What is the best course of action for a patient with shortness of breath, fever, and a crusty rash with pus, who has an oxygen saturation level of hypoxemia?

Immediate Management of Patient with Shortness of Breath, Fever, Crusty Pustular Rash, and Hypoxemia

This patient requires immediate oxygen therapy to achieve target saturation of 94-98%, urgent evaluation for sepsis with possible skin and soft tissue infection, and consideration of hospital transfer given the combination of hypoxemia (SpO2 91%) and systemic signs of infection. 1

Immediate Oxygen Therapy

• Administer oxygen immediately via nasal cannulae at 2-6 L/min to target SpO2 of 94-98%, as the patient's current saturation of 91% indicates hypoxemia requiring urgent correction 1, 2
• If SpO2 remains below 94% despite initial oxygen, escalate to a simple face mask at 5-10 L/min 1
• Monitor oxygen saturation continuously until the patient stabilizes 2
• Obtain arterial or capillary blood gases to assess PaO2, PaCO2, and pH to guide further management 1

Sepsis Evaluation and Management

The combination of fever, hypoxemia, and pustular skin lesions raises concern for sepsis from skin and soft tissue infection, requiring immediate assessment and treatment. 2

Vital Signs and Clinical Assessment

• Measure complete vital signs including temperature, heart rate, blood pressure, and respiratory rate immediately 2
• Assess for signs of shock: cold extremities, altered mental status, urine output <15 mL/hour, or systolic blood pressure <85 mmHg 2
• Examine the skin lesions carefully for extent, purulent drainage, surrounding erythema, and signs of necrotizing infection 2

Laboratory Evaluation

• Obtain complete blood count with differential looking for WBC >14,000 cells/mm³ or left shift (band neutrophils ≥6% or >1500/mm³) as indicators of bacterial infection 2
• Draw at least 2-3 sets of blood cultures before initiating antibiotics 2
• If resources permit, obtain specimens from pustular lesions for Gram stain and culture 2

Fluid Resuscitation and Hemodynamic Support

• If hypotensive or showing signs of shock, administer intravenous crystalloid bolus of 1000-2000 mL 2
• Monitor blood pressure frequently (every 5-15 minutes) if patient shows signs of hemodynamic instability 2
• Consider vasopressor support (dopamine or epinephrine) if hypotension persists despite fluid resuscitation 2

Respiratory Assessment

The presence of shortness of breath with hypoxemia requires evaluation for pneumonia versus primary skin/soft tissue infection with systemic effects. 2

• Assess respiratory rate; rates >25 breaths/minute warrant pulse oximetry and consideration of pneumonia 2
• If respiratory rate is elevated or patient has increased work of breathing, obtain chest radiograph to evaluate for pneumonia or other pulmonary complications 2
• Place patient in semi-recumbent position (head of bed elevated 30-45°) unless hemodynamically unstable 2

Transfer Considerations

This patient likely requires hospital-level care given the combination of hypoxemia, fever, and systemic infection. 2

• Transfer to acute care facility should be considered for patients with:
  • Persistent hypoxemia despite oxygen therapy 2
  • Signs of septic shock or hemodynamic instability 2
  • Extensive skin infection requiring intravenous antibiotics and possible surgical intervention 2
• Ensure adequate oxygen supply during transfer with continuous monitoring of oxygen saturation 2

Antibiotic Therapy

• Initiate empiric broad-spectrum antibiotics covering skin flora (including Staphylococcus aureus and Streptococcus species) once cultures are obtained 2
• Consider MRSA coverage if patient has risk factors or if pustular lesions suggest staphylococcal infection 2

Critical Pitfalls to Avoid

• Do not delay oxygen therapy while awaiting diagnostic workup; hypoxemia with SpO2 <90% is associated with increased short-term mortality 2
• Do not assume hypoxemia is solely respiratory in origin; sepsis can cause tissue hypoxia through multiple mechanisms including increased oxygen consumption and impaired oxygen delivery 2
• Do not overlook necrotizing soft tissue infection, which can present with crusty, pustular lesions and requires urgent surgical evaluation 2
• Do not administer excessive oxygen beyond what is needed to achieve target saturation, as this causes vasoconstriction and reduced cardiac output 2