POINTS & PEARLS
A Quick-Read Review Of Key Points & Clinical Pearls, October 2018
Updates and Controversies in the Early
Management of Sepsis and Septic Shock
Points
• Sepsis is a life-threatening organ dysfunction
caused by a dysregulated host response to infection.
• Sepsis is the most expensive cause of hospitalization.
• The systemic inflammatory respiratory syndrome
(SIRS) criteria have poor sensitivity and specificity
for identifying sepsis.
• Sepsis-3 proposed a new bedside assessment tool
called qSOFA (quick systemic organ failure assess-
ment). qSOFA has 3 components: (1) respiratory
rate > 22 breaths/min, (2) altered mental status, and
(3) systemic blood pressure (SBP) ≤ 100 mm Hg.
Having 2 or more criteria in the correct clinical set-
ting is suggestive of sepsis.
• For a patient with a qSOFA score < 2, a full SOFA
score can be calculated to assess for sepsis and
organ dysfunction.
• For presumed septic patients, prehospital IV fluids
has been associated with shorter hospital stays, but
has not been associated with improved mortality.
• Lactate levels should be remeasured until there is a
reasonable trend toward improvement.
• For patients requiring multiple vasopressors to
achieve stability, corticosteroids may be beneficial.
• Current CMS and Surviving Sepsis Guidelines
recommend the following for initial management of
sepsis and septic shock.
In the first 3 hours:
l
Measure serum lactate
l
Obtain 2 sets of blood cultures (prior to antibi-
otic administration, if possible)
l
Administer appropriate IV antibiotics
l
Give IV fluid challenge (30 mL/kg if hypoten-
sive or lactate > 4 mmol/L)
In the first 6 hours:
l
Administer vasopressors for mean arterial pres-
sure (MAP) > 65 mm Hg
l
Reassess volume status and tissue perfusion
l
Remeasure lactate if initial lactate > 2 mmol/L
• Peripheral infusion of catecholamine vasopressors
may be safe for brief periods, while central access
is established. Vasopressin should be administered
October 2018 • Emergency Medicine Practice
Pearls
Under Sepsis-3 guidelines, septic shock has
been redefined as hypoperfusion not respon-
sive to IV fluid resuscitation, with the added
requirement of vasopressors to maintain a
MAP ≥ 65 mm Hg and a lactate > 2 mmol/L.
The current CMS SEP-1 quality measure,
which is used for institutional sepsis bundle
compliance, has not adopted Sepsis-3. It is
important to know both guidelines.
Cardiac output and fluid status can be evaluat-
ed rapidly with bedside ultrasound in the ED.
Norepinephrine is the first-line vasopressor for
septic shock.
only centrally.
• Blood transfusion is not routinely recommended
in sepsis management, unless the hemoglobin is
≤ 7 g/dL, there is obvious blood loss, or there are
other special circumstances.
• Consider ketamine over etomidate for endotra-
cheal intubation of septic patients, given concern
for adrenal suppression with etomidate.
Issue Author
Faheem Guirgis, MD, FACEP
Associate Professor of Emergency Medicine, University of Florida College of
Medicine-Jacksonville, Jacksonville, FL
Lauren Page Black, MD, MPH
Research Fellow, Department of Emergency Medicine, University of Florida
College of Medicine-Jacksonville, Jacksonville, FL
Elizabeth L. DeVos, MD, MPH, FACEP
Associate Professor, Department of Emergency Medicine, University of
Florida College of Medicine-Jacksonville, Jacksonville, FL
Points & Pearls Contributors
Nachi Gupta, MD, PhD
Department of Emergency Medicine, Icahn School of Medicine at Mount
Sinai, New York, NY
Jeffrey Nusbaum, MD
EMS Fellow, University of Pittsburgh Medical Center, Pittsburgh, PA
1 Copyright © 2018 EB Medicine. All rights reserved.
 Table 5. Historical and Physical Examination Most Important References
Findings Concerning for Sepsis
Historical Findings 1. Singer M, Deutschman CS, Seymour CW, et al. The Third In-
Clinical history Allergies, chronic illness, recent antibiotic use, ternational Consensus definitions for sepsis and septic shock
surgery or procedures, corticosteroid use, HIV (Sepsis-3). JAMA. 2016;315(8):801-801. (Policy)
DOI: http://dx.doi.org/10.1001/jama.2016.0287
or other immune compromise, recent hospital-
3. Mouncey PR, Osborn TM, Power GS, et al. Trial of early,
ization or long-term care residence, indwelling
goal-directed resuscitation for septic shock. N Engl J Med.
