Eduovisual
CCS Integrated Cases
CCS case: septic shock requiring vasopressors
— Suspected/confirmed infection + SBP <90, MAP <65, or SBP drop >40 from baseline
— Lactate ≥2 (and especially ≥4) mmol/L
— Altered mentation, mottling, oliguria (<0.5 mL/kg/h), cool extremities or warm vasodilated shock
— qSOFA ≥2 (RR ≥22, SBP ≤100, AMS) — useful at triage but not required for diagnosis
— Pneumonia (most common overall, ~40%), UTI/pyelonephritis, intra-abdominal (cholangitis, perforation, C. difficile colitis), skin/soft tissue (necrotizing fasciitis, cellulitis), CLABSI/endocarditis, meningitis
CCS pearl: On the CCS interface, the moment vitals show hypotension + infection signs, your simultaneous orders should be: two large-bore IVs, lactate, blood cultures ×2, CBC/CMP/coags/lipase, UA + urine culture, CXR, ECG, broad-spectrum antibiotics within 1 hour, and 30 mL/kg crystalloid bolus — all entered in the same clock-tick before advancing time.
Board pearl: Septic shock mortality is 30–40%; each hour antibiotics are delayed increases mortality ~4–7%. Recognition is the test.
— Pulmonary: cough, purulent sputum, pleuritic pain, dyspnea, recent influenza
— GU: dysuria, flank pain, indwelling Foley, recent instrumentation, pregnancy (pyelo)
— GI/hepatobiliary: RUQ pain + jaundice (Charcot triad → cholangitis), diffuse pain + rigid abdomen (perforation), diarrhea + recent antibiotics (C. diff)
— Skin/soft tissue: rapidly spreading erythema, pain out of proportion to exam (nec fasc), bullae, crepitus, IVDU injection sites
— CNS: headache, neck stiffness, photophobia, AMS
— Line-related: central line, port, dialysis catheter, rigors with flushes
— Recent hospitalization or IV antibiotics within 90 days → cover MRSA + Pseudomonas
— Neutropenia (chemo within 2 weeks) → febrile neutropenia pathway, cover Pseudomonas
— Asplenia/sickle cell → encapsulated organisms (S. pneumo, H. flu, N. meningitidis)
— Cirrhosis with ascites → SBP (E. coli, Klebsiella) → ceftriaxone + albumin
— Travel, animal exposure, tick bites, IVDU, HIV status, vaccination
Step 3 management: Always ask about antibiotic exposure in the prior 90 days and prior resistant organisms (MRSA, ESBL, VRE) — these single-handedly change empiric therapy choice.
Key distinction: SIRS criteria are sensitive but nonspecific (pancreatitis, trauma, burns trigger them); organ dysfunction is what converts infection → sepsis.
— Temp >38.3 or <36 (hypothermia is a bad prognostic sign), HR >90, RR >22, SBP <90 or MAP <65, SpO2 often ↓
— Pulse pressure widening + warm extremities = early distributive (warm) shock
— Narrow pulse pressure + cool, mottled extremities = late/decompensated shock
— Mottling score (knees), cap refill >3 sec, livedo reticularis, purpura fulminans (meningococcemia, DIC)
— Petechiae on palms/soles → endocarditis/RMSF; Janeway lesions, Osler nodes
— Crepitus, bullae, dusky skin, anesthesia over erythema → necrotizing fasciitis — surgical emergency
— Lungs: rales, dullness, bronchial breathing
— Abdomen: peritonitis, Murphy sign, CVA tenderness, ascites + tenderness (SBP), rectal/perineal exam (Fournier)
— CNS: meningismus, Brudzinski/Kernig, focal deficits
— Lines/wounds: erythema, purulence, fluctuance — remove suspected infected line
— Warm/flushed, bounding pulse, ↑CO, ↓SVR → classic septic (distributive)
— Cold/clamped → mixed cardiogenic-septic (septic cardiomyopathy) — check echo
— JVD, S3 → consider concurrent CHF; flat IVC + collapsible → volume responsive
— Passive leg raise → ↑SV >10% predicts response
— Pulse pressure variation >13% on mechanical ventilation
— IVC variability on POCUS
CCS pearl: Order bedside echo/POCUS early — it differentiates septic (hyperdynamic LV) from septic cardiomyopathy (depressed EF) and identifies tamponade or massive PE masquerading as shock.
