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Approach to the Critical Patient
Recognition and activation
Sepsis recognition and escalation
Suspected infection plus acute organ dysfunction
Acute altered mental status
New hypotension
New hypoxemia
Oliguria
Lactate elevation
Septic shock recognition
Vasopressor requirement for MAP 65 mmHg or higher
Lactate greater than 2 mmol/L despite adequate volume resuscitation
Severe sepsis terminology
Severe sepsis term no longer used in Sepsis 3 definitions
Coding and legacy documentation may still reference severe sepsis
Team activation triggers
Persistent hypotension after initial fluid
Lactate 4 mmol/L or higher
Rapidly increasing oxygen requirement
New need for vasopressors
Concern for immediate source control
Immediate resuscitation
ABCs and time zero actions
Airway and breathing priorities
Work of breathing and mental status deterioration
High flow nasal cannula or NIV if appropriate
Intubation preparation for refractory hypoxemia or exhaustion
Circulation priorities
Large bore IV access times two
Central access if ongoing vasopressor need
Peripheral vasopressor pathway if central delay
Proximal large vein site preference
Frequent site checks for extravasation
Monitoring
Continuous cardiac monitoring
Pulse oximetry
Noninvasive BP cycling every 2 to 3 minutes until stable
Arterial line if ongoing vasopressor titration
Hemodynamic and perfusion goals
Resuscitation targets
Mean arterial pressure 65 mmHg or higher
Higher targets if chronic hypertension or elevated ICP concern
Lower targets may be acceptable in select patients with adequate perfusion markers
Perfusion markers
Mental status improvement
Urine output 0.5 mL/kg/hour or higher
Capillary refill time adjunct
Lactate trend for severity and clearance
Shock reassessment loop
After each intervention repeat perfusion assessment
If worsening perfusion escalate vasopressors and source control pathway
Early bundle elements
Initial bundle within hours
Lactate
Baseline lactate
Repeat lactate if initial 2 mmol/L or higher
Cultures
Blood cultures times two before antibiotics when feasible
Do not delay antibiotics for cultures in shock
Broad spectrum antimicrobials
Immediate for possible septic shock or high likelihood sepsis
Within 3 hours for suspected sepsis without shock when feasible
Crystalloid resuscitation
30 mL/kg for hypotension or lactate 4 mmol/L or higher
Earlier vasopressors if fluid nonresponsive or pulmonary edema risk
Source control planning
Imaging and consults for drainage or surgery
History
Clinical vignette and timing
Sepsis syndrome context
Reported or suspected infection source
Pneumonia symptoms
Urinary symptoms
Abdominal pain
Skin and soft tissue symptoms
Indwelling device symptoms
Timeline
Symptom onset time
Time of last normal
Rapid progression within hours
Prehospital course
Fluid received
Antibiotics received
Vasopressors received
Risk factors and modifiers
Host risk factors
Age 65 years or older
Immunosuppression
Steroids
Chemotherapy
Transplant
HIV
Diabetes
Chronic kidney disease
Chronic liver disease
Asplenia
Pregnancy and postpartum
Exposure and iatrogenic risks
Recent surgery or procedure
Indwelling catheter or central line
Recent hospitalization or antibiotics
Long term care residence
Travel or sick contacts
Medication history relevant to shock
Beta blockers
ACE inhibitor or ARB
Diuretics
Anticoagulants
Symptoms suggesting organ dysfunction
Organ dysfunction features
Altered mental status
Dyspnea
Chest pain
Oliguria
Profound weakness or syncope
New jaundice
Severe abdominal pain
Rash or purpura
Physical Exam
Initial survey and vitals
Shock phenotype and severity
Fever or hypothermia
Tachycardia
Tachypnea
Hypotension
Oxygen saturation and work of breathing
Mental status and agitation
Perfusion exam
Capillary refill time
Skin temperature and mottling
Peripheral pulses
Jugular venous distension pattern
Lung crackles suggesting fluid intolerance
Focused source exam
Pulmonary source findings
Focal crackles
Increased work of breathing
Wheeze with alternative diagnosis consideration
Urinary source findings
Suprapubic tenderness
CVA tenderness
Catheter site assessment
Abdominal source findings
Peritonitis signs
RUQ tenderness
Distension and ileus
Skin and soft tissue source findings
Cellulitis margins
Abscess fluctuance
Necrotizing infection signs
Pain out of proportion
Crepitus
Skin discoloration or bullae
CNS source findings
Meningismus
Focal neurologic deficit
PITFALLS
Exam pitfalls
Normal temperature in sepsis
