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Table 1 First hours of management in life-threatening infections

From: Initial Emergency Department Diagnosis and Management of Adult Patients with Severe Sepsis and Septic Shock

Time Intervention
Triage ·Screen for SIRS with vital signs
  ·Screen for source by history and physical exam
  ·Evaluate for organ dysfunction by assessing vital signs and level of consciousness
Immediate ·Assess ABCs
  ·Establish definitive airway
  ·Initiate NIPPVwhile preparing for intubation unless patient is apneic
  ·Lung protective ventilator strategies
  ·Obtain intravenous access (central or two peripheral)
  ·Begin volume resuscitation
  ·Avoid hyperoxia
1st Hour ·Send labs including lactate and blood cultures
  ·Establish source control via broad spectrum antimicrobials and/or definitive management
  ·Check ABG to ensure adequate gas exchange and avoid hyperoxia
  ·Check plateau pressure to avoid barotrauma
  ·Consider bedside ultrasound to assess cardiac function and IVC collapse
  ·Order appropriate imaging
Does Patient Qualify for EGDT? ·SBP < 90 mmHg after 20-30 cc/kg bolus
  ·Lactate > 4 mmol/L
1st Two Hours ·If EGDT eligible, place CVC in torso vein, assess CVP, ScvO2
·If persistent hypotension (MAP < 65 mmHg), place arterial line
Two Hours ·Repeat lactate and calculate clearance
  ·Assess total volume input and urine output
Three Hours ·Reassess input/output; assess resuscitation goals; is patient still volume responsive?
  ·Repeat labs to assess for correction of organ dysfunction
Four to Six Hours ·Final disposition
  ·If resuscitation goals met, enter maintenance phase
  ·If not met, reassess
  ·Consider corticosteroids for vasopressor dependent hypotension
  ·Assess need for glucose control
Every 20-30 Minutes ·Serial reassessment of response to resuscitation
  1. SIRS = systemic inflammatory response syndrome; ABC = Airway, Breathing, Circulation; IV = Intravenous; IVC = inferior vena cava; SBP = systolic blood pressure; EGDT = early goal directed therapy; CVC = central venous catheter; CVP = central venous pressure; MAP = mean arterial pressure; NIPPV = Noninvasive Positive Pressure Ventilation.