Septic Shock Emergency Management: EMT Guide

Septic Shock: Recognition, Resuscitation and Definitive Management

Why septic shock is time-critical. Septic shock is infection-associated circulatory and cellular/metabolic failure. It can begin with fever, fast breathing, confusion or a subtle change in behaviour and progress to refractory hypotension, kidney injury, respiratory failure and death. Early recognition, appropriate antimicrobials, source control, cautious fluid resuscitation, vasopressor support and frequent reassessment are the core emergency actions. Use the current Uganda Clinical Guidelines, facility sepsis pathway and the latest Surviving Sepsis Campaign guidance.

1. Learning objectives

Define infection, sepsis, septic shock and multiple-organ dysfunction.
Recognise occult hypoperfusion, shock and rapidly deteriorating infection.
Apply an initial ABCDE and sepsis bundle without delaying life-saving treatment.
Describe cultures, empiric antimicrobials, fluids, vasopressors and source control.
Monitor response using perfusion, lactate, urine output, mental status and respiratory findings.
Plan nursing care, antimicrobial stewardship, prevention, referral and post-sepsis recovery.

2. Definitions

Sepsis is life-threatening organ dysfunction caused by a dysregulated response to infection. Septic shock is a severe sepsis state with persistent circulatory/metabolic abnormalities and inadequate tissue perfusion despite appropriate initial resuscitation, requiring vasopressors and intensive monitoring. A patient may have sepsis without fever, positive cultures or obvious hypotension.

Common sources include pneumonia, urinary infection, abdominal infection, meningitis, skin/soft-tissue infection, obstetric infection, infected devices and bloodstream infection. Malaria, dengue, VHF and fungal disease can produce sepsis-like shock and must be considered in Uganda.

Do not use a normal blood pressure to rule out sepsis. Tachypnoea, altered mentation, prolonged capillary refill, cool skin, oliguria or rising lactate can reveal hypoperfusion before hypotension.

3. Pathophysiology and stages

Stage	Physiology/clinical pattern	Priority
Infection with systemic response	Fever or hypothermia, tachycardia, tachypnoea, pain, malaise and inflammatory signs	Find source, measure vitals and identify risk factors.
Early compensated sepsis	Warm peripheries or bounding pulse, fast breathing, confusion, reduced urine or rising lactate	Begin sepsis assessment and treatment before decompensation.
Decompensated shock	Hypotension, cold mottled skin, weak pulse, delayed capillary refill, oliguria and altered consciousness	Resuscitation, antimicrobials, fluids, source control and urgent escalation.
Refractory/multiorgan failure	Persistent vasopressor need, severe acidosis, respiratory/renal/hepatic failure, coagulopathy or coma	ICU/critical care, organ support, prognosis and family communication.

4. Initial recognition and screening

Suspect infection from history, focal symptoms, devices, wounds, pregnancy/postpartum status or epidemiology.
Look for organ dysfunction: confusion, hypotension, hypoxia, oliguria, jaundice, thrombocytopenia, severe pain, acidosis or rising creatinine.
Use an early-warning score or local sepsis screen as an aid—not as a substitute for clinical judgement.
Check serial respiratory rate, pulse, blood pressure, capillary refill, temperature, SpO₂, glucose, mental status and urine output.

High-risk warning signs: respiratory rate ≥22/min or rapidly rising, altered mental state, systolic hypotension, narrow pulse pressure, cool mottled skin, capillary refill >3 seconds, urine <0.5 mL/kg/hr, lactate elevation, hypoxia, cyanosis, severe rigors, purpura, severe pain or rapid deterioration.

5. Immediate ABCDE actions

A – Airway

Assess speech, secretions, vomiting, consciousness and aspiration risk. Prepare suction and an experienced airway plan for exhaustion or reduced consciousness.

B – Breathing

Give oxygen for hypoxaemia or respiratory distress, assess pneumonia/ARDS and prepare assisted ventilation if fatigue develops.

C – Circulation

Obtain reliable IV access, blood samples and cultures when safe; use an intraosseous route if access is urgently impossible.
Assess perfusion before and after every fluid bolus: capillary refill, pulse, mental status, skin, lung sounds and urine output.

D – Disability

Check glucose, AVPU/GCS and pupils; treat hypoglycaemia and seizures immediately.

E – Exposure

Search for pneumonia, urine infection, wounds, devices, meningitis, abdominal/perineal infection, obstetric source and tropical infections; maintain warmth and dignity.

