Cases from litigation highlight missed subtle signs of sepsis.

Cases from litigation highlight missed subtle signs of sepsis.

• Aim: identify red flags often overlooked in the ED.

• Three key lessons:

  1. Fear discharge tachycardia (FEAR mnemonic).

  2. Do not routinely get abdominal x-rays for abdominal pain.

  3. Rule of 10 for kidney stones (infected stones).

Case 1 – 21 y/o F, back pain, IV drug use

• Vitals: BP 111/58, T 99.4, HR 116 (persistent tachycardia), RR 18, SpO₂ 96%.

• Severe back pain, localized lumbar, ESR elevated, MRI negative for epidural abscess.

• Discharged after 8 hrs → worsened → MRSA urosepsis → died.

• Missed red flag: persistent tachycardia despite normal labs/imaging.

Evidence:

• Abnormal vitals ↑ odds of death within 15 days (OR ~3).

• Each HR >100 → ↑ mortality odds by 4% per beat.

• Tachycardia = early warning sign of evolving sepsis.

Mnemonic: FEAR discharge tachycardia

• F – Fix abnormal vital sign if possible (fluids, pain control, etc.).

• E – Explain why it’s abnormal (albuterol, pain, etc.).

• A – Address in documentation/decision-making.

• R – Recheck vitals before disposition.

Case 2 – 69 y/o M, abdominal pain, h/o C. diff

• WBC 24.4, dx presumed recurrent C. diff.

• Imaging: only abdominal flat plate (showed air-fluid levels).

• Admitted on IV Flagyl → worsened → ICU → death from intra-abdominal sepsis.

Key point: abdominal x-rays are poor for abdominal pain workup.

• Constipation: diagnosis is clinical, not radiographic.

  • Stool burden on x-ray often does not match treatment decisions.

• Appendicitis: missed in ~6% adults, 4% kids.

  • Risk factors: constipation dx, comorbidities, use of abdominal x-ray alone.

  • X-ray associated with higher odds of missed appendicitis than no imaging.

Takeaway:

• Do not routinely use abdominal x-rays in abdominal pain.

• Prefer CT or ultrasound if imaging truly warranted.

Case 3 – 67 y/o F, recurrent kidney stones

• Flank pain “like prior stones.”

• Vitals: T 99.9, HR 79, BP 100/57, SpO₂ 98%.

• CT: 2.6 mm distal ureteral stone, hydronephrosis.

• UA: WBCs, bacteria, no nitrites/LE.

• Discharged after urology call.

• Returned 2 days later: septic, hypotensive, renal failure → died.

Rule of 10 for kidney stones:

1. 10% of kidney stones are infected.

2. UA can be negative in 10% of infected cases.

3. If WBCs ≥10 in urine → consider infection.

   • May warrant antibiotics even if afebrile/stable.

   • Outpatient abx possible if well-appearing but must ensure close follow-up.

Lesson:

• Even small stones can harbor infection.

• Have a low threshold for abx if UA shows ≥10 WBCs.

The Takeaways

• Tachycardia is an early sepsis clue → apply FEAR (Fix, Explain, Address, Recheck).

• Abdominal x-rays are not helpful for constipation, appendicitis, or intra-abdominal sepsis → avoid routine use.

• Kidney stones: Rule of 10 → 10% infected, 10% UA false-neg, ≥10 WBCs → treat as possible infection.