Sepsis | Acute Management | ABCDE

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This guide provides an overview of the recognition and immediate management of sepsis using an ABCDE approach.

The ABCDE approach is used to systematically assess an acutely 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 healthcare students in preparing for emergency simulation sessions as part of their training. It is not intended to be relied upon for patient care.

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Background

Sepsis is defined as “life-threatening organ dysfunction due to a dysregulated host response to infection”. Sepsis is a life-threatening condition associated with high mortality. 

Clinical features of sepsis

Clinical features of sepsis are highly variable and will vary depending on the underlying source of infection (e.g. pneumonia, urinary tract infection, cellulitis). There may be localising symptoms of infection (e.g. productive cough or dysuria) or systemic symptoms of the dysregulated host response (e.g. drowsiness/confusion due to profound hypotension causing cerebral hypoperfusion).

Symptoms

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

• 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

The UK Sepsis Trust have produced a sepsis screening tool to help identify patients with sepsis. The tool should be started in patients who look unwell or have an elevated NEWS score (>5). 

If one or more red flags are present, the patient is at high risk of deterioration and should be treated for sepsis.

History

A history of recent chemotherapy is a red flag for sepsis due to the risk of neutropenia. 

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
• 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:

• Objective evidence of new or altered mental 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 (if catheterised), or not passed urine in 18 hours

Sepsis six

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

• Ensure senior clinician attends
• Administer high-flow oxygen if SpO₂ <92%
• IV access & blood tests (blood cultures, lactate, FBC, U&E, CRP)
• Administer broad-spectrum intravenous antibiotics and consider source control
• Administer intravenous fluids
• Monitor urine output and lactate

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Tips before you begin

General tips for applying an ABCDE approach in an emergency setting include:

• Treat problems as you discover them and re-assess after every intervention
• Remember to assess the front and back of the patient when carrying out your assessment (e.g. looking underneath the patient’s legs or at their back for non-blanching rashes or bleeding)
• If the patient loses consciousness and there are no signs of life, put out a crash call and commence CPR
• Make use of the team around you by delegating tasks where appropriate
• All critically unwell patients should have continuous monitoring equipment attached
• If you require senior input, call for help early using an appropriate SBAR handover
• Review results as they become available (e.g. laboratory investigations)
• Use local guidelines and algorithms to manage specific scenarios (e.g. acute asthma)
• Any medications or fluids must be prescribed at the time (you may be able to delegate this to another staff member)
• Your assessment and management should be documented clearly in the notes; however, this should not delay management

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Initial steps

Acute scenarios typically begin with a brief handover, 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.

Preparation

Ensure the patient’s notes, observation chart, and prescription chart are easily accessible.

Ask for another clinical member of staff to assist you if possible.

Interaction

Introduce yourself to the patient, including your name and role.

Ask how the patient is feeling, as this may provide useful information about their current condition.

If the patient is unconscious or unresponsive, and there are no signs of life, start the basic life support (BLS) algorithm as per resuscitation guidelines.

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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: angioedema, cyanosis, see-saw breathing, use of accessory muscles
• Listen for abnormal airway noises: stridor, snoring, gurgling
• 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 called the ‘crash team’). You can perform 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 try and remove it. Be careful not to push it further into the airway.

Jaw thrust

If the patient is suspected of having 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. Place two fingers under the angle of the mandible (on both sides) and anchor your thumbs on the patient’s cheeks
3. Lift the mandible forwards

Other interventions

Airway adjuncts are helpful and, in some cases, essential to maintain a patient’s airway. They should be used in conjunction with the manoeuvres mentioned above.

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 may induce gagging and aspiration in semi-conscious patients. 

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 partly or fully conscious patients than oropharyngeal airways.

Re-assessment

Re-assess the patient after any intervention.

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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 at high risk of CO₂ retention
• Hypoxaemia is a red flag for sepsis

See our guide to performing observations/vital signs for more details.

General inspection

Inspect the patient from the end of the bed:

• Cyanosis: bluish discolouration of the skin due to poor circulation or inadequate oxygenation
• 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

Tracheal position

Gently assess the position of the trachea, which should be central in healthy individuals:

• The trachea deviates away from tension pneumothorax and large pleural effusions
• The trachea deviates towards lobar collapse and pneumonectomy

Palpation of the trachea can be uncomfortable, so warn the patient and be gentle. 

Palpation

Assess chest expansion, which may be reduced in respiratory conditions such as pleural effusion.

Percussion of the chest

Percuss the patient’s chest to identify areas of dullness which may be associated with consolidation, lobar collapse or pleural effusion.

Auscultation

Auscultate the patient’s chest and identify any abnormalities such as:

• Bronchial breathing: harsh-sounding (similar to auscultating over the trachea), inspiration and expiration are equal, and there is a pause between. This type of breath sound is associated with consolidation.
• Coarse crackles: discontinuous, brief, popping lung sounds typically associated with consolidation.

