THE CHIEF
COMPLAINT

Infectious Disease

Sepsis / Septic Shock

  • Scope: Adult ED recognition and initial management.
    • Pediatric sepsis, pregnancy, and specialized infection syndromes require their respective pathways.
  • Treat In Parallel: Resuscitation, indicated antibiotics, and source-control assessment.
    • Do not finish treating shock before treating the infection. SSC 2026

The Algorithm…

01 Sepsis? — Recognize / Assess Severity

  • Infection + New Organ Dysfunction?
    • Assess mentation, breathing, kidneys, perfusion, platelets, and liver function.
    • Consider another cause or a mixed process.
  • Unstable?
    • Resuscitate now.
    • Do not wait for complete laboratory results, a score, or a positive culture.

02 Shock / Immediate Threat? — Resuscitate

  • Immediate Actions Together
    • Support oxygenation and circulation.
    • Obtain cultures without delaying indicated antibiotics.
    • Contact the procedural team early when source control may be needed.
  • Hypoperfusion / Hypotension
    • Crystalloid when indicated.
    • Norepinephrine for persistent or profound hypotension.
      • Do not wait for a central line or a fixed fluid total.
  • More Fluid?
    • Reassess need, responsiveness, and tolerance.
  • Still In Shock?
    • Recheck the mechanism, drug delivery, and infection treatment.
    • Escalate vasoactive support; consider steroids or inotropes for the appropriate problem.
  • Organ Failure?
    • Start the required respiratory or other support while resuscitation continues.

03 Source? — Identify And Treat

  • Cultures + Focused Source Assessment
    • Obtain promptly, alongside treatment.
  • Septic Shock Or Probable / Definite Sepsis
    • Active empiric antimicrobials immediately—ideally within one hour.
  • Possible Sepsis Without Shock
    • Rapid, time-limited assessment—not open-ended observation.
  • Drain / Debride / Remove?
    • Arrange source control early.
    • Antibiotics do not replace an indicated procedure.

04 Reassess / Disposition

  • Response: Repeat perfusion, organ function, fluid tolerance, and infection assessment.
  • Admission: Ongoing organ dysfunction requires inpatient care.
  • Critical Care: Vasopressors or intensive organ support require the appropriate capability.
  • Handoff: Treatment delivered, response, pending cultures, and source-control plan. SSC 2026

Sepsis? — Recognize / Assess Severity

Infection, Sepsis, Or Septic Shock?

  • Sepsis: Infection causing acute, life-threatening organ dysfunction through a dysregulated host response.
    • Fever, leukocytosis, or tachycardia alone does not establish sepsis.
    • A positive blood culture is not required.
  • Acute Organ Dysfunction
    • Compare with baseline.
    • Assess whether infection explains the change.
    • Sepsis-3 uses an acute SOFA increase ≥2 to operationalize organ dysfunction.
      • Do not wait to calculate SOFA before treating an unstable patient.
  • Septic Shock — Sepsis-3 Criteria
    • Sepsis requiring vasopressors to maintain MAP ≥65 mm Hg.
    • Lactate >2 mmol/L despite adequate volume assessment / resuscitation.
    • These criteria identify a particularly high-risk group—not a prerequisite for pressure support.
      • Persistent hypotension is dangerous even with a normal lactate.
  • “Severe Sepsis”
    • Redundant within Sepsis-3 because organ dysfunction is already part of sepsis.
    • Keep the distinction between infection without organ dysfunction, sepsis, and shock. Sepsis-3 — Singer 2016

Clinical / Red Flags — What Moves The Needle?

  • Infection Plausible?
    • Localizing symptoms and examination findings.
    • Recent procedures, devices, prior cultures, and antibiotic exposure.
    • Immune status and other host risks.
    • No Fever: Does not exclude serious infection, particularly in older or immunocompromised patients.
  • New Organ Dysfunction?
    • Neurologic: New confusion, reduced alertness, or functional decline.
    • Respiratory: New oxygen requirement, increased work of breathing, or worsening gas exchange.
    • Renal: Falling urine output or rising creatinine.
      • Assess baseline function, volume status, medications, and obstruction.
    • Circulatory: Hypotension, delayed capillary refill, mottling, cool extremities, or altered mentation.
      • Warm skin or preserved BP does not establish adequate perfusion.
    • Hematologic / Hepatic: Falling platelets, new coagulopathy, or rising bilirubin.
  • Does Infection Explain It?

