Sepsis post pic

Sepsis | Acute Management | ABCDE

If you'd like to support us and get something great in return, check out our awesome products:


To be the first to know about our latest videos, subscribe to our YouTube channel πŸ™Œ


This guide provides an overview of theΒ recognitionΒ andΒ immediateΒ managementΒ of sepsis using anΒ ABCDEΒ approach.

TheΒ ABCDEΒ approach can be used to perform a systematic assessment of a critically unwell patient. It involves working through the following steps:

  • Airway
  • Breathing
  • Circulation
  • Disability
  • Exposure

Each stage of the ABCDE approach involvesΒ clinicalΒ assessment,Β investigationsΒ andΒ interventions. Problems are addressed as they are identified and the patient is re-assessed regularly to monitor their response to treatment.

This guide has been created to assist students in preparing for emergencyΒ simulationΒ sessionsΒ as part of their training,Β it is not intended to be relied upon for patient care.

You may also be interested in our overview of the ABCDE approach and other emergency management guides.

Background

Clinical features of sepsis

Symptoms

Symptoms of sepsis are often non-specific and may include:

  • Localising symptoms of infection (e.g. productive cough, vomiting, diarrhoea, dysuria)
  • Drowsiness
  • Confusion
  • Dizziness
  • Malaise

Signs

Clinical signs of sepsis may include:

  • Tachycardia
  • Hypotension
  • Tachypnoea
  • Cyanosis
  • Fever/hypothermia
  • Oliguria
  • Non-blanching rash
  • Mottled/ashen appearance

Red flags for sepsis

If one or more of the following red flags are present, the patient should be treated for sepsis.

Breathing

The following red flags may be identified during the breathing part of your assessment:

  • Respiratory rate of β‰₯ 25 breaths per minute
  • Oxygen required to keep SpO2 β‰₯ 92%

Circulation

The following red flags may be identified during the circulation part of your assessment:

  • Heart rate of >130 beats per minute
  • Systolic blood pressure ≀ 90 mmHg (or drop of >40 from normal)
  • Lactate β‰₯2 mmol/l

Disability

The following red flags may be identified during the disability part of your assessment:

  • Responds only to voice or pain or unresponsive (i.e. V, P or U on AVPU scale).
  • Acute confusional state

Exposure

The following red flags may be identified during the exposure part of your assessment:

  • Non-blanching rash
  • Mottled, ashen or cyanotic appearance
  • Urine output less than 0.5 ml/kg/hour

Summary of sepsis management

Sepsis 6

Follow theΒ sepsis 6 care bundle within the first hour of the patient’s presentation:

  • Administer high flow oxygen and maintain SpO2 >94%
  • Take blood cultures
  • Measure serial lactate levels
  • Administer intravenous antibiotics
  • Administer intravenous fluids
  • Monitor urine output
Tip

You can remember the sepsis 6 by thinking of them as ‘taking 3 and giving 3’:

  • Take blood cultures, give IV antibiotics
  • Take lactate, give oxygen
  • Take urine output, give IV fluids

Tips before you begin

GeneralΒ tipsΒ for applying anΒ ABCDEΒ approachΒ in an emergency setting include:

  • Treat all problemsΒ as you discover them.
  • Re-assessΒ regularly and after every intervention to monitor a patient’s response to treatment.
  • Make use of the team around you byΒ delegating tasksΒ where appropriate.
  • All critically unwell patients should haveΒ continuous monitoringΒ equipment attached for accurateΒ observations.
  • Clearly communicate how often would you like the patient’s observations relayed to you by other staff members.
  • If you require senior input,Β call for help earlyΒ using an appropriateΒ SBARR handoverΒ structure.
  • Review resultsΒ as they become availableΒ (e.g.Β laboratory investigations).
  • Make use of your localΒ guidelinesΒ andΒ algorithmsΒ in managing specific scenarios (e.g.Β acute asthma).
  • AnyΒ medicationsΒ orΒ fluidsΒ will need to beΒ prescribedΒ at the time (in some cases you may be able to delegate this to another member of staff).
  • Your assessment and management should beΒ documentedΒ clearly in the notes, however, this shouldΒ not delayΒ initial clinical assessment, investigations and interventions.

Initial steps

Acute scenarios typically begin with aΒ briefΒ handoverΒ from a member of theΒ nursing staffΒ including theΒ patient’s name,Β age,Β backgroundΒ and theΒ reasonΒ theΒ reviewΒ has been requested.