Board pearl: Hypothermia (<36°C) in suspected sepsis carries higher mortality than fever — don't be reassured by a "normal" temp.
— CBC with diff (leukocytosis, bandemia, leukopenia, thrombocytopenia of DIC)
— CMP (AKI, hyperglycemia, transaminitis from shock liver, anion gap)
— Lactate — single most important resuscitation biomarker; recheck at 2–4 h
— VBG or ABG (metabolic acidosis, type A lactic)
— Coags + fibrinogen + D-dimer (DIC screen)
— Procalcitonin (supports bacterial source; trend for de-escalation — not for initial Dx)
— Troponin, BNP (demand ischemia, septic cardiomyopathy)
— Blood cultures ×2 from different sites BEFORE antibiotics — but never delay antibiotics >45 min for cultures
— Urinalysis + urine culture
— Lipase if abdominal symptoms
— HIV, pregnancy test when relevant
— CXR (portable) — pneumonia, ARDS, effusion
— CT abdomen/pelvis with contrast if intra-abdominal source suspected (cholangitis, perforation, abscess) — proceed despite mild AKI when source control critical
— CT head before LP if AMS, focal deficits, papilledema, immunocompromised
— POCUS — cardiac function, IVC, lungs (B-lines), bladder, ascites
Step 3 management: Get 2 sets of blood cultures from 2 separate venipunctures — one positive set from a single draw can be a contaminant; two positive sets for the same organism = true bacteremia.
Board pearl: Lactate ≥4 defines "cryptic shock" even with normal BP — resuscitate aggressively and recheck within 2 hours; failure of clearance >10%/h predicts mortality.
— Assess LV function (septic cardiomyopathy in 40–60%), RV size (PE/ARDS), valvular vegetations, effusion/tamponade
— Repeat if hemodynamics worsen on adequate pressors
— TEE if endocarditis suspected and TTE non-diagnostic, or prosthetic valve
— RUQ ultrasound for cholangitis/cholecystitis (followed by MRCP or ERCP)
— CT with IV contrast for abscess, perforation, necrotizing soft tissue (gas in fascia)
— MRI spine if epidural abscess (back pain + fever + focal neuro)
— Lumbar puncture if meningitis suspected — do not delay antibiotics; give empiric ceftriaxone + vancomycin (+ ampicillin if >50 or immunocompromised; + dexamethasone for pneumococcal)
— Paracentesis in any cirrhotic with ascites + fever/AMS/abdominal pain — PMN >250 = SBP
— Thoracentesis if parapneumonic effusion: pH <7.2, glucose <40, or purulence → chest tube
— Arthrocentesis for septic joint
— Rapid PCR panels (respiratory, meningitis/encephalitis, GI, BioFire)
— MRSA nares swab — high NPV to de-escalate vancomycin in pneumonia
— Beta-D-glucan, galactomannan if invasive fungal risk
— Urine Legionella + pneumococcal antigens for severe CAP
— Arterial line for continuous MAP once on pressors
— Central venous access for vasopressors and ScvO2 monitoring
— Consider PA catheter or noninvasive CO monitoring in mixed/refractory shock
CCS pearl: When CCS case shows refractory hypotension despite fluids + norepi, order bedside echo and cortisol level before piling on a third pressor.
Key distinction: Procalcitonin guides de-escalation/duration, not initial decision to start antibiotics — never withhold empiric therapy because procalcitonin is "low."
