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Diagnosis of sepsis

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Diagnosis of Sepsis

Definition (Sepsis-3, 2016)

The current standard is the Sepsis-3 definition from the Third International Consensus Definitions Task Force (2016):
Sepsis = life-threatening organ dysfunction caused by a dysregulated host response to infection.
The older SIRS-based model (2+ of: fever/hypothermia, tachycardia, tachypnea, leukocytosis/leukopenia) has been retired as a diagnostic criterion because it is overly sensitive and nonspecific - it occurs in burns, trauma, pancreatitis, and even after routine surgery, and does not convey an increased mortality risk on its own. However, SIRS criteria still have value in alerting clinicians to physiological stress warranting further investigation.
  • ROSEN's Emergency Medicine, p. 2755; Schwartz's Principles of Surgery, p. 3265-3267

Sepsis-3 Diagnostic Criteria

Organ Dysfunction: SOFA Score

Organ dysfunction is operationalized by an increase of ≥2 points from baseline in the Sequential Organ Failure Assessment (SOFA) score. A rise of ≥2 points correlates with approximately 10% in-hospital mortality.
ParameterScore 0Score 1Score 2Score 3Score 4
PaO₂/FiO₂ ratio>400301-400<300<200<100
Platelets (×10³/µL)>150101-15051-10021-50<20
Bilirubin (mg/dL)<1.21.2-1.92.0-5.96-11.9>12
MAP>70<70Vasopressors (low dose)Vasopressors (mod.)Vasopressors (high)
GCS1513-1410-126-9<6
Creatinine (mg/dL)<1.21.2-1.92.0-3.43.5-4.9>5
  • Current Surgical Therapy 14e, p. 1615

Septic Shock Criteria (Sepsis-3)

Septic shock is a subset of sepsis with circulatory and cellular/metabolic derangements sufficient to substantially increase mortality. It is identified by ALL of:
  • Vasopressor requirement to maintain MAP ≥65 mmHg, AND
  • Serum lactate >2 mmol/L (18 mg/dL) despite adequate volume resuscitation
  • In-hospital mortality exceeds 40%
  • Current Surgical Therapy 14e; Schwartz's Principles of Surgery, p. 3271

Bedside Screening: qSOFA

The quick SOFA (qSOFA) was developed as a rapid, non-lab-dependent screening tool for use outside the ICU. Score 1 point for each of:
  1. Respiratory rate ≥22 breaths/min
  2. Altered mental status (GCS <15)
  3. Systolic blood pressure ≤100 mmHg
A qSOFA ≥2 suggests potentially life-threatening sepsis and warrants further evaluation. qSOFA is more specific but less sensitive than SIRS criteria for identifying end-organ dysfunction. It does not require labs or imaging and can be applied at the bedside.
Note: In the ICU, the full SOFA score is preferred over qSOFA. Multiple other screening tools exist (NEWS, MEWS, AI-based TREWS), but none is preferentially endorsed by the 2021 Surviving Sepsis Campaign guidelines over others.
  • Harrison's Principles of Internal Medicine 22E (2025), p. 2363; Rosen's Emergency Medicine, p. 2755

Clinical Approach to Diagnosis

No Gold Standard Test

There is no single diagnostic test for sepsis. Diagnosis requires a high index of clinical suspicion combined with evidence of:
  1. A suspected or confirmed source of infection
  2. Evidence of organ dysfunction (SOFA ≥2)
Bacteremia is NOT required - only 30-40% of clinically septic patients have positive blood cultures.

History and Physical Examination

Sepsis may present with nonspecific signs: fever, tachycardia, tachypnea, lethargy, myalgias, with or without localizing signs (cough, pyuria, abdominal pain). Signs of end-organ dysfunction - oliguria or altered mental status - are important clues.