Elderly and immunocompromised blunted tachycardia and fever
Early septic shock with warm extremities
Fluid overload obscuring perfusion signs
Differential Diagnosis
Life threatening mimics of sepsis
Shock and systemic inflammation mimics
Hemorrhagic shock
GI bleeding
Trauma
Cardiogenic shock
Acute coronary syndrome
Myocarditis
Arrhythmia
Obstructive shock
Massive pulmonary embolism
Cardiac tamponade
Tension pneumothorax
Anaphylaxis
Adrenal crisis
Thyroid storm
Heat stroke
Toxicologic syndromes
Neurogenic shock
Infectious sources and syndromes
Common infection sources
Pneumonia
ICD 10 J18.9
Urinary tract infection and pyelonephritis
ICD 10 N39.0
ICD 10 N10
Intra abdominal infection
Cholangitis
Appendicitis
Diverticulitis
Skin and soft tissue infection
Meningitis and encephalitis
Line associated bloodstream infection
Endocarditis
Sepsis coding anchors
Sepsis unspecified organism ICD 10 A41.9
Severe sepsis without septic shock ICD 10 R65.20
Severe sepsis with septic shock ICD 10 R65.21
Septic shock ICD 10 R65.21
Laboratory Tests
Core labs and interpretation
Initial sepsis lab set
Lactate
Marker of illness severity and hypoperfusion
Lactate greater than 2 mmol/L associated with higher risk
Lactate 4 mmol/L or higher high risk even without hypotension
Complete blood count
Leukocytosis or leukopenia supportive but nonspecific
Thrombocytopenia as organ dysfunction marker
Basic metabolic panel
Creatinine rise for AKI
Bicarbonate low for metabolic acidosis
Glucose mmol/L for stress hyperglycemia or hypoglycemia
Liver enzymes and bilirubin
Cholestasis pattern for biliary source
Hyperbilirubinemia as organ dysfunction marker
Coagulation studies
INR elevation for hepatic dysfunction or DIC
Fibrinogen if DIC concern
Venous blood gas
pH
pCO2 mmHg
HCO3 mmol/L
Arterial blood gas if respiratory failure
PaO2 mmHg for oxygenation assessment
PaCO2 mmHg for ventilation assessment
Microbiology
Cultures and pathogen testing
Blood cultures times two
Before antibiotics when feasible
Do not delay antibiotics in shock
Urine culture
With UA abnormalities or urinary source concern
Respiratory sampling
Sputum culture if productive cough and severe pneumonia
Endotracheal aspirate if intubated
Site cultures
Wound culture if purulence
CSF studies if meningitis concern and safe LP
Viral testing based on season and syndrome
Influenza
SARS CoV 2
Adjunct and special labs
Additional tests by syndrome
Troponin for myocardial injury and shock differential
BNP or NT proBNP if cardiogenic component suspected
Procalcitonin
Antibiotic de escalation adjunct in select ICU pathways
Not required for sepsis diagnosis
Cortisol only in selected adrenal crisis concern
Type and screen
Suspected bleeding
Need for urgent surgery
Diagnostic Tests
Scoring Systems
Sepsis risk stratification tools
qSOFA
Systolic BP 100 mmHg or lower
Respiratory rate 22 per minute or higher
Altered mentation
Two or more suggests higher risk of poor outcome
SOFA
Sepsis definition anchor
Acute increase 2 points or more consistent with organ dysfunction
Components
PaO2 to FiO2 ratio
Platelet count
Bilirubin
Mean arterial pressure and vasopressor dose
GCS
Creatinine or urine output
SIRS
Screening only
Not part of Sepsis 3 definition
NEWS2
Early deterioration detection adjunct
Escalation trigger in ward settings
MRI
MRI indications in sepsis
CNS source
Epidural abscess
Brain abscess
Spine source control planning
Osteomyelitis and discitis
Soft tissue infection
Deep fascial involvement if CT nondiagnostic
Practical limitations
Hemodynamic instability
Ventilator and infusion pump compatibility
Delay risk compared with CT
CT
CT for source identification and complications
CT chest
Pneumonia complications
Empyema
CT abdomen and pelvis with IV contrast
Intra abdominal sepsis
Abscess
Perforation
Obstructive uropathy with infection
CT head
New focal deficit
Concern for intracranial bleed before LP
Contrast considerations
Sepsis associated AKI risk balance with source control urgency
If critical source control decision depends on imaging proceed with mitigation
Ultrasound (or US)
POCUS and formal ultrasound roles
Cardiac POCUS
LV function estimate
RV strain for PE mimic
Pericardial effusion
IVC and venous congestion adjunct
Fluid responsiveness limitations acknowledged
Venous excess ultrasound patterns if available
Lung ultrasound
Consolidation and pleural effusion
B lines for pulmonary edema risk
Abdominal ultrasound
Biliary dilation and cholecystitis
Hydronephrosis and obstruction
Procedural guidance
Central line
