1. Recognition and definitions
2. Initial ABCDE assessment and investigations
3. Sepsis screening and shock identification
4. First-hour resuscitation: oxygen, IV access, fluids, lactate
5. Blood cultures and early broad-spectrum antibiotics
6. Vasopressors and source control
7. Monitoring response and ICU referral
8. Special groups: elderly, pregnancy, immunocompromise, renal/heart failure
9. Complications: septic shock, DIC, AKI, ARDS

Adult ED sepsis management algorithm

0. Recognize and triage immediately

• Altered mental status
• Hypotension or poor peripheral perfusion
• Tachypnea, hypoxemia, increasing oxygen requirement
• Oliguria or acute kidney injury
• Lactate elevation or metabolic acidosis
• Thrombocytopenia, coagulopathy, bilirubin rise
• Mottled/cool skin or prolonged capillary refill

Time-zero actions: first 5-10 minutes

1. ABCDE and immediate stabilization

• Assess ability to protect airway, secretions, vomiting, GCS, facial/airway infection.
• Prepare early intubation if refractory hypoxemia, impending exhaustion, severe encephalopathy, or airway compromise.
• In shock, anticipate peri-intubation hypotension. Have vasopressor running or immediately available before induction.

• Monitor SpO₂ continuously.
• Give oxygen for hypoxemia or respiratory distress.
• Obtain VBG or ABG if shock, significant respiratory compromise, severe acidosis, or ventilatory failure is suspected.
• Bedside lung ultrasound can help assess pulmonary edema, pneumonia, pleural fluid, or alternative diagnoses.

• Cardiac monitor, BP cycling frequently, temperature, continuous pulse oximetry.
• Establish two large-bore IV lines. If access is difficult, obtain intraosseous access.
• Assess perfusion: mental status, pulse quality, capillary refill, skin temperature/mottling, urine output, lactate.
• If hypotension is marked, start fluid and prepare vasopressor support without waiting for all test results.

• Record GCS or AVPU, glucose, full examination for infection source.
• Look specifically for rash/purpura, cellulitis, indwelling devices, wounds, joint infection, abdominal tenderness, obstructed urinary tract, and necrotizing soft-tissue infection.

2. Identify time zero and communicate

• Resuscitation/airway
• IV access and bloods
• Antibiotic selection and administration
• Source-control workup
• ICU/specialty communication

First hour: investigations, cultures, antimicrobials, fluids

3. Essential investigations

Blood tests

• Serum lactate
• CBC with differential and platelets
• Electrolytes, urea/creatinine, glucose
• Liver tests and bilirubin
• Coagulation profile, fibrinogen if DIC is suspected
• VBG/ABG with acid-base status
• Blood group and crossmatch if bleeding, surgery, or major procedure is possible
• Troponin and ECG if ischemia, dysrhythmia, or myocardial dysfunction is suspected
• Pregnancy test when relevant

Microbiology

• Obtain at least two sets of blood cultures from separate sites before antimicrobials if this causes no meaningful delay.
• Culture likely sources: urine, sputum, wound/pus, CSF when appropriate, synovial fluid, stool, device/catheter cultures.
• Do not wait for cultures in a crashing patient.

Imaging and source identification

• Portable chest radiograph
• Point-of-care ultrasound: heart, lungs, abdomen, IVC, biliary system, urinary obstruction, free fluid
• CT with contrast if stable enough and it will guide urgent source control
• Ultrasound for biliary, renal/urinary, pelvic, or abscess pathology

4. Give antimicrobials early

Timing

• Septic shock or very high likelihood of sepsis: give broad-spectrum IV antimicrobials immediately, ideally within 1 hour.
• Possible sepsis without shock and diagnostic uncertainty: rapidly investigate alternative diagnoses, but make a treatment decision within 3 hours.

Principles of empiric therapy

• Likely source: lung, urinary tract, abdomen, skin/soft tissue, CNS, catheter/device, bone/joint
• Community versus healthcare-associated acquisition
• Prior microbiology and recent antibiotics
• Local antibiogram
• MRSA, Pseudomonas, ESBL, VRE, and fungal risk
• Allergy history
• Renal/hepatic function and body weight
• Neutropenia or immunocompromise

Hemodynamic resuscitation

5. Initial fluids

• Start balanced crystalloid, such as lactated Ringer's or Plasma-Lyte, in boluses.
• The SSC suggests at least 30 mL/kg IV crystalloid within the first 3 hours for sepsis-induced hypoperfusion or septic shock, followed by individualized reassessment.
• Avoid starch solutions. Albumin may be considered only after large crystalloid requirements.

