11/13/24, 7\:38 PM Guide | Sepsis

Sepsis

Table of contents
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Introduction

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 identi
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.

Background

Sepsis is de
. Sepsis is a life-
threatening condition associated with high mortality.

Clinical features of sepsis

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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-speci
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

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
History
A history of recent chemotherapy is a red
Breathing
The following red
Respiratory rate of ≥ 25 breaths per minute
Oxygen required to keep SpO 2
≥ 92%
Circulation
The following red
Heart rate of >130
Systolic blood pressure ≤ 90 mmHg (or drop of >40 from normal)
Lactate ≥2 mmol/l
Disability
The following red
Objective evidence of new or altered mental state
Exposure
The following red
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
Ensure senior clinician attends
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Administer high-2
\<92%
IV access & blood tests (blood cultures, lactate, FBC, U&E, CRP)
Administer broad-spectrum intravenous antibiotics and consider source control
Administer intravenous
Monitor urine output and lactate
Sepsis six mnemonic
You can remember the sepsis six using the acronym BUFALO\:
Blood Cultures
Urine output
Fluids
Antibiotics
Lactate
Oxygen
Or, you can remember it by thinking of the steps as ‘taking 3 and giving 3’
\:
Taking 3\: blood cultures, lactate and urine output
Giving 3\: antibiotics, oxygen (to maintain SpO 2
>94%),

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 speciacute asthma)
Any medications or must be prescribed at the time (you may be able to delegate this to another sta
Your assessment and management should be documented clearly in the notes; however, this should not delay
management
Methodical approach
For each section of the ABCDE assessment (e.g. airway, breathing, circulation etc.), ask yourself\:
Have I checked the relevant observations for this section? (e.g. checking respiratory rate and SpO 2
as part of your
‘breathing’ assessment)
Have I examined the relevant parts of the system in this section? (e.g. peripheral perfusion, pulses, JVP, heart sounds,
and peripheral oedema as part of your ‘circulation’ assessment)
Have I requested relevant investigations based on my
glucose as part of your ‘disability’ assessment)
Have I intervened to correct the issues I have identi
depletion/hypotension as part of your ‘circulation’ assessment)
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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 sta

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.

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
and remove it. Be careful not to push it further into the airway.
Jaw thrust
If the patient is suspected of having su
than a head-tilt chin-lift manoeuvre\:
1. Identify the angle of the mandible
2. Place two
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.
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An oropharyngeal airway is a curved plastic tube with a
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
tolerated in partly or fully conscious patients than oropharyngeal airways.

Re-assessment

Re-assess the patient after any intervention.
Assess the patient's airway

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 (SpO )\:
2
A normal SpO 2 2
range is 94-98% in healthy individuals and 88-92% in patients with COPD at high risk of CO retention
Hypoxaemia is a red
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
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\:
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The trachea deviates away from tension pneumothorax and large pleural e
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 e
Percussion of the chest
Percuss the patient’s chest to identify areas of dullness which may be associated
with consolidation, lobar collapse or pleural e
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 SpO ) to quantify the degree of hypoxia and help determine the potential underlying cause.
2
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 sta
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 2
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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Record respiratory rate

Circulation

Clinical assessment

Pulse
Tachycardia is a common feature of sepsis.
A heart rate >130 is considered a red
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
Capillary re
Capillary re
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
Review the patient’s current
output, stool output, vomiting) to inform resuscitation e
0.5ml/kg/hour in an adult and is a red
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
Patients with clinical features of

Investigations and procedures

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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
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 signi
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
Hypovolaemic patients require
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
After each
Repeat administration of
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 for more details on resuscitation
ECG
response).
If the patient is tachycardic, an ECG should be performed to rule out arrhythmia (e.g. atrial

Re-assessment

Re-assess the patient after any intervention.
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Measure blood pressure

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
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
anxiolytics).
Review the patient's drug chart for medications which may cause neurological abnormalities (e.g. opioids, sedatives,
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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 de≤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.
Assess consciousness level using ACVPU
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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
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
Brie
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 sta

Interventions

Catheterisation
Catheterise the patient to monitor urine output to guide

Re-assessment

Re-assess the patient after any intervention.
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Measure body temperature

Re-assessment and escalation

Re-assess the patient using the ABCDE approach to identify any changes in their clinical condition and assess the
e
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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