Screening Is Not Diagnosis

  • NEWS / NEWS2, MEWS, Or SIRS
    • May trigger assessment.
    • Do not substitute the score for a clinical diagnosis.
  • qSOFA
    • Do not use as the sole screen or exclusion test.
    • A low score does not exclude infection-related organ dysfunction.
  • Biomarkers
    • No single lactate, WBC, CRP, or procalcitonin result establishes or excludes sepsis. SSC 2026

Focused Initial Testing

  • CBC / Chemistry
    • Platelets, creatinine, electrolytes, glucose, and liver tests.
    • Add coagulation studies / blood gas for suspected coagulopathy, bleeding, respiratory failure, or acidemia.
  • Lactate
    • Obtain when sepsis is suspected; repeat an elevated value during resuscitation.
    • Elevation may reflect hypoperfusion, adrenergic stress, or impaired clearance.
    • Lactate is not a measurement of circulating volume.
      • Persistent elevation does not automatically require more fluid.
  • Cultures / Imaging

Shock / Immediate Threat? — Resuscitate

Treat In Parallel

  • Oxygenation / Perfusion: Start the support the patient needs now.
  • Cultures: Obtain promptly without delaying indicated antibiotics.
  • Antibiotics: Treat septic shock or likely sepsis promptly—including likely sepsis without shock.
  • Source Control: Contact the procedural team as soon as a drainable / removable source is suspected.
  • Reassess: What remains uncorrected—volume, vascular tone, cardiac output, or the infection source? SSC 2026

Immediate Support

  • Access / Monitoring
    • IV access, cardiac monitoring, frequent BP measurement, and urine-output assessment.
    • Urinary catheter when accurate output measurement or retention management is needed.
      • Not automatically for every infection.
  • Respiratory Failure
    • Titrate oxygen to the clinical situation.
    • Escalate support for worsening oxygenation or work of breathing.
    • High-flow nasal oxygen is an option for selected acute hypoxemic failure.
    • Intubate: Failed oxygenation / ventilation, exhaustion, or inability to protect the airway.
      • Anticipate peri-intubation hypotension.
      • Prepare circulatory support; use the Airway / RSI pathway.
  • Ventilated ARDS
    • Lung-protective ventilation: approximately 6 mL/kg predicted body weight.
    • Plateau pressure ≤30 cm H₂O.
    • Use the ARDS / ventilation pathway for PEEP, proning, and rescue support. SSC 2026

Perfusion — What Needs Correcting?

  • Mechanism
    • Septic shock may combine vasodilation, volume deficit, and cardiac dysfunction.
    • Fluid, vasopressors, and inotropes treat different problems.
  • Bedside Response
    • Follow mentation, capillary refill, skin temperature / mottling, urine output, and BP together.
    • Better BP alone does not prove restored perfusion.
  • Echo / POCUS
    • Assess ventricular function, filling, and alternative / mixed shock mechanisms.
    • Normal MAP does not exclude low output.
    • A small LV or isolated IVC measurement does not establish a fluid requirement.
  • Lactate Trend
    • Interpret with the examination and treatment response.
    • Falling lactate supports improvement.
    • Persistent elevation requires assessment of perfusion and other contributors.
    • Do not keep giving fluid solely to normalize lactate. ESICM 2025 — Hemodynamic Monitoring · SSC 2026

Journal Club — Personalized Resuscitation

  • ANDROMEDA-SHOCK-2, 2025
    • A capillary-refill-guided, personalized strategy improved a hierarchical composite outcome, mainly through less organ-support time.
    • 28-day mortality: 26.5% versus 26.6%—no significant difference.
    • This tested a multistep assessment / treatment strategy—not capillary refill alone. ANDROMEDA-SHOCK-2

IV Fluid — Initial Volume And Reassessment

  • Crystalloid For Sepsis-Induced Hypoperfusion
    • Balanced crystalloid generally preferred over saline.
    • Heart failure or CKD changes the tolerance assessment—not an automatic reason to withhold all fluid.
    • Saline remains appropriate in selected circumstances, including concomitant traumatic brain injury.
  • 30 mL/kg? — SSC 2026
    • Suggests at least 30 mL/kg within the first three hours for sepsis-induced hypoperfusion / septic shock.
    • Conditional recommendation; low-certainty evidence.
    • Individualize volume and rate; reassess frequently.
    • Not a prescription for every patient with infection.
    • Weight: Actual body weight; adjusted / ideal weight is an option when BMI >30.
      • Document the weight used.
    • Do not delay a needed vasopressor to complete the volume.
  • After Each Bolus / Aliquot
    • Count fluid already received.
    • Did perfusion improve?
    • Did oxygenation or congestion worsen?
    • Absent benefit or worsening congestion → change the plan, not automatic additional liters.
  • More Fluid?
    • Need: Is hypoperfusion still present, and would increased flow help?
    • Responsiveness: Does passive leg raise / fluid challenge increase measured stroke volume or cardiac output?
    • Tolerance: Will additional volume worsen pulmonary or venous congestion?
    • A positive fluid-response test is not an unlimited-fluid prescription.
  • Static Measurements
    • Do not direct boluses to an isolated CVP or IVC target.
    • CVP / venous oxygen measurements may help selected complex cases—not mandatory targets for everyone.
  • Albumin / Colloids