Reassess after each bolus

• MAP and pulse pressure
• Mental status
• Capillary refill and skin perfusion
• Urine output
• Lung examination and ultrasound B-lines
• Bedside cardiac ultrasound
• Passive leg raise with stroke-volume/cardiac-output assessment where available
• Lactate trend, interpreted in clinical context

Heart failure, renal failure, pulmonary edema, frailty

6. Start vasopressors early when needed

Indications

• MAP remains <65 mmHg during/after initial fluid resuscitation
• Profound hypotension is present and waiting for fluid completion is unsafe
• Further fluid is unlikely to improve perfusion or risks overload

First line

• Norepinephrine is first-line.
• Target initial MAP ≥65 mmHg.
• It is acceptable to start norepinephrine through a well-functioning, proximal peripheral IV while central access is being arranged. Use a dedicated line, frequent site checks, and transition to central access if prolonged or escalating infusion is expected.

Escalation

• Add vasopressin when norepinephrine requirements are rising.
• Add or substitute epinephrine if MAP remains inadequate.
• Consider dobutamine if there is persistent hypoperfusion with suspected cardiac dysfunction or low cardiac output despite adequate MAP and volume status.
• Avoid dopamine routinely because of arrhythmia risk.

Refractory shock

• In persistent vasopressor-dependent septic shock, consider hydrocortisone 200 mg/day IV, for example 50 mg every 6 hours or continuous infusion.
• Obtain arterial access when shock is persistent or vasopressor requirements are significant, if this does not delay treatment.

Source control: start planning in parallel, not after stabilization

7. Find and control the source

• Drainage of abscess or empyema
• Debridement of necrotizing soft-tissue infection
• Removal of infected vascular catheter or implanted device
• Urinary decompression for infected obstruction
• ERCP or biliary drainage for ascending cholangitis
• Surgery or interventional radiology for perforation, ischemic bowel, intra-abdominal sepsis, or infected collections
• Drainage of septic arthritis

• Pain out of proportion, bullae, crepitus, rapidly spreading cellulitis, skin necrosis
• Peritonitis, perforation, ischemic bowel
• Obstructed infected urinary tract
• Cholangitis with shock or organ dysfunction
• Empyema or large infected collection
• Septic joint with systemic illness

Ongoing reassessment: every 15-30 minutes during active resuscitation

8. Monitor response and complications

• MAP, heart rate, respiratory rate, SpO₂, temperature
• Mental status and peripheral perfusion
• Urine output. Insert a catheter in shock or when accurate output is needed; target generally ≥0.5 mL/kg/hour.
• Serial lactate if initially elevated
• Glucose, electrolytes, renal function
• Platelets/coagulation if DIC is possible
• Pulmonary edema and fluid balance
• Vasopressor dose trend

Respiratory failure

• Use lung-protective mechanical ventilation if intubated.
• Avoid excessive tidal volumes.
• Treat ARDS using ICU protocols and seek early critical-care input.

Other supportive care

• Correct hypoglycemia and severe electrolyte abnormalities.
• Treat fever or pain for comfort, but do not mistake temperature response for resolution of shock.
• Give blood products for active bleeding or standard restrictive transfusion thresholds in stable non-bleeding patients, rather than targeting a hematocrit of 30%.
• Consider DVT and stress-ulcer prophylaxis after admission where indicated.
• Avoid routine bicarbonate for lactic acidosis unless there is a separate indication, such as severe acidemia with selected complications.

Disposition

9. ICU / critical care referral

• Vasopressor requirement
• Persistent hypotension, rising lactate, worsening perfusion
• Need for invasive or noninvasive ventilation
• Altered consciousness or airway risk
• Oliguria/AKI or need for renal replacement therapy
• DIC, severe thrombocytopenia, major coagulopathy
• Multi-organ dysfunction
• Urgent source-control procedure
• High-risk immunocompromise or rapidly progressive infection

One-page bedside sequence

1. Suspect infection + organ dysfunction? Activate sepsis pathway.
2. ABCDE, monitors, two IVs/IO, senior help, ICU alerted if shock.
3. Lactate, blood cultures, key labs, targeted imaging.
4. Give IV antimicrobials immediately for shock/high-likelihood sepsis. Cultures must not delay treatment.
5. Balanced crystalloid, initially aiming toward 30 mL/kg within 3 hours for hypoperfusion/shock, with frequent dynamic reassessment.
6. Norepinephrine early if MAP <65 mmHg persists or fluids are unsafe/ineffective. Peripheral initiation is acceptable short term.
7. Find source and arrange source control in parallel.
8. Reassess perfusion repeatedly: mental state, capillary refill, urine output, lung status, MAP, lactate trend.
9. Escalate: vasopressin/epinephrine, hydrocortisone for refractory vasopressor-dependent shock, ventilation, ICU, surgery/IR.
10. De-escalate antimicrobials once cultures and source data return, and tailor duration to source control and clinical response.