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This guide provides an overview of the recognition and immediate management of sepsis using an ABCDE approach.
The ABCDE 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 involves clinical assessment, investigations and 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 emergency simulation sessions as part of their training, it is not intended to be relied upon for patient care.
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 ≥ 25 breaths per minute
- Oxygen required to keep SpO2 ≥ 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 ≥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 the 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
General tips for applying an ABCDE approach in an emergency setting include:
- Treat all problems as you discover them.
- Re-assess regularly and after every intervention to monitor a patient’s response to treatment.
- Make use of the team around you by delegating tasks where appropriate.
- All critically unwell patients should have continuous monitoring equipment attached for accurate observations.
- Clearly communicate how often would you like the patient’s observations relayed to you by other staff members.
- If you require senior input, call for help early using an appropriate SBARR handover structure.
- Review results as they become available (e.g. laboratory investigations).
- Make use of your local guidelines and algorithms in managing specific scenarios (e.g. acute asthma).
- Any medications or fluids will need to be prescribed at the time (in some cases you may be able to delegate this to another member of staff).
- Your assessment and management should be documented clearly in the notes, however, this should not delay initial clinical assessment, investigations and interventions.
Initial steps
Acute scenarios typically begin with a brief handover from a member of the nursing staff including the patient’s name, age, background and the reason the review has been requested.
You may be asked to review a patient with sepsis due to fever, hypotension and/or tachycardia.
Introduction
Introduce yourself to whoever has requested a review of the patient and listen carefully to their handover.
Interaction
Introduce yourself to the patient including your name and role.
Ask how the patient is feeling as this may provide some useful information about their current symptoms.
An inability to speak in full sentences indicates significant shortness of breath.
Preparation
Make sure the patient’s notes, observation chart and prescription chart are easily accessible.
Ask for another clinical member of staff to assist you if possible.
If the patient is unconscious or unresponsive, start the basic life support (BLS) algorithm 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 of airway compromise: these include cyanosis, see-saw breathing, use of accessory muscles, diminished breath sounds and added sounds.
- Open the mouth and inspect: look for anything obstructing the airway such as secretions or a foreign object.
Interventions
Regardless of the underlying cause of airway obstruction, seek immediate expert support from an anaesthetist and the emergency medical team (often referred to as the ‘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 airway using a head-tilt chin-lift manoeuvre:
1. Place one hand on the patient’s forehead and the other under the chin.
2. Tilt the forehead back whilst lifting the chin forwards to extend the neck.
3. Inspect the airway for obvious obstruction. If an obstruction is visible within the airway, use a finger sweep or suction to remove it.
Jaw thrust
If the patient is suspected to have suffered significant trauma with potential spinal involvement, perform a jaw-thrust rather than a head-tilt chin-lift manoeuvre:
1. Identify the angle of the mandible.
2. With your index and other fingers placed behind the angle of the mandible, apply steady upwards and forward pressure to lift the mandible.
3. 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.
To insert an oropharyngeal airway:
1. 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. 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 180°. The reason for inserting the airway upside down initially is to reduce the risk of pushing the tongue backwards and worsening airway obstruction.
3. Advance the airway until it lies within the pharynx.
4. 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. 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. Lubricate the NPA.
3. Insert the airway bevel-end first, vertically along the floor of the nose with a slight twisting action.
4. If any obstruction is encountered, remove the tube and try the left nostril.
Other interventions
If the patient has clinical signs of anaphylaxis (e.g. angioedema, rash) commence appropriate treatment as discussed in our anaphylaxis 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.
Breathing
Clinical assessment
Observations
Review the patient’s respiratory rate:
- A normal respiratory rate is between 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’s oxygen saturation (SpO2):
- A normal SpO2 range is 94-98% in healthy individuals and 88-92% in patients with COPD who are at high-risk of CO2 retention.
- Hypoxaemia is a red flag for sepsis.
See our guide to performing observations/vital signs for more details.
Inspection
Inspect the patient from the end of the bed:
- Cyanosis: bluish discolouration of the skin due to poor circulation or inadequate oxygenation of the blood.
- Shortness of breath: 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 the apex beat, which is typically located in the 5th intercostal space in the midclavicular line. A large pleural effusion, tension pneumothorax or right ventricular hypertrophy can cause a displaced apex beat.
Assess chest expansion, which may be reduced in the context of consolidation and pleural effusion.
Auscultation
Auscultate both lungs:
- Bronchial breath sounds and/or coarse crackles are associated with consolidation.
Percussion
Percuss the patient’s chest to identify areas of dullness which may be associated with consolidation, lobar collapse or pleural effusion.
Investigations
Arterial blood gas
Take an ABG if indicated (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 our CXR interpretation guide for more details.
Sputum culture
Ask the nursing staff to obtain a sputum sample to be sent to the microbiology lab for culture and sensitivity.
This information can be useful later to understand the causative organism and its antibiotic sensitivities.
Interventions
Oxygen
Administer oxygen to all critically unwell patients during your initial assessment. This typically involves the use of a non-rebreathe mask with an oxygen flow rate of 15L. If the patient has COPD and a history of CO2 retention you should switch to a venturi mask as soon as possible and titrate oxygen appropriately.
If the patient is conscious, sit them upright 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 time may be prolonged in the context of 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 one wide-bore intravenous cannula (14G or 16G) and take blood tests as discussed below.
See our intravenous cannulation guide for more details.
Blood tests
Collect blood tests 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 ≥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 administered 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 require fluid 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, reassess for clinical evidence of fluid overload (e.g. auscultation of the lungs, assessment of JVP).
Repeat administration of fluid boluses up to four times (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 our fluid prescribing guide for more details on 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). The normal reference range for capillary blood glucose is 4.0-11.0 mmol/L.
A blood glucose level may already be available from earlier investigations (e.g. ABG, venepuncture).
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 a 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.
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 our urinalysis guide 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-assess the patient using the ABCDE approach to identify any changes in their clinical condition and assess the effectiveness of your previous interventions.
Deterioration should be recognised quickly and acted upon immediately.
Seek senior help 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 should not delay seeking help if you have concerns about your patient.
Use an effective SBARR handover 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 our history taking guides for more details.
Review
Review the patient’s notes, charts and recent investigation results.
Review the patient’s current medications and check any regular medications are prescribed appropriately.
Document
Clearly document your ABCDE assessment, including history, examination, observations, investigations, interventions, and the patient’s response.
See our documentation guides for more details.
Discuss
Discuss the patient’s current clinical condition with a senior clinician using an SBARR style handover.
Questions which may need to be considered include:
- Are any further assessments or interventions required?
- Does the patient need a referral to 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 be made aware of any patient in their department who has recently deteriorated.
References
- NICE guideline. Sepsis: recognition, diagnosis and early management. Published September 2017. Available from: [LINK].
- UK Sepsis Trust. Clinical Tools: Sepsis 6. Available from: [LINK].
