Key Points
- Stabilize ABCs; begin targeted evaluation without delaying life-saving therapy.
- Use system-specific risk tools to guide testing and disposition.
- Order high-yield tests first; escalate imaging when indicated.
- Start evidence-based initial therapy and reassess frequently.
Algorithm
- Primary survey and vitals; IV access and monitors.
- Focused history/physical; identify red flags and likely etiologies.
- Order system-appropriate labs and imaging (see Investigations).
- Initiate guideline-based empiric therapy (see Pharmacology).
- Reassess response; arrange consultation and definitive management.
Clinical Synopsis & Reasoning
Sepsis represents dysregulated host response with life‑threatening organ dysfunction; prioritize rapid recognition using qSOFA/SOFA elements, attention to mentation, perfusion, and lactate trends. Clinically, integrate history for potential sources (pulmonary, urinary, abdominal, device‑related), examine for shock phenotypes, and obtain paired blood cultures without delaying therapy. Point‑of‑care ultrasound refines volume status and source hypotheses (e.g., pneumonia, cholecystitis, obstructive uropathy). Early identification of patients likely to decompensate guides ICU triage and invasive monitoring.
Treatment Strategy & Disposition
Initiate balanced crystalloid resuscitation targeting MAP ≥65 mmHg and improving capillary refill/lactate; start time‑appropriate empiric antibiotics within 60 min tailored to suspected source and local resistance. If hypotension persists after 30 mL/kg or sooner when indicated, begin norepinephrine and titrate to perfusion targets; add vasopressin for catecholamine‑sparing effects. Pursue urgent source control (drainage, device removal, debridement) and de‑escalate antimicrobials with culture data. Disposition hinges on shock and organ failure—ICU for vasopressors/respiratory support; otherwise step‑down/ward with protocolized reassessment.
Management Notes
Reassess with bedside ultrasound for fluid responsiveness. Narrow antibiotics with culture results to reduce resistance.
Epidemiology / Risk Factors
- Varies by presentation; age/comorbidities matter
Investigations
| Test | Role / Rationale | Typical Findings | Notes |
|---|---|---|---|
| CBC/BMP | Baseline labs | Abnormalities | |
| CXR/targeted imaging | Common ED complaints | Findings vary | |
| Troponin/EKG (chest pain) | ACS rule-out | MI changes | Use risk tools |
1‑Hour Bundle
| Item | Target |
|---|---|
| Antibiotics | Start ASAP |
| Cultures | Before antibiotics if no delay |
| Lactate | Measure; repeat if elevated |
| Fluids | 30 mL/kg crystalloid if shock |
| Vasopressors | MAP ≥65 mmHg |
Pharmacology
| Medication | Mechanism | Onset | Role in Therapy | Limitations |
|---|---|---|---|---|
| Balanced crystalloids | Plasma volume expansion | Immediate | Initial resuscitation (e.g., 30 mL/kg) | Fluid overload; monitor oxygenation; ED use |
| Vasopressin (adjunct) | V1 receptor agonist | Minutes | Catecholamine-sparing add-on in refractory shock | Ischemia at high dose; ED use |
| Norepinephrine | α1-adrenergic agonist | Minutes | First-line vasopressor to target MAP ≥65 mmHg | Arrhythmia, ischemia; ED use |
| Hydrocortisone (refractory shock) | Glucocorticoid | Hours | Adjunct in pressor-refractory septic shock | Hyperglycemia, infection risk; ED use |
| Broad empiric antibiotics | Bactericidal (varies) | Variable | Start within 1 hour; de-escalate to source | Allergy, resistance; ED use |
Prognosis / Complications
- Outcomes tied to emergency and timeliness of care
Patient Education / Counseling
- Explain red flags and when to seek emergent care.
- Reinforce medication adherence and follow-up plan.
References
- Surviving Sepsis ED — Link