Laboratory Evaluation

TestFindings and Significance
CBC with differentialLeukocytosis or leukopenia; bandemia (≥5-10% bands) suggests infection; thrombocytopenia in severe sepsis/DIC
Metabolic panelElevated creatinine (renal dysfunction); low bicarbonate/elevated anion gap (lactic acidosis); electrolyte disturbances
Serum lactate>2 mmol/L indicates tissue hypoperfusion; lactate >4 mmol/L carries ~28% mortality. Used to guide resuscitation
Liver function testsElevated bilirubin (hepatic dysfunction or biliary source); elevated lipase (pancreatitis as cause of SIRS)
Coagulation panelElevated PT/PTT, low fibrinogen, elevated fibrin split products suggest DIC
UrinalysisEssential in all patients; especially in elderly where urinary source may lack localizing symptoms
Blood gasesClassify acid-base disturbance; metabolic acidosis suggests inadequate tissue perfusion

Biomarkers

  • Lactate: included in septic shock definition; guides resuscitation; mortality correlates with level (0-2.5 mmol/L: ~5% mortality; 2.5-4: ~9%; >4: ~28%)
  • Procalcitonin (PCT): sensitivity ~77%, specificity ~79% for infection in sepsis. Best used for serial measurements and antibiotic stewardship rather than as a single diagnostic test
  • CRP: sensitivity ~75%, specificity ~67% - limited ability to differentiate infectious from non-infectious inflammation
  • Normalization of biomarkers with treatment is associated with improved outcomes; serial measurements guide decisions about antibiotic adequacy and source control
  • Rosen's Emergency Medicine, p. 2757; Current Surgical Therapy 14e, p. 1616

Microbiologic Testing

  • Blood cultures x2 (peripheral, ideally before antibiotics) - yield in clinical sepsis is 30-40%
  • Targeted cultures: urine, sputum, CSF, wound, as clinically indicated
  • Gram stain results available rapidly to guide initial therapy
  • Antibiotic initiation should not be significantly delayed while waiting for culture samples

Imaging

  • Chest X-ray (pneumonia, effusion)
  • CT scan (abdominal source, abscess, perforation)
  • Ultrasound (biliary, cardiac - assess for effusion/tamponade)
  • Imaging should be targeted to the suspected source of infection

Differential Diagnosis

Sepsis mimics are common - in one ICU study, 25% of patients admitted for sepsis had a mimic on retrospective review.
Non-infectious conditions mimicking sepsis:
  • Cardiovascular: heart failure, cardiac arrest, myocardial infarction, pericardial tamponade
  • Pulmonary: ARDS, pulmonary embolism
  • Metabolic: DKA, adrenal dysfunction, hyperthyroidism
  • Neurological: neuroleptic malignant syndrome, hypothalamic injury
  • Inflammatory: vasculitis, pancreatitis, connective tissue diseases
  • Toxicologic: drug overdose/poisoning
  • Environmental: heat stroke, burns
"In patients with suspected sepsis or septic shock in whom infection is not confirmed, continuous reevaluation for alternative diagnoses is imperative." - Harrison's 22E
  • Rosen's Emergency Medicine, Box 127.2, p. 2756; Harrison's 22E, p. 2363

Summary: Step-by-Step Diagnostic Approach

  1. Screen with qSOFA (≥2/3 criteria = high-risk, evaluate further)
  2. History + physical exam - identify signs of infection and organ dysfunction
  3. Labs: CBC, BMP, LFTs, coagulation, serum lactate, ± procalcitonin
  4. Cultures: blood x2 + targeted sites before antibiotics
  5. Imaging: chest X-ray; CT or ultrasound targeted to suspected source
  6. SOFA score: calculate to quantify organ dysfunction (≥2 from baseline = sepsis)
  7. Assess for septic shock: vasopressor need + lactate >2 mmol/L despite fluids
  8. Consider mimics and maintain clinical suspicion if infection not confirmed
Key References:
  • Harrison's Principles of Internal Medicine 22E (2025), Chapter on Sepsis, pp. 2363-2364
  • ROSEN's Emergency Medicine, Chapter 127, pp. 2755-2757
  • Current Surgical Therapy 14e, pp. 1615-1616
  • Schwartz's Principles of Surgery 11e, pp. 3265-3271
  • Sepsis-3: Singer et al., JAMA 2016 (Third International Consensus Definitions)