Guideline Context — Initial Fluids And ED Practice

  • Fluid-Volume Guidance Differs
    • SSC 2026 suggests at least 30 mL/kg in the first three hours.
    • ESICM’s separate 2025 fluid-volume guideline suggests up to 30 mL/kg initially, adjusted to clinical context and reassessment.
    • Neither establishes one ideal volume for every patient. SSC 2026 · ESICM 2025 — Resuscitation Fluid Volume
  • U.S. Endorsement
  • Bedside Application
    • Give fluid when indicated, reassess benefit and congestion, and start pressure support when needed.
    • Do not turn a volume recommendation into an automatic instruction to continue despite harm. SSC 2026 · ESICM 2025 — Hemodynamic Monitoring

Journal Club — Fluid / Vasopressor Strategy

  • CLOVERS 2023
    • Restrictive fluid / earlier vasopressors did not significantly improve the primary mortality outcome versus a liberal strategy.
    • Patients had already received 1–3 L before randomization—not a comparison with no initial fluid.
  • CLASSIC 2022
    • Restriction after initial fluid treatment in ICU septic shock did not improve 90-day survival.
  • ARISE FLUIDS 2026
    • Earlier vasopressors / less fluid versus more fluid / later vasopressors.
    • Median days alive and outside hospital through day 90: 76 versus 76.
    • Pulmonary edema was less frequent with earlier vasopressors; survival superiority was not established.
  • Takeaway

Journal Club — Balanced Fluids And Older Resuscitation Targets

  • SMART Sepsis Analysis 2019
    • The sepsis secondary analysis favored balanced crystalloid.
  • PLUS 2022
    • Neutral mortality / kidney outcomes in a broader ICU population.
    • Support the fluid preference without promising a consistent survival advantage for every patient.
  • PRISM 2017
    • Patient-level analysis of ProCESS, ARISE, and ProMISe.
    • Mandatory early goal-directed therapy did not improve survival over contemporary usual care.
    • Retire The Mandatory Sequence
      • Routine CVP / ScvO₂-driven interventions.
      • Transfusion to Hct >30% solely to increase ScvO₂.
    • Do not retire prompt resuscitation or physiologic reassessment. SMART Sepsis Analysis · PLUS · PRISM · TRISS

Vasopressors — Restore Pressure Without Delaying

  • Norepinephrine
    • First-line vasopressor for typical septic shock.
    • Start for persistent hypotension during initial resuscitation.
    • Profound / Unstable Shock: Start while fluid assessment and appropriate replacement continue.
    • Do not wait for a predetermined fluid total.
  • Initial Dose
    • 0.05 mcg/kg/min is one studied low-dose starting approach.
    • Not a ceiling or a required starting rate for profound hypotension.
    • Titrate promptly to pressure and perfusion.
    • Confirm concentration and pump units.
  • MAP Target
    • Start around 65 mm Hg; individualize to perfusion and treatment tolerance.
    • SSC suggests an initial 60–65 mm Hg range in adults ≥65 years.
      • Conditional recommendation; worsening perfusion overrides a nominal target.
    • Do not escalate vasoconstriction solely to reach a normal outpatient BP.
  • Peripheral Access
    • Start through a suitable monitored peripheral IV rather than waiting for a central line.
    • Follow local concentration, site-selection, patency, and extravasation protocols.
    • Arrange central access when ongoing support or local safety limits require it.
      • No single universal peripheral duration / dose cutoff.
  • Escalating Norepinephrine
    • Add vasopressin when indicated rather than only increasing catecholamines.
    • Vasopressin: Common adjunctive dose 0.03 units/min IV; follow the institutional protocol.
    • MAP Still Inadequate: Add epinephrine after norepinephrine / vasopressin as appropriate. SSC 2026 · CENSER · VASST
  • Arterial Line? — SSC 2026
    • Favor invasive monitoring with escalating / multiple vasopressors, unreliable cuff readings, or frequent arterial sampling.
    • Line placement must not delay treatment. SSC 2026

Still In Shock?