You may be asked to review a patient with sepsis due to fever, hypotension and/or tachycardia.

Introduction

IntroduceΒ yourselfΒ to whoever has requested a review of the patient andΒ listenΒ carefullyΒ to their handover.

Interaction

IntroduceΒ yourselfΒ to theΒ patientΒ including yourΒ nameΒ andΒ role.

AskΒ how the patient is feelingΒ as this may provide some useful information about their currentΒ symptoms.

AnΒ inability to speak in full sentencesΒ indicates significant shortness of breath.

Preparation

Make sure theΒ patient’sΒ notes,Β observationΒ chartΒ andΒ prescriptionΒ chartΒ are easily accessible.

Ask for anotherΒ clinicalΒ memberΒ ofΒ staffΒ toΒ assistΒ you if possible.

If the patient isΒ unconsciousΒ orΒ unresponsive, start theΒ basic life supportΒ (BLS)Β algorithmΒ as per resuscitation guidelines.


Airway

Clinical assessment

Can the patient talk?

Yes: if the patient can talk, their airway is patent and you can move on to the assessment of breathing.

No:

  • Look for signs ofΒ airwayΒ compromise: these include cyanosis, see-saw breathing, use of accessory muscles, diminished breath sounds and added sounds.
  • Open the mouthΒ andΒ inspect: look for anything obstructing the airway such as secretions or a foreign object.

Interventions

Regardless of the underlying cause of airway obstruction, seekΒ immediate expert supportΒ from an anaesthetist and the emergency medical team (often referred to as the β€˜crash team’). In the meantime, you can perform some basic airway manoeuvres to help maintain the airway whilst awaiting senior input.

Head-tilt chin-lift manoeuvre

Open the patient’s airwayΒ using aΒ head-tiltΒ chin-lift manoeuvre:

1.Β Place one hand on the patient’s forehead and the other under the chin.

2.Β Tilt the forehead back whilst lifting the chin forwards to extend the neck.

3.Β Inspect theΒ airwayΒ for obviousΒ obstruction. If an obstruction is visible within the airway, use aΒ fingerΒ sweepΒ orΒ suctionΒ to remove it.

Jaw thrust

If the patient is suspected to have sufferedΒ significantΒ traumaΒ with potential spinal involvement, perform aΒ jaw-thrustΒ rather than a head-tilt chin-lift manoeuvre:

1.Β Identify the angle of the mandible.

2.Β With your index and other fingers placed behind the angle of the mandible, apply steady upwards and forward pressure to lift the mandible.

3.Β Using your thumbs, slightly open the mouth by downward displacement of the chin.

Oropharyngeal airway (Guedel)

Airway adjuncts are often helpful and in some cases essential to maintain a patient’s airway. They should be used in conjunction with the maneuvres mentioned above as the position of the head and neck need to be maintained to keep the airway aligned.

An oropharyngeal airway is a curved plastic tube with a flange on one end that sits between the tongue and hard palate to relieve soft palate obstruction. It should only be inserted in unconscious patients as it is otherwise poorly tolerated and may induce gagging and aspiration.

ToΒ insertΒ anΒ oropharyngealΒ airway:

1.Β Open the patient’s mouth to ensure there is no foreign material that may be pushed into the larynx. If foreign material is present, attempt removal using suction.

2.Β Insert the oropharyngeal airway in the upside-down position until you reach the junction of the hard and soft palate, at which point you should rotate it 180Β°. The reason for inserting the airway upside down initially is to reduce the risk of pushing the tongue backwards and worsening airway obstruction.

3.Β Advance the airway until it lies within the pharynx.

4.Β Maintain head-tilt chin-lift or jaw thrust and assess the patency of the patient’s airway by looking, listening and feeling for signs of breathing.

Nasopharyngeal airway (NPA)

A nasopharyngeal airway is a soft plastic tube with a bevel at one end and a flange at the other. NPAs are typically better tolerated in patients who are partly or fully conscious compared to oropharyngeal airways. NPAs should not be used in patients who may have sustained a skull base fracture, due to the small but life-threatening risk of entering the cranial vault with the NPA.

To insert a nasopharyngeal airway:

1.Β Check the patency of the patient’s right nostril and if required (depending on the model of NPA) insert a safety pin through the flange of the NPA.

2.Β Lubricate the NPA.

3.Β Insert the airway bevel-end first, vertically along the floor of the nose with a slight twisting action.

4.Β If any obstruction is encountered, remove the tube and try the left nostril.