6. First-hour sepsis bundle

Recognise and call: alert the senior clinician, sepsis team and receiving ICU/transfer service.
Measure lactate where available and repeat if elevated or the patient deteriorates.
Take cultures: blood cultures and source-specific specimens before antibiotics when this does not create a dangerous delay.
Give appropriate antimicrobials: start promptly for septic shock/high-probability sepsis using local formulary and resistance data.
Give crystalloid for hypoperfusion: use a measured bolus and reassess for response and overload; individualise in heart/renal failure, pregnancy, dengue or haemorrhage.
Start vasopressor support: if hypotension persists, use norepinephrine first-line in adults under critical-care protocol; do not wait for a central line if delay is dangerous and trained peripheral administration is available.
Find and control the source: drain pus, remove infected devices, debride necrotic tissue, relieve obstruction or operate when indicated.

7. Investigations

Test	Purpose	Clinical caution
Blood cultures and source cultures	Identify organism and narrow treatment	Collect safely before antibiotics when feasible; do not delay antibiotics in shock.
Lactate/ABG or VBG	Perfusion and acid–base trend	Interpret with clinical status, seizures, liver disease and beta-agonist use.
FBC, electrolytes, renal/liver tests, glucose and coagulation	Organ dysfunction, anaemia, thrombocytopenia, dosing and DIC	Repeat to identify trajectory and treatment harm.
Urinalysis/culture, chest imaging, ultrasound or CT	Localise urinary, pulmonary, abdominal or pelvic source	Stabilise first; imaging cannot replace source control.
Malaria, VHF, dengue, HIV/TB or other targeted tests	Identify endemic or outbreak causes	Use appropriate isolation and laboratory notification.

8. Antimicrobial management

Choose empiric treatment by source, severity, community/hospital exposure, recent antibiotics, allergies, pregnancy, renal function and local resistance.
Cover likely gram-positive, gram-negative and anaerobic pathogens only as broadly as the clinical risk requires.
Use a loading dose in shock when appropriate; adjust maintenance dosing after renal/hepatic review and therapeutic monitoring.
Review cultures and clinical response daily; narrow, stop or change therapy when a non-infectious cause or resistant organism is identified.
Do not use antibiotics for every fever without infection probability; stewardship protects future patients and the individual from adverse effects.
Consider antifungal or antiviral therapy only for appropriate risk and specialist indications.

9. Fluid resuscitation

9.1 Principles

Use isotonic crystalloid as the usual first fluid for septic hypoperfusion unless a specific protocol says otherwise.
Give smaller reassessed boluses rather than an unmeasured litre after litre; use dynamic signs of responsiveness when available.
Assess lungs, oxygen requirement, jugular venous pressure/ultrasound, oedema, urine output, capillary refill, mentation and blood pressure.
Balanced crystalloids may be preferred in many adults; follow available local products and protocol.

9.2 Avoiding harm

Individualise in heart failure, kidney failure, cirrhosis, pregnancy, severe anaemia, dengue, VHF or concomitant haemorrhage.
Fluid overload causes pulmonary oedema, abdominal compartment syndrome and worse renal outcomes; reassess cumulative balance.
When hypotension persists after adequate fluid assessment, move promptly to vasopressor support rather than continuing blind fluids.

10. Vasopressors and advanced support

Norepinephrine is the recommended first-line vasopressor for adults with septic shock; titrate to a clinician-defined perfusion/MAP target.
Use a large, well-monitored peripheral vein temporarily if central access would delay treatment; inspect frequently for extravasation.
Add vasopressin in adults with inadequate pressure on escalating norepinephrine according to critical-care protocol.
Consider epinephrine or inotropy for selected refractory shock or cardiac dysfunction under ICU guidance.
Use arterial pressure monitoring, echocardiography, lung ultrasound, lactate/capillary refill trends and urine output to guide ongoing therapy.
Mechanical ventilation, renal replacement therapy, blood products and ECMO are specialist organ-support decisions.

11. Source control

Possible source	Source-control action	EMT/ward priority
Abscess/necrotising soft-tissue infection	Drainage, debridement and surgical review	Do not delay for imaging when necrotising disease is suspected.
Infected IV/urinary/vascular device	Remove or exchange when safe and send cultures	Maintain access for resuscitation; coordinate replacement.
Obstructed urinary/biliary system	Urgent drainage/stent/nephrostomy or surgery	Antibiotics alone may fail without relief of obstruction.
Peritonitis, perforation or infected obstetric tissue	Urgent surgical/obstetric intervention	Early transfer and theatre notification.
Pneumonia/meningitis	Respiratory support, cultures and targeted antimicrobial care	Isolation and airway readiness.