— 1. Measure lactate; remeasure if initial >2
— 2. Obtain blood cultures before antibiotics
— 3. Administer broad-spectrum antibiotics within 1 hour
— 4. Begin 30 mL/kg crystalloid for hypotension or lactate ≥4 (within 3 hours)
— 5. Initiate vasopressors if hypotensive during/after fluids to maintain MAP ≥65 mmHg
— Two large-bore peripheral IVs; NS or LR 30 mL/kg bolus (≈2 L for 70 kg) wide open
— Continuous cardiac monitor, pulse ox, automated BP q5min, Foley with hourly UOP
— Labs as in chunk 4; cultures ×2 + urine culture
— Empiric antibiotics within 60 min (see chunk 7)
— Portable CXR, ECG
— Repeat lactate, MAP, mental status, UOP, cap refill
— If MAP <65 after 30 mL/kg → start norepinephrine via best available access (peripheral acceptable short-term in large vein) and place central line + arterial line
— If still under-resuscitated and unclear fluid status → PLR, POCUS IVC, dynamic measures rather than more empiric boluses
— MAP ≥65, UOP ≥0.5 mL/kg/h, lactate clearing (>10%/h), improving mentation
— Balanced crystalloids (LR, Plasma-Lyte) preferred over normal saline (less hyperchloremic acidosis, lower AKI)
CCS pearl: Don't chase a CVP number — dynamic measures and MAP/lactate/UOP drive resuscitation. Over-resuscitation (>60 mL/kg total) worsens outcomes.
Step 3 management: Use balanced crystalloids (LR) as first-line; reserve albumin for cirrhotic SBP or refractory resuscitation.
— Unknown source/community: ceftriaxone 2 g IV + vancomycin 25–30 mg/kg load
— Healthcare-associated, neutropenic, or shock: piperacillin-tazobactam 4.5 g IV (extended infusion) OR cefepime 2 g IV q8h OR meropenem 1 g IV q8h, PLUS vancomycin for MRSA
— Suspected MDR/ESBL/prior resistance: meropenem 1 g q8h
— Necrotizing fasciitis: vancomycin + pip-tazo + clindamycin (toxin suppression) + emergent surgical debridement
— Intra-abdominal: pip-tazo or ceftriaxone + metronidazole
— Meningitis (community): ceftriaxone 2 g q12h + vancomycin + dexamethasone (± ampicillin if >50, immunocompromised, pregnant)
— Febrile neutropenia: cefepime or pip-tazo monotherapy; add vanc if line, mucositis, hypotension
— Toxic shock syndrome: vancomycin + clindamycin ± IVIG
— Influenza season + severe CAP: add oseltamivir
— Norepinephrine = first-line (α1 + β1); titrate 0.05–0.5+ mcg/kg/min to MAP ≥65
— Add vasopressin 0.03 U/min as second agent (catecholamine-sparing, ↓ AF risk)
— Add epinephrine if still refractory
— Dobutamine if septic cardiomyopathy (low CO, adequate MAP)
— Phenylephrine in tachyarrhythmia limiting norepi
— Avoid dopamine (↑ arrhythmia, ↑ mortality vs norepi)
— Hydrocortisone 200 mg/day IV (50 mg q6h or infusion) if refractory shock on ≥2 pressors or escalating norepi >0.25 mcg/kg/min
— Stress-dose also for known adrenal insufficiency, chronic steroid use
Board pearl: Norepinephrine + vasopressin is the standard two-drug combo; vasopressin is fixed-dose (0.03 U/min), not titrated.
Step 3 management: Reassess and narrow antibiotics by 48–72 h based on cultures/sensitivities; total course typically 7–10 days (longer for endocarditis, osteomyelitis, undrained collections).