  • Recheck Delivery / Measurements
    • Is the infusion running through functioning access?
    • Is the BP accurate?
    • How much fluid was given, and what changed?
  • Reassess The Mechanism
    • Persistent volume deficit, vasoplegia, cardiac dysfunction, obstruction, or occult hemorrhage.
    • Repeat focused echo / perfusion assessment—not another liter for every low BP.
  • Recheck Infection Treatment
    • Was the antibiotic given—and does it cover the likely source?
    • Is drainage / debridement still pending?
    • See Source Control.
  • Cardiac Dysfunction + Persistent Hypoperfusion
    • Consider an inotrope after volume status and arterial pressure are adequate.
    • Options: dobutamine added to norepinephrine, or epinephrine alone.
      • Guideline-supported, with very-low-certainty evidence.
    • An inotrope does not replace needed vasopressor support.
    • Low EF alone is not the indication.
      • Assess output, perfusion, and treatment response.
  • Hydrocortisone?
    • Consider for ongoing vasopressor-dependent septic shock.
    • 200 mg/day IV
      • 50 mg every six hours, or continuous infusion.
    • Not routine treatment for infection without shock.
    • Avoid high-dose, short-duration steroid regimens.
  • Refractory Shock

Journal Club — Corticosteroids

  • ADRENAL 2018
    • Hydrocortisone accelerated shock resolution without a significant 90-day mortality benefit.
  • APROCCHSS 2018
    • Hydrocortisone plus fludrocortisone reduced 90-day mortality.
  • Interpretation
    • Different populations and regimens prevent attributing the difference to fludrocortisone alone.
    • Steroids do not replace antibiotics or source control. ADRENAL · APROCCHSS

Other Immediate Organ Threats

  • Anemia
    • Restrictive RBC strategy: transfusion threshold generally around Hb 7 g/dL without another indication.
    • Active hemorrhage, myocardial ischemia, or severe hypoxemia requires individualized assessment.
  • AKI / Hyperkalemia / Acidemia
    • Treat the complication.
    • Assess dialysis for conventional urgent indications—not creatinine alone.
  • Bicarbonate?
    • Consider selectively in septic shock with pH ≤7.2 and moderate–severe AKI.
    • Do not routinely give bicarbonate to correct hyperlactatemia or reduce vasopressor requirements.
  • Glucose
    • Correct hypoglycemia.
    • Start protocolized insulin for persistent glucose ≥180 mg/dL.
    • Monitor for hypoglycemia.
  • Other Adjuncts
    • IV vitamin C is not routine sepsis treatment.
    • Do not add therapies solely to normalize numbers without an identified clinical benefit.
  • Shared Pathways

Journal Club — Bicarbonate

  • BICARICU-2, 2025
    • Severe metabolic acidemia with moderate–severe AKI.
    • Less kidney-replacement use, but no improvement in 90-day mortality. BICARICU-2
  • SODa-BIC 2026
    • 500 vasopressor-treated ICU patients with metabolic acidosis; not limited to sepsis.
    • Primary outcome: death, renal-replacement therapy, or persistent renal dysfunction within 30 days.
    • 40.2% with bicarbonate versus 39.4% with placebo—no significant benefit.
    • Broader population than BICARICU-2; do not treat the trials as interchangeable. SODa-BIC 2026
  • Takeaway
    • Routine bicarbonate for shock-associated acidosis is not supported.
    • The selective severe-acidemia / substantial-AKI decision remains separate. SSC 2026 · BICARICU-2 · SODa-BIC 2026

Source? — Identify And Treat

  • Start During Resuscitation: Source evaluation and antimicrobials do not wait for shock to resolve. SSC 2026

Source — Which Diagnosis Changes Treatment?

