. Medical was scratching their head to look for source of infection as TWC 39 showed patient is having ongoing infection. But nevertheless they planned to refer our in house nephrologist for HD support due to very bad AKI with almost zero urine output.

But I think the main issue here is the mismanagement from the private hospital side. They simply transferred an ill and deteriorated patient without proper resuscitation and documentation to us. A few peculiar issues to discuss about, including giving cefepime to the patient as initial antibiotics treatment even though C+S result has shown the enterococcus faecalis is resistant to cefepime. 

And for me, I think it is too soon to jump into conclusion and label patient as possible cefepime neurotoxicity without further investigation other than CT brain. Because cefepime neurotoxicity is rather rare, I had only seen 1 so far. Also, other than swab C+S from the scalded wound, they could have taken blood C+S as well, at least to diagnose or rule out ongoing sepsis that could possibly cause patient to deteriorate. The high TWC (36 when patient was first presented) is alarming, but they seemed to be not care.

And while patient developed anuria and hypotension, which could be end organ failure or third space loss causing patient in shock, all they did was giving patient IV furosemide to induce urine output. How could there be any urine output when patient is losing fluid into third space? 

However I did understood some test or investigations could not be done in private because it costs extra lot for the patient. But I think there are still a lot that they can do, at least a proper resuscitation, instead of throwing patient to us in this bad shape. I do hope this patient can survive in our setting because the initial condition wasn't too bad to begin with.