Thoracentesis
Abscess drainage guidance
Disposition
Level of care selection
Admission disposition
ICU criteria
Vasopressor requirement
Persistent hypotension after fluids
Lactate 4 mmol/L or higher
Need for invasive ventilation
Rapidly worsening organ dysfunction
Step down criteria
Stable MAP without vasopressors after resuscitation
Oxygen requirement moderate and stable
Lactate trending down and no ongoing hypoperfusion signs
Ward criteria
Source identified and controlled or controllable without urgent procedure
No hypotension after resuscitation
No escalating oxygen need
Transfer criteria
Need for surgical or interventional source control not available
Need for ICU bed not available
ECMO or advanced critical care need
ED observation and discharge rare pathway
Discharge only when strict criteria met
No organ dysfunction
No hypotension
Lactate normal and stable if measured
Reliable follow up within 24 to 48 hours
Oral antibiotics appropriate and tolerated
Clear return precautions
Shared decision making documentation
Treatment
Antimicrobials
Empiric antibiotic strategy
Timing
If septic shock or high likelihood sepsis initiate immediately and ideally within 1 hour
If suspected sepsis without shock initiate within 3 hours when feasible
Spectrum selection principles
Cover likely source pathogens
Cover local resistance patterns
Prior colonization and recent antibiotics
Immunocompromised broadened coverage
De escalation and stewardship
Narrow based on cultures and syndrome
Stop antibiotics if alternative diagnosis confirmed
Dosing principles
Loading doses in shock
Renal dosing adjustments after initial stabilization
Extended infusion beta lactams when appropriate
Fluids
Crystalloid resuscitation
Initial bolus
30 mL/kg isotonic crystalloid for hypotension or lactate 4 mmol/L or higher
Smaller aliquots with frequent reassessment in fluid intolerance risk
Fluid type
Balanced crystalloids reasonable first choice
Normal saline acceptable alternative
Reassessment guided titration
Capillary refill and extremity perfusion
Lung exam and ultrasound for congestion
Dynamic measures when feasible
Albumin
Consider when substantial crystalloid volumes required and ongoing instability
Vasopressors and inotropes
Vasopressor initiation and targets
Target MAP 65 mmHg or higher
Titrate every 2 to 5 minutes in ED and ICU transition
Consider higher MAP target in chronic hypertension with hypoperfusion
Norepinephrine first line
Initiate infusion if hypotension persists after fluids
Typical starting range 0.05 to 0.1 mcg/kg/min
Titrate to MAP target
Peripheral start acceptable with protocol if central delay
Short duration goal
Early central access planning
Vasopressin second line adjunct
Add if norepinephrine escalating
Fixed dose 0.03 units/min
Not titrated
Epinephrine add on option
Add if MAP not achieved with norepinephrine plus vasopressin
Start 0.02 to 0.05 mcg/kg/min
Titrate to effect
Dopamine limited role
Consider only in selected patients with bradycardia and low arrhythmia risk
Inotrope for myocardial dysfunction
Dobutamine
If low cardiac output with persistent hypoperfusion despite MAP goal
Start 2.5 to 5 mcg/kg/min
Titrate by perfusion and tachyarrhythmia risk
Corticosteroids
Refractory septic shock steroids
Hydrocortisone
If ongoing vasopressor requirement despite adequate fluids and vasopressors
200 mg/day IV total dosing
50 mg IV every 6 hours option
Continuous infusion option per ICU pathway
Monitor
Hyperglycemia mmol/L monitoring
Secondary infection risk
Source control
Source control pathway
Timing
As early as possible after stabilization
Within hours for uncontrolled source
Examples
Drain abscess
Remove infected catheter
Debride necrotizing infection
ERCP for cholangitis with obstruction
Surgery for perforation
Consultation triggers
General surgery
Interventional radiology
Urology
OB GYN
Infectious diseases for complex cases
Respiratory support and ventilation
Oxygenation and ventilation strategy
Noninvasive support
High flow nasal cannula for hypoxemia
NIV for selected COPD or cardiogenic overlap
Intubation considerations in shock
Pre oxygenation optimization
Hemodynamic optimization before induction
Push dose vasopressor preparation
ARDS protective ventilation if intubated
Low tidal volume 6 mL/kg predicted body weight
Plateau pressure 30 cmH2O or lower
PEEP per ARDS strategy
Prone positioning for severe ARDS per ICU protocol
Transfusion and coagulopathy
Blood product strategy
RBC transfusion threshold