Investigations

Arterial blood gas

Take an ABG if indicated (e.g. low SpO₂) to quantify the degree of hypoxia and help determine the potential underlying cause. 

Chest X-ray

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

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 using 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 (guided by ABG results) and titrate oxygen appropriately.

Re-assessment

Re-assess the patient after any intervention.

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Circulation

Clinical assessment

Pulse

Tachycardia is a common feature of sepsis.

A heart rate >130 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.

Auscultation

In an acute situation, cardiac auscultation should be brief and focused on identifying acute cardiovascular conditions:

• A murmur of recent onset may suggest endocarditis

Fluid balance assessment

To determine the patient’s fluid balance:

• Review 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
• Assess the patient’s jugular venous pressure (JVP)
• Check the patient’s legs for peripheral pitting oedema (start at the ankles and assess the limbs proximally)

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

Patients with clinical features of fluid overload (e.g. significant peripheral pitting oedema) will likely need senior input to guide fluid resuscitation.

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

Request a full blood count (FBC), urea & electrolytes (U&E) and liver function tests (LFTs) for all acutely unwell patients. In the context of sepsis, also request:

• CRP: typically elevated in the context of sepsis
• Serial lactates: to assess for evidence of reduced end-organ perfusion (lactate ≥2 mmol/l is a red flag for sepsis) and response to treatment (a venous blood gas can provide a rapid lactate level)
• Coagulation studies: to assess for evidence of disseminated intravascular coagulation that can develop in sepsis.
• Blood cultures: to isolate the causative organism and part of the sepsis six 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 rapidly provide results to guide management:

• pH
• Serum glucose level
• Lactate

ECG

Record a 12-lead ECG if appropriate (e.g. tachycardia, irregular pulse).

Consider continuous cardiac monitoring for critically unwell patients.

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 improve patient outcomes significantly.

Antibiotics should be prescribed according to local microbiology guidelines and consider any patient allergies. 

Fluid resuscitation

Patients 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 less than 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 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).

Re-assessment

Re-assess the patient after any intervention.

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Disability

Clinical assessment

Consciousness

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

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

• Alert: the patient is fully alert
• Confusion: the patient has new onset confusion or worse confusion than usual
• 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:

• 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).

Brief neurological assessment

Perform a brief neurological assessment by asking the patient to move their limbs. 

If a patient cannot move one or all of their limbs, this may be a sign of focal neurological impairment, which requires a more detailed assessment.

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). 

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

The normal reference range for fasting plasma glucose is 4.0 – 5.8 mmol/l.

Hypoglycaemia is defined as a plasma glucose of less than 3.0 mmol/l. In hospitalised patients, a blood glucose ≤4.0 mmol/L should be treated if the patient is 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 clinician. 

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

Interventions

Maintain the airway

Alert a senior clinician immediately if you have concerns about a patient’s consciousness level.

A GCS of 8 or below, or a P or U on the ACVPU scale, 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.

Correct hypoglycaemia

Hypoglycaemia should always be considered in patients presenting with a reduced level of consciousness, regardless of whether they have diabetes. The management of hypoglycaemia involves the administration of glucose (e.g. oral or intravenous).

Re-assessment

Re-assess the patient after any intervention.

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Exposure

Exposing the patient during your assessment may be necessary. Remember to prioritise patient dignity and the 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). Also, inspect for any signs of infection (e.g. cellulitis, abscess). 

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

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

Palpation

Briefly palpate the abdomen for signs of peritonism or tenderness. 

Palpate the calves for tenderness which may suggest a deep vein thrombosis.

Temperature

Review the patient’s body temperature:

• A normal body temperature range is between 36°c – 37.9°c
• Sepsis can present with pyrexia or hypothermia.

Investigations and procedures

Urinalysis

Perform urinalysis to screen for possible urinary tract infection and send for culture.

See our urinalysis guide for more details.

Cultures/swabs

Ask the nursing staff to take relevant swabs/samples of any potential infection source (e.g. line tip culture).

Interventions

Catheterisation

Catheterise the patient to monitor urine output to guide fluid resuscitation closely.

Re-assessment

Re-assess the patient after any intervention.

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Re-assessment and escalation

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

Any clinical 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.

Escalation

Haemodynamically unstable patients with sepsis will require urgent critical care input.

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Next steps

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.

Discuss

Discuss the patient’s clinical condition with a senior clinician using an SBAR 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)?

The next team of clinicians on shift should be informed of any acutely unwell patient.

Document

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

The ABCDE approach can also form the structure for documenting your assessment.

See our documentation guides for more details.

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Reviewer

Dr Leah Williams

Doctor

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Editor

Dr Chris Jefferies

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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].

Image references

• Figure 1 and Figure 2. Reproduced with the kind permission of the UK Sepsis Trust. Available from: [LINK]

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