Emergency cases and there management in hospital

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Emergency Cases and Their Management in Hospital

General Principles: Initial Assessment (ABCs)

Every emergency begins with the same primary survey - Airway, Breathing, Circulation (ABC) - followed by Disability (neurological status) and Exposure. Simultaneously:
  • Establish IV access (large-bore, 16-18G preferred)
  • Continuous cardiac monitoring, pulse oximetry, and blood pressure monitoring
  • Supplemental oxygen as indicated
  • Finger-stick glucose
  • IV fluids as clinically indicated

1. Cardiac Arrest

Presentation

Abrupt loss of consciousness due to failure of cardiac pump function. The most common rhythms in out-of-hospital cardiac arrest (OHCA): asystole (~50%), VF/pulseless VT (~20-25%), and PEA (~20-25%). In-hospital cardiac arrest (IHCA) is dominated by respiratory arrest, asystole, and PEA (61%), with VF/VT accounting for only ~33%.

Management - BLS/ACLS

RhythmImmediate Action
VF / Pulseless VTImmediate defibrillation + CPR
Asystole / PEAHigh-quality CPR + identify reversible causes (Hs and Ts)
Reversible causes (Hs and Ts):
  • Hypoxia, Hypovolemia, Hypo/hyperkalemia, Hypothermia, Hydrogen ion (acidosis)
  • Tension pneumothorax, Tamponade, Toxins, Thrombosis (PE or MI)
CPR: 30:2 compressions to ventilations; rate 100-120/min; depth ≥5 cm; minimize interruptions. Epinephrine 1 mg IV/IO every 3-5 min for non-shockable rhythms; amiodarone 300 mg IV for shock-refractory VF/VT. Post-ROSC (Return of Spontaneous Circulation): targeted temperature management, treat underlying cause, ICU care.
  • Braunwald's Heart Disease, Rosen's Emergency Medicine

2. Acute Coronary Syndrome (ACS)

Types

  • STEMI - ST elevation myocardial infarction (full occlusion)
  • NSTEMI - Non-ST elevation MI
  • Unstable Angina

Presentation

Classic: chest pain radiating to left arm/jaw, diaphoresis, nausea. Atypical (especially elderly, women, diabetics): dyspnea, syncope, epigastric pain, weakness, fatigue, delirium. In patients >85 years, only ~50% present with chest pain.

Management

Immediate (first 10 min):
  • MONA: Morphine (if pain uncontrolled), Oxygen (if SpO₂ <90%), Nitrates (sublingual), Aspirin 325 mg (chewed)
  • 12-lead ECG within 10 min
  • IV access, cardiac monitoring, troponin, CBC, BMP, coagulation
STEMI - Reperfusion:
  • Primary PCI preferred if available within 90 min (door-to-balloon time)
  • Fibrinolysis (e.g., tenecteplase, alteplase) if PCI unavailable within 120 min of symptom onset and no contraindications; give within 30 min of arrival (door-to-needle)
  • Dual antiplatelet therapy: Aspirin + P2Y12 inhibitor (clopidogrel, ticagrelor, or prasugrel)
  • Anticoagulation: UFH, LMWH, or bivalirudin
NSTEMI/UA:
  • Early invasive strategy preferred for high-risk patients (AHA guidelines - no absolute age restriction)
  • Anticoagulation + dual antiplatelets + beta-blocker + ACE inhibitor
  • Rosen's Emergency Medicine, p. 4015-4021; Braunwald's Heart Disease

3. Acute Ischemic Stroke

Presentation

Sudden onset of focal neurological deficit: facial droop, arm weakness, speech difficulty (FAST mnemonic - Face, Arms, Speech, Time). A deficit maximal at onset or that remits suggests ischemia; depressed consciousness + high BP suggests hemorrhage.