Other interventions

If the patient has clinical signs ofΒ anaphylaxisΒ (e.g. angioedema, rash) commence appropriate treatment as discussed in ourΒ anaphylaxis guide.

CPR

If the patientΒ loses consciousnessΒ and there areΒ no signs of lifeΒ on assessment, put out aΒ crash callΒ andΒ commence CPR.

Re-assessment

Make sure toΒ re-assessΒ the patient after anyΒ intervention.


Breathing

Clinical assessment

Observations

Review the patient’sΒ respiratoryΒ rate:

  • AΒ normalΒ respiratory rate is betweenΒ 12-20 breaths per minute.
  • Tachypnoea is a common feature of sepsis (either due to metabolic acidosis or primary respiratory tract infection).

Review the patient’sΒ oxygen saturationΒ (SpO2):

  • AΒ normal SpO2Β rangeΒ isΒ 94-98%Β in healthy individuals andΒ 88-92%Β in patients withΒ COPDΒ who are at high-risk ofΒ CO2Β retention.
  • Hypoxaemia is a red flag for sepsis.

See our guide to performingΒ observations/vital signsΒ for more details.

Inspection

Inspect the patientΒ from the end of the bed:

  • Cyanosis:Β bluish discolouration of the skin due to poor circulation or inadequate oxygenation of the blood.
  • Shortness of breath:Β signs may include nasal flaring, pursed lips, use of accessory muscles, intercostal muscle recession and the tripod position.
  • Cough: a productive cough with purulent sputum may indicate a chest source of sepsis.

Palpation

Locate theΒ apex beat, which is typically located in theΒ 5th intercostal spaceΒ in theΒ midclavicular line. A largeΒ pleural effusion,Β tension pneumothoraxΒ orΒ right ventricular hypertrophyΒ can cause a displaced apex beat.

AssessΒ chest expansion, which may beΒ reducedΒ in the context ofΒ consolidationΒ andΒ pleural effusion.

Auscultation

AuscultateΒ both lungs:

  • Bronchial breath soundsΒ and/orΒ coarse cracklesΒ are associated with consolidation.

Percussion

PercussΒ the patient’s chest to identify areas ofΒ dullnessΒ which may be associated withΒ consolidation,Β lobarΒ collapseΒ orΒ pleuralΒ effusion.

Investigations

Arterial blood gas

Take anΒ ABGΒ ifΒ indicatedΒ (e.g. low SpO2) to quantify the degree of hypoxia.

Chest X-ray

A chest X-ray is a useful investigation when considering the chest as a source of sepsis and may identify evidence of consolidation. A chest X-ray should not delay the emergency management of sepsis (e.g. the sepsis 6).

See ourΒ CXR interpretation guideΒ for more details.

Sputum culture

Ask the nursing staff to obtain aΒ sputum sampleΒ to be sent to the microbiology lab for culture and sensitivity.

This information can be useful later to understand theΒ causative organismΒ and itsΒ antibiotic sensitivities.

Interventions

Oxygen

Administer oxygen to all critically unwell patients during yourΒ initialΒ assessment. This typically involves the use of aΒ non-rebreathe maskΒ with an oxygen flow rate ofΒ 15L. If the patient has COPD and a history of CO2Β retention you should switch to aΒ venturi maskΒ as soon as possible andΒ titrate oxygen appropriately.

If the patient is conscious, sit themΒ uprightΒ as this can also help with oxygenation.

CPR

If the patient loses consciousness and there are no signs of life on assessment, put out a crash call and commence CPR.

Re-assessment

Make sure to re-assess the patient after any intervention.


Circulation

Clinical assessment

Pulse

Tachycardia is a common feature of sepsis.

A heart rate >130 beats per minute is considered a red flag for sepsis.

Blood pressure

Hypotension is also a common clinical feature of sepsis.

A systolic blood pressure of less than or equal to 90 mmHg or a drop of greater than 40 mmHg from the patient’s normal blood pressure are considered red flags for sepsis.

Capillary refill time

Capillary refill timeΒ may be prolonged in the context ofΒ sepsis.

Cardiac auscultation

Auscultate the patient’s praecordium to assess heart sounds: a new murmur may indicate a diagnosis of infective endocarditis.

Fluid balance assessment

Calculate the patient’s fluid balance:

  • Calculate the patient’s current fluid balance using their fluid balance chart (e.g. oral fluids, intravenous fluids, urine output, drain output, stool output, vomiting) to inform resuscitation efforts.
  • Reduced urine output (oliguria) is typically defined as less than 0.5ml/kg/hour in an adult and is a red flag for sepsis.