devices, intravenous drug use 2015;372(14):1301-1311. (Randomized clinical trial; 1260
Review of systems Fever; headache; confusion; neck pain; cough, patients) DOI: http://dx.doi.org/10.1056/NEJMoa1500896
shortness of breath; abdominal pain; back pain; 12. Seymour CW, Liu VX, Iwashyna TJ, et al. Assessment of
flank pain; dysuria, urinary frequency, hematuria; clinical criteria for sepsis: for the third International Consen-
extremity pain, rash, warmth sus definitions for sepsis and septic shock (Sepsis-3). JAMA.
2016;315(8):762-774. (Retrospective; 706,399 patients)
Physical Examination Components to
DOI: http://dx.doi.org/10.1001/jama.2016.0288
Assess for Occult Infection 70. Pandharipande PP, Shintani AK, Hagerman HE, et al. Deri-
Body System Finding vation and validation of SpO2/FiO2 ratio to impute for PaO2/
Central nervous Altered mental status, seizure
FiO2 ratio in the respiratory component of the sequential or-
gan failure assessment score. Crit Care Med. 2009;37(4):1317-
system
1321. (Prospective observational; 2986 patients)
Head and neck Airway, oropharyngeal infection, scalp, ears, cer- DOI: http://dx.doi.org/10.1097/CCM.0b013e31819cefa9
vical soft tissue, lymphadenopathy, neck mobility 73. Jones AE, Shapiro NI, Trzeciak S, et al. Lactate clearance vs
Heart New murmurs, rubs, distant heart sounds, central venous oxygen saturation as goals of early sepsis
crackles therapy: a randomized clinical trial. JAMA. 2010;303(8):739-
746. (Clinical trial; 300 patients)
Lung Rhonchi, rales, reduced breath sounds DOI: http://dx.doi.org/10.1001/jama.2010.158
Abdomen Focal tenderness, guarding, rebound, fluid wave, 104. Puskarich MA, Trzeciak S, Shapiro NI, et al. Association be-
organomegaly, oliguria tween timing of antibiotic administration and mortality from
septic shock in patients treated with a quantitative resuscita-
Genitourinary Skin lesions or redness, abscess, discharge,
tion protocol. Crit Care Med. 2011;39(9):2066-2071. (Clinical
bleeding
trial; 291 patients)
Extremities Color, temperature, perfusion, erythema, swelling, DOI: http://dx.doi.org/10.1097/CCM.0b013e31821e87ab
warmth 121. De Backer D, Biston P, Devriendt J, et al. Comparison of
Skin Rash, erythema, crepitus, mottling dopamine and norepinephrine in the treatment of shock. N
Engl J Med. 2010;362(9):779-789. (Clinical trial; 1679 patients)
Indwelling devices Tenderness, erythema, warmth, purulent dis- DOI: http://dx.doi.org/10.1056/NEJMoa0907118
charge

MDCalc Score Calculator

SOFA Score:
https://www.mdcalc.com/sequential-organ-failure-
assessment-sofa-score
qSOFA Score:
https://www.mdcalc.com/qsofa-quick-sofa-score-sepsis
Clinical Pathway for Sepsis Clinical Pathway for Initial Manage- Glasgow Coma Scale Score:
Screening in the Emergency ment of Patients With Sepsis https://www.mdcalc.com/glasgow-coma-scale-score-gcs
Department
Managing sepsis in
pediatric patients?
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Management Infection issue of Pediatric Emergency
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