Management

Immediate:
  1. ABCs - attend to airway, breathing, circulation
  2. Finger-stick glucose - treat hypoglycemia or hyperglycemia
  3. Non-contrast CT head to rule out hemorrhagic stroke (MANDATORY before thrombolysis)
  4. Time of onset documentation
Thrombolysis - IV tPA (alteplase):
  • Dose: 0.9 mg/kg IV (max 90 mg); 10% as bolus, rest over 60 min
  • Time window: ≤3 hours (FDA-approved in US); ≤4.5 hours (approved in Europe/Canada; excludes age >80 and prior stroke + diabetes)
  • Key contraindications: sustained BP >185/110 mmHg despite treatment, active hemorrhage, recent major surgery (<14 days), GI bleed (<21 days), any prior intracranial hemorrhage, ischemic stroke in prior year
Blood pressure management in ischemic stroke:
  • Do NOT lower BP unless >220/120 mmHg (or >185/110 if tPA candidate)
  • Avoid aggressive BP lowering - collateral flow to ischemic penumbra may be BP-dependent
  • Treat fever aggressively (detrimental to ischemic brain)
  • Keep glucose 3.3-10.0 mmol/L (60-180 mg/dL)
Endovascular thrombectomy: for large vessel occlusion within 6-24 h depending on perfusion imaging criteria.
Cerebral edema (5-10% of patients): peaks day 2-3; treat with water restriction + IV mannitol; consider hemicraniectomy for malignant MCA infarction.
  • Harrison's Principles of Internal Medicine 22E (2025), pp. 2467-2510

4. Anaphylaxis

Presentation

Rapid-onset multisystem reaction: urticaria, angioedema, bronchospasm, hypotension, tachycardia, stridor. May occur within minutes of exposure to allergen (foods, drugs, insect stings, contrast media).

Management (Steps Taken Simultaneously)

  1. Remove the triggering agent
  2. Supine position (or semi-recumbent if respiratory distress)
  3. Cardiac monitoring, pulse oximetry, BP monitoring
  4. Large-bore IV access (16 or 18G); supplemental O₂
  5. Ensure patent airway; be prepared for endotracheal intubation
Drug Treatment:
PriorityDrugAdult DosePediatric Dose
1st LineEpinephrine IM (anterolateral thigh)0.3-0.5 mg IM (1:1000) q5-10 min0.01 mg/kg IM (1:1000) q5-10 min
2nd LineDiphenhydramine50 mg IV1 mg/kg IV
2nd LineFamotidine (H2 blocker)40 mg IV0.5 mg/kg IV
BronchospasmAlbuterol nebulized2.5 mg in 3 mL NS2.5 mg in 3 mL NS
AdjunctMethylprednisolone (no acute benefit)125-250 mg IV1-2 mg/kg IV
Fluid resuscitation: Adults: 1000 mL isotonic saline in first 5 min (several liters may be needed); Pediatrics: 20-30 mL/kg boluses.
Refractory hypotension: Continuous epinephrine IV drip (1 mg in 1000 mL NS = 1 µg/mL), titrated to response.
  • Rosen's Emergency Medicine, p. 640-682

5. Pulmonary Embolism (PE)

Risk Stratification

Risk CategoryDefinitionTreatment
Low-riskHemodynamically stable, no RV dysfunctionStandard anticoagulation; outpatient possible
Intermediate-riskStable but RV dysfunction on echo OR elevated troponinAnticoagulation; monitor closely; consider PERT
High-risk (massive)SBP <90 mmHg sustained ≥15 min, vasopressors neededSystemic thrombolysis or catheter-directed therapy
Hemodynamic instability definition: SBP <90 mmHg sustained 15 min (not from dysrhythmia), drop from baseline >40 mmHg, vasopressor requirement, or profound bradycardia (<40 bpm).