  • Pulmonary
    • Respiratory symptoms / findings → chest imaging and selected respiratory testing.
    • Pleural collection? Assess whether drainage is needed.
  • Urinary
    • Urinary / flank symptoms or plausible upper-tract infection → UA / culture and renal assessment.
    • Obstruction? Ultrasound / CT when indicated.
      • Infected obstruction → urgent drainage.
  • Abdominal / Biliary / Pelvic
    • Localizing pain, peritoneal findings, jaundice, or procedural history → targeted imaging + early procedural consultation.
    • Assess perforation, ischemic bowel, abscess, cholangitis, or a pelvic source.
  • Skin / Soft Tissue
    • Expose wounds, pressure areas, and the perineum.
    • Necrotizing Infection? Disproportionate pain, rapid progression, or toxic appearance → urgent surgical assessment.
  • CNS / Spine / Joint
    • Headache / meningism, focal spine pain / neurologic change, or an acutely inflamed joint.
    • Use the corresponding diagnostic and treatment pathway.
  • Devices / Endovascular
    • Assess lines, prosthetic material, recent instrumentation, and possible endocarditis.
    • Secure alternative access before removing an essential suspected infected line when feasible.
  • No Source Yet
    • Repeat the history and examination.
    • Choose further imaging for the remaining clinical question.
    • Do not label bacteriuria or an equivocal image as the source merely to close the differential. SSC 2026 · IDSA — Diagnostic Uncertainty / SEP-1

Cultures — Before Antibiotics When Feasible

  • Blood Cultures
    • Obtain promptly, ideally before antimicrobials.
    • Do not delay urgent antibiotics for difficult access or repeated unsuccessful sampling.
  • Source Specimens
    • Urine, respiratory material, CSF, joint fluid, or operative specimens when indicated.
    • A delayed procedure should not postpone treatment of a compelling emergency.
  • Interpretation
    • Use cultures to narrow therapy.
    • Negative cultures do not independently establish that infection was absent. SSC 2026

Antibiotics — How Urgent?

  • Procalcitonin
    • A low value does not justify withholding otherwise indicated initial treatment. SSC 2026

Journal Club — Antibiotic Timing

  • Seymour 2017
    • Longer time to antibiotics was associated with higher adjusted mortality during mandated sepsis care.
    • Observational data—not proof of a fixed causal mortality penalty for every hour in every patient.
  • Clinical Distinction

Empiric Therapy — Active Against What?

  • Likely Source / Organism
    • Match the regimen to the anatomic site and severity.
    • Meningitis, neutropenic sepsis, endocarditis, and necrotizing infection need their own regimens.
  • Resistance Risk
    • Review prior cultures / colonization, recent antibiotics, hospitalization, devices, and the local antibiogram.
    • Add MRSA or other resistant-organism coverage when that risk is meaningful.
    • Not automatically for every sepsis label.
  • Anaerobes
    • Include coverage for a compatible source: intra-abdominal, deep pelvic, or necrotizing soft-tissue infection.
  • Fungal Infection
    • Empiric antifungal treatment is not routine.
    • Consider in selected high-risk presentations with appropriate specialist input. SSC 2026

First Dose / Ongoing Dosing

  • First Dose
    • Give the severe-infection loading regimen promptly.
  • Beta-Lactam Maintenance
    • Use prolonged infusion after the initial loading dose, through the institutional drug-specific protocol.
    • SSC 2026: strong recommendation, moderate-certainty evidence.
    • Do not delay the first active dose while arranging the maintenance infusion. SSC 2026
  • Maintenance / Monitoring
    • Adjust for organ function, weight, drug properties, and changing physiology.
    • Involve pharmacy for drug-specific monitoring and evolving renal function. SSC 2026

Journal Club — Prolonged Beta-Lactam Infusion

  • BLING III, 2024
    • Continuous infusion did not significantly reduce mortality in the unadjusted primary analysis.
    • Clinical cure improved. BLING III
  • Abdul-Aziz 2024 Meta-Analysis
    • Pooled randomized trials supported lower mortality with prolonged infusion.
    • The pooled result does not make BLING III’s primary mortality comparison positive. Abdul-Aziz 2024 — Meta-Analysis

Source Control — Drain / Debride / Remove?

  • Procedure Needed?
    • Contact surgery, IR, urology, GI, or the appropriate team early.
    • Infected Urinary Obstruction: Drainage.
    • Necrotizing Infection: Debridement.
    • Abscess / Infected Device / Ongoing Contamination: Appropriate drainage, removal, or procedural control.
  • Timing
    • SSC suggests source control ideally within six hours once sepsis requiring source control is diagnosed.
    • Conditional recommendation; very-low-certainty evidence.
    • Not a six-hour waiting allowance.
    • Stabilize while arranging the procedure; do not wait for all physiology to normalize.
  • Antibiotics Alone?
    • They do not drain pus, relieve infected obstruction, or remove necrotic tissue. SSC 2026

