Sepsis is a potentially life-threatening clinical syndrome in which the body’s immune and coagulation system are activated by an infection. It may be accompanied by the ‘systemic inflammatory response syndrome’ (see below) and lead to septic shock. This guide gives an overview of the recognition and immediate management of sepsis (using an ABCDE approach).
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.
Sepsis: life-threatening organ dysfunction due to a dysregulated host response to infection.
Systemic inflammatory response syndrome (SIRS):
Two or more of the following:
Temperature >38°C or <36°C
Tachycardia: >90 beats per minute
Tachypnoea: >20 breaths per minute) or PCO2 <4.3kPa
WCC >12 or <4 (or >10% immature (band) forms)
Septic shock: sepsis with hypotension that does not respond to adequate fluid resuscitation and/or evidence of end-organ dysfunction or failure (e.g. hypoxaemia, oliguria, lactic acidosis or cerebral hypoperfusion)
I like to remember these by pairing them as take 3 and give 3:
Take blood cultures, give IV antibiotics
Take lactate, give oxygen
Take urine output, give IV fluids
Tips before you begin
Treat all problems as you find them
Re-assess regularly and after every intervention to see if your management is effective
Make use of the team around you to delegate tasks where appropriate – is another clinical member of staff available to help you?
All critically unwell patients should have continuous monitoring equipment attached for accurate observations (e.g. pulse oximetry)
If you need senior input for your patient, call for help early using an appropriate SBARR handover structure (check out the guide here)
Review results (e.g. laboratory investigations) as they become available
Make use of medical school/hospital guidelines and algorithms for managing specific situations such as sepsis
Any medications or fluids will need to be prescribed
Your assessment and management should be documented in the notes (however this should not delay clinical management)
You are likely to see this patient after a brief handover from another member of staff.
Introduce yourself to the patient
Ask the patient how they are feeling
Pay attention to their ability to speak in full sentences (an inability to do this suggests significant respiratory distress)
Perform a quick general inspection of the patient to get a sense of how unwell they are:
Check consciousness level using AVPU
How do they look?
How is their breathing?
What is around the bedside? (look for IV lines, sputum cup, vomit bags etc)
Make sure the patient’s notes, observation chart and prescription chart are on hand (however this should not delay initial clinical assessment and management)
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.
Can the patient talk?
Airway is patent; move on to breathing assessment
Look for signs of airway compromise (e.g. see-saw breathing, use of accessory muscles, diminished breath sounds, added sounds)
Is the patient cyanosed?
Open the mouth and inspect: is there anything obviously compromising the airway (e.g. secretions)?
In any case of airway obstruction, seek immediate expert help from an anaesthetist. You may need the crash team. In the meantime, you can perform some basic airway manoeuvres to help maintain the airway.
Maintain the airway whilst awaiting senior input
1. Perform head tilt, chin lift manoeuvre.
2. If noisy breathing persists try a jaw thrust.
3. If airway still appears compromised use an airway adjunct:
Insert an oropharyngeal airway (Guedel) only if unconscious (as otherwise patient may gag/aspirate)
Alternatively, use a nasopharyngeal airway (better tolerated if the patient is partially conscious)
Respiratory rate: likely to be high (if >20 this fulfils one of the criteria for SIRS)
Oxygen saturations: aim for saturations above 94%
Inspection: look for signs of respiratory distress (e.g. sweating, use of accessory muscles, abdominal breathing) as the chest may be the source of sepsis
Palpation: chest expansion, tracheal deviation
Percussion: dull percussion note with consolidation
Auscultation: throughout both lungs noting air entry, reduced breath sounds, coarse crackles etc
High flow oxygen (15L / min) via a non-rebreather mask (provided patient is not a CO2 retainer)
To assess for evidence of a septic source (e.g. consolidation or effusion)
This investigation is a key component of a full septic work up
Gain IV access to allow administration of antibiotics and fluids (see our guide here)
If sepsis is suspected, broad-spectrum IV antibiotics should be commenced as soon as possible (within 1 hour of presentation), as this has been shown to significantly improve outcome
Antibiotics should be prescribed in keeping with local guidelines
Patient’s with sepsis often have signs of hypovolaemia or shock due to shifts in fluid distribution within the body. As a result, they require IV fluid resuscitation to maintain adequate end-organ perfusion. See our guide to prescribing IV fluids.
Check drug chart for opioids, sedatives, anxiolytics and antihypertensives
Check blood glucose:4.0 – 11.0 mmol/L is normal
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. The crash team may be needed. Be very cautious of a patient not maintaining their own airway if the GCS is reduced.
It may be necessary to fully expose the patient to complete a full assessment. Remember to prioritise patient dignity and conservation of body heat.
Rashes – e.g. the non-blanching petechial rash of meningococcal sepsis
Evidence of wound/surgical site infections
It is essential to continually reassess ABCDE and treat issues as you encounter them. This allows continual reassessment of the response to treatment and early recognition of deterioration.
If the patient does not respond to treatment or deteriorates, critical care input should be involved as soon as possible.
Well done! You’ve stabilised the patient and they’re doing much better. Just a few more things to do…
Take a history
Take a more detailed history of what has happened and how the patient has been. Involve staff or family members as appropriate.
Review the patient’s notes, observations, fluid charts, and any investigation findings. Double check the medications you have just prescribed, and any routine medications the patient is taking.
Document your ABCDE assessment clearly, including examination, observations, investigations, interventions, and patient response/changing condition. Write down any pertinent details from your history-taking.
If a senior doctor hasn’t already been involved, it is important to contact them and make them aware of the unwell patient. As a junior doctor, it would be appropriate to give an SBARR handover outlining your assessment and actions, and to discuss the following:
Are any further assessments or interventions required?
Does the patient need a referral to HDU/ICU?
Should they be referred for a review by a speciality doctor?
Should any changes be implemented to the management of any underlying conditions?
The next team of doctors on shift should be made aware of any patient in their department who has become acutely unwell.