Management

Anticoagulation (first-line):
  • DOACs: Apixaban or Rivaroxaban are first-line for most patients (no prior heparin bridge needed, oral, rapid onset)
  • LMWH (e.g., enoxaparin): preferred in pregnancy, severe PE not yet tested with DOACs, antiphospholipid syndrome
  • UFH: for severe renal impairment (CrCl <30 mL/min), hemodynamic instability requiring titration
Thrombolysis (for high-risk PE):
  • Alteplase 100 mg IV over 2h (or 0.6 mg/kg over 15 min in cardiac arrest)
  • Absolute contraindications: prior intracranial hemorrhage, ischemic stroke <1 year, active intracranial neoplasm, GI bleed <30 days, active hemorrhage, head trauma with LOC <7 days, INR elevated (liver failure)
Pulmonary Embolism Response Team (PERT): multidisciplinary team for intermediate- and high-risk PE to expedite advanced therapies (catheter-directed thrombolysis, surgical embolectomy).
  • Rosen's Emergency Medicine, pp. 961-979

6. Hypertensive Emergency

Definition

Markedly elevated BP (typically >180/120 mmHg) WITH end-organ damage:
  • Hypertensive encephalopathy, intracranial hemorrhage
  • Acute MI or unstable angina
  • Acute pulmonary edema / heart failure
  • Aortic dissection
  • Eclampsia / severe pre-eclampsia
  • Acute kidney injury
(Distinguish from hypertensive urgency: elevated BP without acute target organ damage)

Management Principles

  • Goal: Reduce BP by no more than 25% within the first hour, then to 160/100-110 mmHg over 2-6 hours; normalize over 24-48 hours
  • Do NOT rapidly normalize BP - risks cerebral, coronary, or renal ischemia
  • Route: IV agents in ICU/HDU with continuous monitoring
  • Avoid sublingual nifedipine (unpredictable, may cause ischemia)
  • Assess volume status before diuretics - many patients are volume-depleted (pressure natriuresis)
Drug choices by situation:
Emergency TypePreferred Agent(s)
Most hypertensive emergenciesLabetalol IV, Nicardipine IV, Clevidipine IV
Aortic dissectionLabetalol IV or Esmolol + Nitroprusside
Acute MI / ACSLabetalol, Nitroglycerin
Pulmonary edemaNitroprusside or Nitroglycerin + diuretic
EclampsiaLabetalol, Hydralazine, Magnesium sulfate (seizure prophylaxis)
PheochromocytomaPhentolamine (alpha-blocker first, then beta-blocker)
Ischemic strokeOnly treat if >220/120 mmHg (or >185/110 if tPA candidate)
  • Comprehensive Clinical Nephrology 7th Ed., pp. 606-660

7. Sepsis and Septic Shock

Definition (Sepsis-3)

  • Sepsis: life-threatening organ dysfunction (SOFA ≥2) from dysregulated host response to infection
  • Septic Shock: sepsis + vasopressors to maintain MAP ≥65 mmHg + lactate >2 mmol/L despite fluids (mortality >40%)

Management (Surviving Sepsis Campaign Bundles)

Within 1 hour ("Hour-1 Bundle"):
  1. Measure serum lactate (re-measure if >2 mmol/L)
  2. Blood cultures x2 before antibiotics
  3. Broad-spectrum antibiotics administered
  4. IV crystalloid 30 mL/kg for hypotension or lactate ≥4 mmol/L
  5. Vasopressors (Norepinephrine first-line) for refractory hypotension to target MAP ≥65 mmHg
Ongoing:
  • Source control (drain abscess, remove infected catheter, surgical debridement)
  • Reassess fluid responsiveness dynamically
  • Hydrocortisone IV for septic shock refractory to vasopressors
  • Lung-protective ventilation if mechanically ventilated (6 mL/kg tidal volume)

8. Diabetic Ketoacidosis (DKA)

Presentation

Polyuria, polydipsia, vomiting, abdominal pain, Kussmaul breathing, altered consciousness. Labs: hyperglycemia, anion gap metabolic acidosis, ketonemia/ketonuria.