Hemoglobin 70 g/L threshold in stable sepsis without active bleeding
Higher threshold in active ischemia or ongoing hemorrhage
Platelets and plasma
Procedure related thresholds per institutional policy
DIC management guided by bleeding and labs
Glycemic and temperature management
Metabolic and supportive care
Glucose control
Avoid hypoglycemia
ICU insulin protocols typically target moderate range
Temperature
Treat discomfort and extreme hyperthermia
Hypothermia recognition as high risk sign
Special Populations
Pregnancy
Pregnancy and postpartum considerations
Physiologic changes
Lower baseline BP
Higher baseline heart rate
Leukocytosis baseline
Source differentials
Pyelonephritis
Chorioamnionitis
Endometritis postpartum
Resuscitation modifications
Left uterine displacement in late pregnancy
Early OB consultation
Antibiotic safety
Avoid known teratogens when alternatives exist
Adjust dosing by increased volume of distribution
Fetal considerations
Fetal monitoring when viable gestation and maternal stabilization ongoing
Geriatric
Older adult considerations
Atypical presentation
Afebrile sepsis
Delirium as primary sign
Fluid tolerance
Higher risk pulmonary edema
Smaller bolus aliquots with frequent reassessment
Medication considerations
Higher vasopressor sensitivity variability
Renal dosing adjustments common
Goals of care
Early discussion in advanced comorbidity
Pediatrics
Pediatric sepsis considerations
Recognition differences
Hypotension late sign
Tachycardia and delayed cap refill early clues
Fluid strategy
Weight based boluses with reassessment
Early vasoactive support if fluid refractory
Antibiotic dosing
Weight based dosing and maximum dose limits
Consultation
Pediatric critical care early
Transfer to pediatric capable center when needed
Background
Epidemiology
Sepsis burden and outcomes
High global incidence and hospital mortality
Septic shock higher mortality than sepsis without shock
ED and hospital early recognition improves outcomes
Older adults and comorbid patients highest risk
Pathophysiology
Mechanisms of sepsis and shock
Dysregulated host response to infection
Endothelial dysfunction and capillary leak
Vasoplegia and maldistributed flow
Mitochondrial and cellular metabolic dysfunction
Microcirculatory impairment
Coagulopathy spectrum
DIC
Microthrombosis
Organ dysfunction pathways
AKI
ARDS
Encephalopathy
Hepatic dysfunction
Therapeutic Considerations
Rationale for key interventions
Early antimicrobials reduce mortality in septic shock
Fluids restore preload and perfusion in hypovolemia
Vasopressors counter vasoplegia and maintain perfusion pressure
Source control removes ongoing pathogen and toxin burden
Excess fluids worsen pulmonary edema and outcomes in some patients
Reassessment driven resuscitation balances perfusion and overload risk
Evidence frameworks
Surviving Sepsis Campaign recommendations use GRADE strength and quality
ACEP policy statements may differ for ED operational metrics
Patient Discharge Instructions
Copy discharge instructions
Discharge instructions for infection with sepsis concern ruled out
Diagnosis and expected course
Treated for infection
No current evidence of sepsis after evaluation
Medications
Antibiotic name and schedule as prescribed
Hydration guidance
Fever control dosing per local protocol
Return to ED now for red flags
Trouble breathing
Fainting or severe dizziness
Confusion or new drowsiness
Persistent vomiting or inability to keep fluids down
Worsening pain
Fever persisting beyond 48 hours on antibiotics
New rash or purple spots
Urine much less than usual
Follow up
Primary care within 24 to 48 hours
Culture result follow up plan
Safety
Do not drive if dizzy or confused
Avoid alcohol while ill and on antibiotics
References
Guidelines and consensus
Surviving Sepsis Campaign International Guidelines for Management of Sepsis and Septic Shock 2021
Initial MAP target 65 mmHg recommendation
Immediate antimicrobials for possible septic shock guidance
Third International Consensus Definitions for Sepsis and Septic Shock Sepsis 3 2016
Sepsis definition organ dysfunction with SOFA increase 2 or more
Septic shock criteria vasopressors for MAP 65 mmHg or higher plus lactate greater than 2 mmol/L
CDC clinical care resources for sepsis for healthcare professionals
Emphasis on rapid recognition and treatment
National or regional sepsis pathways and bundles as locally adopted
ED protocol alignment with institutional policy
ICU pathway alignment with critical care service
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.