Journal Club — Source-Control Timing

  • Reitz 2022
    • Source control within six hours was associated with lower adjusted 90-day mortality in community-acquired sepsis.
    • Observational design limits causal inference.
    • Supports early procedural assessment—not one guaranteed deadline for every source. Reitz 2022

Narrow / Stop / Set Duration

  • Organism Identified
    • Narrow to susceptibility and the clinical source.
    • Stop unnecessary overlapping coverage.
  • Cultures Negative
    • Reassess source, response, and alternative diagnoses.
    • Do not continue broad therapy solely because it was started.
  • Noninfectious Explanation Established
    • Stop empiric antimicrobials when infection no longer warrants treatment.
  • Duration
    • Follow the disease, source control, organism, and response—not a universal “sepsis course.”
    • Procalcitonin may help with discontinuation when duration remains uncertain.
      • Use alongside clinical assessment, not instead of it. SSC 2026

Reassessment / Disposition

Is The Patient Improving?

  • Perfusion / Organs
    • Repeat mentation, capillary refill, urine output, BP / pressor requirement, oxygenation, and relevant laboratory trends.
    • Better BP alone does not establish restored perfusion.
  • Fluid Balance
    • Reassess responsiveness and congestion before more fluid.
    • After acute resuscitation, persistent overload may require decongestion.
    • Do not automatically continue resuscitation fluids into recovery.
  • Infection Treatment
    • Confirm the antibiotic was administered.
    • Does the suspected source still fit?
    • Is source control completed or actively arranged?
  • Trajectory / Treatment Goals
    • Escalate worsening support needs.
    • Clarify baseline function, treatment preferences, and surrogate input without delaying emergency care. SSC 2026

Discharge

  • Ongoing Sepsis / Organ Dysfunction
    • Not a routine ED discharge pathway.
  • Assessment Supports Uncomplicated Infection Or Another Diagnosis
    • Reassuring physiology, function, oral intake, treatment access, and follow-up.
    • Normalized lactate, lower fever, or transient BP improvement alone is insufficient.
  • Home Plan
    • Assign responsibility for culture review.
    • Return for worsening illness, confusion, dyspnea, reduced urine, or inability to take treatment. SSC 2026

Monitored Admission

  • Infection-Related Organ Dysfunction
    • Persistent AKI, oxygen requirement, altered mentation, coagulopathy, or other findings needing serial assessment / treatment.
  • Unresolved Source / Treatment Needs
    • Required investigation, IV therapy, source control, or inability to arrange safe outpatient treatment.
  • Choose The Required Capability
    • Not every stable organ abnormality requires ICU.
    • Necessary procedure / transfer must not wait for routine bed placement. SSC 2026

ICU Admission

  • Circulatory Support
    • Ongoing vasopressors, recurrent instability, or refractory hypoperfusion.
  • Respiratory / Other Organ Support
    • Invasive ventilation, rapidly escalating support, dangerous metabolic complications, or monitoring beyond ward capability.
  • Before Transfer / Handoff
    • Start necessary support before transfer.
    • Communicate:
      • Antibiotics administered and timing.
      • Fluid type / volume, response, and congestion.
      • Pressors, access, organ-function trends, and pending cultures.
      • Source-control needs, consultant decisions, and treatment goals. SSC 2026

In The Pit

  • Infection + New Organ Dysfunction
    • Assess sepsis and competing causes.
    • Do not wait for a score to treat an unstable patient.
  • Septic Shock Or Likely Sepsis
    • Active empiric antibiotics promptly—including likely sepsis without shock.
    • Cultures first when this causes no delay.
  • Uncertain Infection Without Shock
    • Rapid focused assessment.
    • Treat persistent concern; defer only with close monitoring and a clear reassessment plan.
  • Hypoperfusion / Hypotension
    • Crystalloid when indicated.
    • Norepinephrine when needed—not after a fixed fluid total or central line.
  • More Fluid?
    • Need, responsiveness, and tolerance.
    • Persistent lactate elevation alone is not an instruction for another liter.
  • Still In Shock?
    • Recheck delivery, mechanism, and infection treatment.
    • Escalate pressors; consider hydrocortisone.
    • Cardiac dysfunction + persistent hypoperfusion despite adequate volume / pressure → consider an inotrope.
  • Drain / Debride / Remove?
    • Contact the source-control team early.
    • Antibiotics do not replace the procedure.
  • Before Handoff
    • Confirm treatment delivered, response, pending cultures, source-control plan, and level of care. SSC 2026

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