Management

Fluids: Normal saline 1 L/hr initially; switch to 0.45% NaCl when glucose <250 mg/dL; add dextrose to IV fluid when glucose <200 mg/dL to prevent hypoglycemia while continuing insulin.
Insulin: Regular insulin 0.1 units/kg/hr IV infusion (or 0.14 units/kg/hr without bolus). Continue until anion gap closes; transition to subcutaneous insulin when patient eating and pH >7.3.
Potassium replacement: Check K+ before insulin. Hold insulin if K+ <3.3 mEq/L - replace first. Maintain K+ 4.0-5.0 mEq/L.
Bicarbonate: Only if pH <6.9 (controversial).
Monitor glucose hourly, electrolytes every 2-4 hours. Identify and treat precipitating cause (infection, non-compliance, new DM).

9. Upper GI Hemorrhage

Presentation

Hematemesis, melena, hematochezia (massive upper bleed), syncope, hypotension, tachycardia. Risk stratify with Glasgow-Blatchford or Rockall score.

Management

  1. Resuscitation: Large-bore IV x2; crystalloid/blood products; target Hb >7-8 g/dL (or >9-10 g/dL in ACS)
  2. PPI: IV pantoprazole/omeprazole bolus 80 mg + 8 mg/hr infusion for suspected peptic ulcer
  3. Octreotide: 50 mcg IV bolus + 25-50 mcg/hr infusion for suspected variceal bleed
  4. Endoscopy: within 24 hours for most; within 12 hours for variceal/high-risk bleeding
  5. Balloon tamponade (Sengstaken-Blakemore tube): temporizing measure for refractory variceal bleeding
  6. TIPS or surgery if endoscopy fails

10. Status Epilepticus

Definition

Seizure lasting ≥5 min OR ≥2 seizures without return to baseline.

Management (Time-Based Protocol)

TimeIntervention
0-5 minABCs, IV access, fingerstick glucose, O₂, monitors
5-20 min (1st line)Lorazepam 0.1 mg/kg IV (max 4 mg) OR Midazolam 0.2 mg/kg IM
20-40 min (2nd line)Fosphenytoin 20 mg PE/kg IV OR Valproate 40 mg/kg IV OR Levetiracetam 60 mg/kg IV
>40 min (refractory)Intubation + Propofol or Midazolam or Pentobarbital infusion; EEG monitoring
Identify and treat cause: hypoglycemia, electrolyte disturbances, infection, drug toxicity, structural lesion.

Summary Table

EmergencyKey Immediate ActionTarget/Goal
Cardiac ArrestCPR + defibrillation (if VF/VT)ROSC
STEMIPrimary PCIDoor-to-balloon <90 min
Ischemic StrokeNon-contrast CT → IV tPA if eligibleDoor-to-needle <60 min
AnaphylaxisIM Epinephrine (anterolateral thigh)Airway, BP stabilization
PE (massive)Systemic thrombolysisHemodynamic stabilization
Hypertensive EmergencyIV antihypertensive (titrated)Reduce BP by ≤25% in 1st hour
Septic ShockFluids + cultures + antibiotics + vasopressorsMAP ≥65 mmHg, lactate clearance
DKAFluids + insulin + K+ replacementClose anion gap, normalize glucose
Upper GI BleedResuscitate + PPI + endoscopyHemostasis
Status EpilepticusBenzodiazepine IV/IMSeizure cessation <20 min
Key Sources:
  • Harrison's Principles of Internal Medicine 22E (2025)
  • Rosen's Emergency Medicine: Concepts and Clinical Practice
  • Tintinalli's Emergency Medicine: A Comprehensive Study
  • Braunwald's Heart Disease
  • Comprehensive Clinical Nephrology 7th Ed.
  • Current Surgical Therapy 14e
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