Patients with sepsis are typically intravascularly depleted due to third space fluid loss.

Investigations and procedures

Intravenous cannulation

Insert at least oneΒ wide-bore intravenous cannulaΒ (14G or 16G) and take blood tests as discussed below.

See ourΒ intravenous cannulation guideΒ for more details.

Blood tests

CollectΒ blood testsΒ after cannulating the patient including:

  • FBC: to rule out anaemia and to look for a raised white cell count which is typical of sepsis.
  • U&Es: to assess renal function which may be impaired secondary to pre-renal acute kidney injury (e.g. hypovolaemia).
  • CRP: typically elevated in the context of sepsis.
  • Serial lactates: to assess for evidence of reduced end-organ perfusion (a lactate β‰₯2 mmol/l is a red flag for sepsis) and response to treatment.
  • Coagulation studies: to assess for evidence of disseminated intravascular coagulation which can develop in the context of sepsis.
  • Blood cultures: to isolate the causative organism and part of the sepsis 6 pathway. Ideally, blood cultures should be taken before the administration of antibiotics, however, they should not delay treatment.

Venous blood gas

A venous blood gas can provide results much more quickly than standard blood tests which can be used to inform diagnosis and management:

  • Serum glucose level
  • Lactate

Interventions

Antibiotics

If sepsis is suspected, broad-spectrum IV antibiotics should be administeredΒ as soon as possible (ideally within 1 hour of presentation), as this has been shown to significantly improve patient outcomes.

Antibiotics should be prescribed in keeping with local guidelines.

Intravenous fluids

Patient’s with sepsis often have signs of hypovolaemia due to shifts in fluid distribution within the body.

Hypovolaemic patients requireΒ fluidΒ resuscitation:

  • Administer a 500ml bolus Hartmann’s solution or 0.9% sodium chloride (warmed if available) over 15 mins.
  • Administer 250ml boluses in patients at increased risk of fluid overload (e.g. heart failure).

After each fluid bolus,Β reassessΒ for clinical evidence of fluid overload (e.g. auscultation of the lungs, assessment of JVP).

Repeat administrationΒ of fluid boluses up toΒ four timesΒ (e.g. 2000ml or 1000ml in patients at increased risk of fluid overload), reassessing the patient each time.

Seek senior input if the patient has a negative response (e.g. increased chest crackles) or if the patient isn’t responding adequately to repeated boluses (i.e. persistent hypotension).

See ourΒ fluid prescribing guideΒ for more details onΒ resuscitation fluids.

ECG

If the patient is tachycardic, an ECG should be performed to rule out arrhythmia (e.g. atrial fibrillation with rapid ventricular response).

CPR

If the patient loses consciousness and there are no signs of life on assessment, put out a crash call and commence CPR.

Re-assessment

Make sure to re-assess the patient after any intervention.


Disability

Clinical assessment

Consciousness

In the context of sepsis, a patient’s consciousness level may be reduced secondary to hypovolaemia, infection or hypoxia.

Assess the patient’s level of consciousness using the AVPU scale:

  • Alert: the patient is fully alert, although not necessarily orientated.
  • Verbal: the patient makes some kind of response when you talk to them (e.g. words, grunt).
  • Pain: the patient responds to a painful stimulus (e.g. supraorbital pressure).
  • Unresponsive: the patient does not show evidence of any eye, voice or motor responses to pain.

Red flags for sepsis include:

  • The patient only responding to voice/pain or the patient being unresponsive (i.e. V, P or U on AVPU scale).
  • The patient developing an acute confusional state.

If a more detailed assessment of the patient’s level of consciousness is required, use the Glasgow Coma Scale (GCS).

Pupils

Assess the patient’s pupils:

  • Inspect the size and symmetry of the patient’s pupils. Asymmetrical pupillary size may indicate intracerebral pathology (e.g. cerebral abscess).
  • Assess direct and consensual pupillary responses which may reveal evidence of intracranial pathology (e.g. cerebral abscess).

Drug chart review

Review the patient’s drug chart for medications which may cause neurological abnormalities (e.g. opioids, sedatives, anxiolytics).

Investigations

Blood glucose and ketones

Measure the patient’s capillary blood glucose level to screen for causes of a reduced level of consciousness (e.g. hypoglycaemia or hyperglycaemia).Β 

A blood glucose level may already be available from earlier investigations (e.g. ABG, venepuncture).