12. Nursing management and monitoring

Record observations at high frequency initially and trend them on one chart.
Measure urine hourly in shock; report oliguria, haematuria or sudden diuresis during recovery.
Maintain strict input/output, cumulative fluid balance and daily weight where feasible.
Assess skin, perfusion, mental status, pain, respiratory effort, lung sounds and line sites.
Administer antimicrobials on time, check cultures, allergies, renal dosing and infusion reactions.
Prevent pressure injury, delirium, aspiration, venous thromboembolism and stress-related complications.
Use aseptic line care, hand hygiene, PPE and isolation precautions for the source pathogen.
Communicate deterioration using a structured escalation tool and document response to each intervention.

13. Special populations

Children: use paediatric sepsis guidance, weight-based fluids and vasoactive support; reassess after each bolus and monitor for fluid overload.
Pregnancy/postpartum: evaluate maternal source, fetal status and obstetric causes; choose pregnancy-safe antimicrobials and involve obstetrics early.
Older adults: fever may be absent; delirium, falls and functional decline can be the presenting signs.
Renal/heart failure: use smaller fluid challenges, bedside ultrasound and earlier vasopressor/critical-care input.
Neutropenia/HIV: broaden the differential, use protective precautions where indicated and escalate empiric therapy promptly.
Malaria/VHF/dengue areas: test and isolate appropriately; fluid strategy may differ from routine bacterial sepsis.

14. Complications

Complication	Clues	Response
ARDS/respiratory failure	Increasing oxygen need, crackles, work of breathing or low SpO₂	Oxygen, lung-protective ventilation/critical care and fluid review.
Acute kidney injury	Oliguria, rising creatinine, hyperkalaemia or acidosis	Perfusion/source management, avoid nephrotoxins, renal review/RRT.
DIC/bleeding	Purpura, oozing lines, falling platelets/fibrinogen	Source control, labs, blood components only for clinical indications.
Encephalopathy/seizures	Confusion, reduced GCS or convulsions	Glucose, oxygen, seizure treatment and neurological review.
Fluid overload	Oedema, pulmonary crackles, weight gain, worsening oxygenation	Stop unnecessary fluids, reassess perfusion and consider diuresis/RRT when stable.

15. Prevention and antimicrobial stewardship

Hand hygiene, safe injections, device bundles, wound care, vaccination and early treatment of localized infection prevent sepsis.
Use sterile technique for lines and catheters; remove devices as soon as no longer needed.
Educate patients to seek care for confusion, fast breathing, severe pain, cold skin, low urine or worsening infection.
Audit time-to-antibiotic, culture quality, source-control delays, fluid overload and de-escalation.
Follow infection-prevention precautions for meningitis, VHF, respiratory or gastrointestinal sources.

16. Handover and transfer

State “suspected septic shock” early and report source, onset and response to treatment.
Give serial vital signs, lactate, urine output, mental status, oxygen/ventilation, fluids, antimicrobials, vasopressor dose and access site.
Tell the receiving team about allergies, pregnancy, renal/heart disease, resistant organisms and pending cultures.
Transfer with pumps, oxygen, monitoring, emergency drugs and an escort trained to manage deterioration.

17. Clinical scenarios

Scenario 1 – Pneumonia and shock. A patient has fever, RR 34/min, SpO₂ 86%, confusion, BP 82/48 and crackles. The EMT gives oxygen, obtains glucose/IV access, calls the sepsis team, obtains cultures without delaying broad empiric antibiotics, gives reassessed crystalloid, prepares norepinephrine/critical care when hypotension persists and arranges monitored transfer.

Scenario 2 – Obstructed urinary sepsis. A patient with fever, flank pain, oliguria and hypotension has hydronephrosis. Antibiotics are started, but the team also alerts urology because drainage is source control; repeated fluids alone will not resolve the obstruction.

Scenario 3 – Fluid overload. A patient with heart failure remains hypotensive after a small bolus but becomes breathless with crackles. The team stops blind fluid loading, gives oxygen, calls critical care, assesses cardiac function and starts vasopressor support when indicated.

18. Common errors

Waiting for a positive culture before treating high-probability shock.
Using qSOFA or one blood-pressure reading as the only screen.
Giving litres of fluid without reassessment or ignoring heart/renal failure.
Delaying vasopressors while repeatedly attempting central access.
Forgetting source control, device removal or surgical referral.
Failing to review/narrow antibiotics when cultures return.
Ignoring post-sepsis weakness, cognitive symptoms and rehabilitation.

19. Quick revision questions

Define sepsis and septic shock.
List six early signs of occult hypoperfusion.
What are the priorities in the first hour?
When should cultures be collected?
Why must antibiotics not be delayed in shock?
What is the usual first-line adult vasopressor?
How do you decide whether more fluid is safe?
Give five examples of source control.
What should the nurse monitor hourly in septic shock?
List five prevention and stewardship measures.

20. Key takeaways