In an adult patient presenting in coma after vomiting and diarrhea with severe hypertension (200/100 mm Hg), atrial fibrillation with a normal ventricular response, fever 39 °C, oxygen saturation 83 % on room air, normal respiratory rate, and normal glucose, what is the immediate management?

Immediate Management of Comatose Patient with Severe Hypertension, Hypoxemia, and Fever

This patient requires immediate airway management with supplemental oxygen to correct the critical hypoxemia (83%), followed by rapid assessment for sepsis and cautious blood pressure reduction—the coma likely represents severe sepsis with end-organ dysfunction rather than a primary hypertensive emergency.

Initial Stabilization (First 5 Minutes)

Airway and Oxygenation:

• Administer 100% oxygen immediately via non-rebreather mask or bag-valve-mask ventilation to correct the SpO2 of 83%. 1
• Prepare for endotracheal intubation if the patient cannot protect their airway or if oxygenation does not improve rapidly. Tracheal intubation is the preferred technique for airway control in critically ill comatose patients. 1
• Target normoxemia once arterial oxygen saturation can be measured reliably; avoid both hypoxia and hyperoxia. 1

Circulatory Access and Monitoring:

• Establish peripheral intravenous access immediately (antecubital vein preferred) without delaying other interventions. 1
• Initiate continuous blood pressure, heart rate, and oxygen saturation monitoring. 1

Diagnostic Priority: Sepsis vs. Hypertensive Emergency

This presentation strongly suggests severe sepsis/septic shock rather than primary hypertensive emergency:

• The combination of fever (39°C), vomiting/diarrhea, coma, and hypoxemia meets criteria for severe sepsis with organ dysfunction (altered mental status, pulmonary dysfunction with SpO2 ≤90%). 1
• Severe hypertension (200/100) in this context is likely a compensatory response to sepsis-induced tissue hypoperfusion rather than the primary pathology. 1
• The atrial fibrillation with normal ventricular response may be pre-existing or precipitated by sepsis and fever. 1, 2

Immediate Management Algorithm

Step 1: Fluid Resuscitation (Within First Hour)

• Administer rapid bolus of at least 20 mL/kg (approximately 1-2 liters) of isotonic crystalloid solution intravenously for suspected sepsis-induced tissue hypoperfusion. 1
• Assess response to fluid loading by monitoring for ≥10% increase in systolic/mean arterial pressure, ≥10% reduction in heart rate, and/or improvement of mental state and peripheral perfusion. 1
• Some adult septic patients may require several liters of fluid during the first 24 hours for adequate resuscitation. 1

Step 2: Urgent Laboratory and Diagnostic Studies

• Obtain blood cultures (2-3 sets) before antibiotics, complete blood count, comprehensive metabolic panel, lactate, and blood glucose. 1, 3
• Measure arterial blood gas to assess PaO2, PaCO2, and acid-base status. 1
• Check procalcitonin and C-reactive protein as markers of bacterial infection (CRP >50 mg/L has 98.5% sensitivity for bacterial sepsis). 3
• Obtain chest X-ray to evaluate for pneumonia or pulmonary edema. 3

Step 3: Empiric Antibiotic Therapy

• Administer broad-spectrum empirical antibiotics within 2 hours of presentation for suspected severe sepsis. 3
• Do not delay antibiotic therapy while awaiting culture results, as bacterial sepsis can rapidly progress to irreversible shock. 3

Step 4: Blood Pressure Management

Critical distinction: This is NOT a hypertensive emergency requiring aggressive BP reduction:

• In sepsis with compensatory hypertension, aggressive BP lowering before adequate fluid resuscitation can precipitate cardiovascular collapse. 1
• Set hemodynamic goals during post-resuscitation care; maintain systolic blood pressure >90 mmHg or mean arterial pressure >65 mmHg. 1
• If blood pressure remains severely elevated (>220/120 mmHg) after fluid resuscitation and sepsis treatment, consider cautious reduction with intravenous agents. 1
• If IV antihypertensive is needed, clevidipine can be initiated at 1-2 mg/hour and titrated carefully, with continuous BP monitoring. 4
• Avoid rapid or excessive BP lowering, which can worsen cerebral perfusion in comatose patients. 1

Post-Stabilization Care

Temperature Management:

• Measure and monitor core temperature continuously; actively prevent and treat fever. 1, 5
• If the patient remains comatose after initial stabilization, consider targeted temperature management (32-36°C) for at least 24 hours. 1, 5
• Fever after initial resuscitation is associated with worse neurologic outcomes and must be actively prevented. 5

Neurologic Monitoring:

• Electrolyte concentrations should be monitored and kept at low-normal levels in comatose patients. 1
• Treat clinical seizures if they occur, but do not use prophylactic anticonvulsants routinely. 1, 5
• Perform EEG if seizures are suspected, as they occur in 12-22% of comatose patients. 5

Atrial Fibrillation Management:

• Control ventricular rate if it becomes rapid, but the current normal ventricular response does not require immediate intervention. 1
• Hypertension is the most important risk factor for atrial fibrillation; blood pressure control is strictly required when anticoagulation is considered. 1
• Assess stroke risk once the patient is stabilized, as atrial fibrillation increases thromboembolic risk 2-5 fold. 1

Critical Pitfalls to Avoid

• Do not aggressively lower blood pressure before ensuring adequate fluid resuscitation in a patient with sepsis. The hypertension may be compensatory for tissue hypoperfusion. 1
• Do not assume this is a primary hypertensive emergency. The constellation of fever, vomiting/diarrhea, and coma points to sepsis as the primary pathology. 1, 6
• Do not delay antibiotics for diagnostic testing. Blood cultures should be obtained first, but antibiotic administration must occur within 2 hours. 3
• Do not overlook the critical hypoxemia (83%). This requires immediate correction and may indicate pneumonia, ARDS, or pulmonary edema. 1
• Do not use beta-blockers to treat reflex tachycardia if IV antihypertensives are used. There is limited experience with this approach and it is not recommended. 4

Prognosis and Ongoing Assessment

• Coma constitutes a medical emergency with substantial risk of death and disability; prognosis depends on the underlying etiology. 6, 7
• Clinical improvement should occur within 48-72 hours with appropriate treatment; monitor temperature, heart rate, and respiratory rate every 4-6 hours. 8
• If no improvement or clinical deterioration occurs, escalate imaging and consider alternative diagnoses including meningitis, encephalitis, or intracranial hemorrhage. 8, 6