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1. CASE: AW is a 65-year-old female who presents with complaint of fever, malaise, and 3-day history of productive cough. Her vitals are as follows: heart rate, 120 beats per minute; blood pressure, 90/60 mmHg (cuff); respiration rate, 24 breaths per minute; and temperature, 101°F. She is alert and oriented x 3, but she is toxic appearing.

What is AW’s quick Sequential Organ Failure Assessment (qSOFA) score?

A. 0 B. 1 C. 2 D. 3 E. Unsure

2. CASE: AW is a 65-year-old female who presents with complaint of fever, malaise, and 3-day history of productive cough. Her vitals are as follows: heart rate, 120 beats per minute; blood pressure, 90/60 mmHg (cuff); respiration rate, 24 breaths per minute; and temperature, 101°F. She is alert and oriented x 3, but she is toxic appearing.

Within the first hour, AW received 3 liters of Lactated Ringer's solution (30 mL/kg), vancomycin, and piperacillin-tazobactam, and central venous access was obtained. After all initial interventions, her mean arterial pressure (MAP) remains at 55 mmHg. What is the next recommended intervention?

A. Administer 1 L of albumin 25% B. Administer an additional 1 L of Lactated Ringer's solution C. Initiate norepinephrine continuous infusion at 5 mcg/min D. Continue to monitor without intervention at this time E. Unsure

3. CASE: AW is a 65-year-old female who presents with complaint of fever, malaise, and 3-day history of productive cough. Her vitals are as follows: heart rate, 120 beats per minute; blood pressure, 90/60 mmHg (cuff); respiration rate, 24 breaths per minute; and temperature, 101°F. She is alert and oriented x 3, but she is toxic appearing.

Four hours have passed. AW is currently receiving intermittent vancomycin, piperacillin-tazobactam, PlasmaLyte-A maintenance fluid, norepinephrine, and vasopressin infusions. Initially, her blood pressure responded to the interventions, but her MAP has now fallen to 45 mmHg. What intervention should be employed next?

A. Initiate dopamine infusion at 5 mcg/kg/min B. Administer tobramycin 7 mg/kg intravenous (IV) piggyback C. Administer methylene blue 4 mg/kg IV push D. Initiate hydrocortisone 50 mg IV push every 6 hours E. Unsure

4. CASE: AW is a 65-year-old female who presents with complaint of fever, malaise, and 3-day history of productive cough. Her vitals are as follows: heart rate, 120 beats per minute; blood pressure, 90/60 mmHg (cuff); respiration rate, 24 breaths per minute; and temperature, 101°F. She is alert and oriented x 3, but she is toxic appearing.

Twelve hours have now passed since AW presented to the hospital. All appropriate resuscitative efforts have been implemented. Her current vitals are as follows: MAP, 55 mmHg; and heart rate, 110 beats per minute. Which of the following interventions would be reasonable to consider at this time?

A. Administer methylene blue 4 mg/kg B. Initiate angiotensin II at 20 ng/kg/min C. Initiate dopamine infusion at 5 mcg/kg/min D. Continue to monitor without intervention at this time E. Unsure

5. KB presents to the emergency department with an initial assessment significant for tachypnea (respiratory rate, 30 breaths per minute), tachycardia (heart rate, 120 beats per minute), hypotension (systolic blood pressure, 80 mmHg), and cardiac index of 2. Further assessment reveals diaphoresis and a gangrenous left lower extremity. Labs reveal leukocytosis (white blood cell count, 22x10⁹/L), acute kidney injury (serum creatinine, 2.5 g/dL), hemoglobin of 13 g/dL, and lactate of 5 mmol/L. Which type of shock does KB likely have?

A. Cardiogenic B. Hemorrhagic C. Neurogenic D. Distributive E. Unsure

6. You have been asked to participate in a focus group for your emergency department to improve sepsis metrics and outcomes. The first task is to educate all providers and staff on the new sepsis definitions to promote early recognition. You educate bedside clinicians to perform rapid assessment screenings for sepsis. The assessment parameters should be based upon the following parameters:

A. Respiratory rate, temperature, heart rate, and leukocytosis/leukopenia B. Age, blood pressure, Glasgow coma scale score, and history of frequent admissions C. Mean arterial pressure, PaO2/FiO2 ratio, bilirubin, and serum creatinine D. Glasgow Coma Scale score, respiratory rate, and systolic blood pressure E. Unsure

7. The next task is to implement a 1-hour bundle to address rapid initiation of treatment interventions for sepsis and septic shock. Which of the following lists includes all first-hour interventions directed by the Surviving Sepsis Campaign guidelines?

A. Administer resuscitative fluid (30 mL/kg), obtain central venous access, administer appropriate antimicrobial therapy, and initiate hydrocortisone 50 mg intravenously (IV) every 6 hours B. Administer resuscitative fluid (30 mL/kg), obtain central venous access, obtain antimicrobial cultures, and administer adequate antimicrobial therapy C. Administer appropriate antimicrobial therapy, initiate resuscitative fluids, initiate vasopressor therapy, and initiate ascorbic acid 1.5 grams IV every 6 hours D. Obtain antimicrobial cultures, initiate resuscitative fluids, initiate hydrocortisone 50 mg IV every 6 hours, and obtain arterial access for blood pressure monitoring E. Unsure

8. Methylene blue has been described in various studies and case reports and several dosing strategies have been proposed, each with varying effectiveness and safety profiles. Which of the following is a potential adverse effect of higher bolus doses (3-4 mg/kg) of methylene blue?

A. Paradoxical bradycardia B. Acute respiratory distress syndrome C. Anaphylaxis D. Increased serum lactate concentration E. Unsure