— Cholangitis: ERCP for biliary decompression (within 24 h, sooner if shock); percutaneous transhepatic drainage if ERCP fails
— Cholecystitis (acute): percutaneous cholecystostomy if too unstable for surgery; cholecystectomy when stabilized
— Intra-abdominal abscess: IR percutaneous drainage; surgery if multiloculated or failed drainage
— Perforated viscus: emergent ex-lap
— Necrotizing fasciitis/Fournier: emergent surgical debridement — antibiotics alone never sufficient; serial debridements
— Empyema: chest tube/thoracostomy; VATS for organized empyema
— Pyelonephritis with obstruction (stone): percutaneous nephrostomy or ureteral stent — urgent
— Infected hardware/line: remove the line or device (CLABSI, infected pacemaker, prosthetic joint)
— Endocarditis with HF, large vegetation, abscess, persistent bacteremia: valve surgery consult
— SBP: no procedure beyond paracentesis; ceftriaxone + albumin 1.5 g/kg day 1, 1 g/kg day 3
— Albumin in SBP (renal protection)
— IVIG in streptococcal/staph toxic shock and nec fasc (some evidence)
— Activated protein C — discontinued (don't pick on exam)
— VTE prophylaxis (LMWH unless contraindicated) once not actively bleeding
— Stress ulcer prophylaxis (PPI/H2) for mechanically ventilated, coagulopathic
— Glucose control 140–180 mg/dL with insulin infusion if persistently >180
— Lung-protective ventilation if intubated: Vt 6 mL/kg IBW, plateau <30, PEEP titration
CCS pearl: On CCS, "consult surgery" or "consult IR" must be entered explicitly — recognition without consultation order loses points. For nec fasc, "surgery STAT" within minutes of suspicion.
Board pearl: No amount of antibiotic salvages an undrained abscess, obstructed pyelo, or infected hardware — source control is the answer when patient fails to improve.
— Often afebrile; present with delirium, falls, anorexia, hypothermia, "failure to thrive"
— Lower physiologic reserve → faster decompensation; higher baseline meds (BP, rate control) blunt vitals
— Polypharmacy: beta-blockers can mask tachycardia; ACEi/ARBs and SGLT2i worsen hypotension/AKI — hold on admission
— Goals of care discussion early; clarify code status before intubation
— Drug dosing: renally adjust after first dose; watch QTc with fluoroquinolones, macrolides
— Type A lactic acidosis + AKI is the rule
— Avoid nephrotoxins: NSAIDs, aminoglycosides if alternative exists, IV contrast when avoidable (but don't withhold for critical Dx)
— Vancomycin — load full 25–30 mg/kg, then dose by AUC/trough monitoring; consider linezolid or daptomycin (not for pneumonia) in worsening AKI
— Pip-tazo + vancomycin combo has additive nephrotoxicity signal — consider cefepime alternative in high-risk patients
— CRRT preferred over intermittent HD if hemodynamically unstable; indications: refractory acidosis, hyperK, volume overload, uremia
— Baseline vasodilation, low SVR → mimics/amplifies septic shock; MAP target same (≥65)
— SBP: ceftriaxone 2 g IV daily + albumin 1.5 g/kg day 1, 1 g/kg day 3 (prevents hepatorenal)
— Avoid hepatotoxic agents; reduce metronidazole dose in severe cirrhosis
— Hepatorenal syndrome: midodrine + octreotide + albumin; terlipressin (now FDA-approved)
— Higher risk for fungal and resistant organisms
Step 3 management: In elderly septic patient on chronic ACEi + diuretic, hold both, give fluids, and resume after hemodynamic stability with recheck of creatinine.
Board pearl: Cirrhotic + fever + abdominal pain → tap the belly before antibiotics adjustments — diagnostic paracentesis is mandatory.
— Physiologic ↑HR (+15–20), ↓BP (mid-pregnancy nadir), ↑WBC — baseline values shift; MAP <65 still abnormal
— Common sources: pyelonephritis (most common cause of septic shock in pregnancy), chorioamnionitis, septic abortion, postpartum endometritis, mastitis
— