SepsisMANAGEMENT

INFECTIOUS DISEASE PRESENTATIONS · 12 SECTIONS

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541 items

☷ Legend

01Approach to the Critical Patient/attcp62

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

02History/hx47

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

03Physical Exam/exam40

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

04Differential Diagnosis/ddx37

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

05Laboratory Tests/lt50

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

06Diagnostic Tests/dt67

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 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

07Disposition/dispo27

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

08Treatment/t107

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

09Special Populations/sp41

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

10Background/b29

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

11Patient Discharge Instructions/pdi23

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

12References/r11

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

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Reviewed by SymptomDx Medical Team · Last reviewed June 16, 2026

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