TheΒ normalΒ reference rangeΒ for fasting plasma glucose isΒ 4.0 – 5.8 mmol/l.

HypoglycaemiaΒ is defined as a plasma glucose ofΒ less thanΒ 3.0 mmol/l. InΒ hospitalised patients, a blood glucose ≀4.0 mmol/LΒ should be treated if the patient isΒ symptomatic.

If the blood glucose is elevated, check ketone levels which if also elevated may suggest a diagnosis of diabetic ketoacidosis (DKA).

See our blood glucose measurement, hypoglycaemia and diabetic ketoacidosis guides for more details.

Imaging

Request a CT head if intracranial pathology is suspected after discussion with a senior.

See our guide on interpreting aΒ CT head for more details.

Interventions

Maintain the airway

Alert a senior immediately if you have any concerns about the consciousness level of a patient. A GCS of 8 or below warrants urgent expert help from an anaesthetist. In the meantime, you should re-assess and maintain the patient’s airway as explained in the airway section of this guide.

CPR

If the patient loses consciousness and there are no signs of life on assessment, put out a crash call and commence CPR.

Re-assessment

Make sure to re-assess the patient after any intervention.


Exposure

It may be necessary to expose the patient during your assessment: remember to prioritise patient dignity and conservation of body heat.Β 

Clinical assessment

Begin by asking the patient if they have pain anywhere, which may be helpful to guide your assessment.

Inspection

Inspect the patient’s skin for evidence of a non-blanching rash or a mottled, ashen or cyanotic appearance (all red flags for sepsis).

Review the output of the patient’s catheter and any surgical drains.

Inspect any wounds for evidence of infection (e.g. erythema, purulent discharge).

Temperature

Measure the patient’s temperature, if not already known: sepsis can present with pyrexia or hypothermia.

Investigations and procedures

Urinalysis

Perform urinalysis to screen for possible urosepsis and send for culture.

See ourΒ urinalysis guideΒ for more details.

Interventions

Catheterisation

Catheterise the patient to closely monitor urine output to guide fluid resuscitation and need for escalation.

CPR

If the patient loses consciousness and there are no signs of life on assessment, put out a crash call and commence CPR.

Re-assessment

Make sure to re-assess the patient after any intervention.


Reassess ABCDE

Re-assessΒ the patient using theΒ ABCDE approachΒ to identify any changes in their clinical condition and assess the effectiveness of your previous interventions.

DeteriorationΒ should be recognised quickly and acted upon immediately.

Seek senior helpΒ if the patient shows no signs of improvement or if you have any concerns.

Support

You should have another member of the clinical team aiding you in your ABCDE assessment, such a nurse, who can perform observations, take samples to the lab and catheterise if appropriate.

You may need further help or advice from a senior staff member and you shouldΒ not delay seeking help if you have concerns about your patient.

Use an effectiveΒ SBARR handoverΒ to communicate the key information effectively to other medical staff.


Next steps

Well done, you’ve now stabilised the patient and they’re doing much better. There are just a few more things to do…

Take a history

Revisit history taking to explore relevant medical history. If the patient is confused you might be able to get a collateral history from staff or family members as appropriate.

See ourΒ history taking guidesΒ for more details.

Review

Review theΒ patient’s notes,Β chartsΒ andΒ recent investigation results.

Review the patient’sΒ current medicationsΒ and check any regular medications areΒ prescribed appropriately.

Document

ClearlyΒ document your ABCDE assessment, including history, examination, observations, investigations, interventions, and the patient’s response.

See ourΒ documentation guidesΒ for more details.

Discuss

Discuss the patient’s current clinical condition with aΒ seniorΒ clinicianΒ using anΒ SBARRΒ style handover.

QuestionsΒ which may need to be considered include:

  • Are any further assessments or interventions required?
  • Does the patient need a referral toΒ HDU/ICU?
  • Does the patient need reviewing by a specialist?
  • Should any changes be made to the current management of their underlying condition(s)?

Handover

The next team of doctors on shift should beΒ made awareΒ of any patient in their department who hasΒ recently deteriorated.


References

  1. NICE guideline. Sepsis: recognition, diagnosis and early management. Published September 2017. Available from: [LINK].
  2. UK Sepsis Trust. Clinical Tools: Sepsis 6. Available from: [LINK].

 

Print Friendly, PDF & Email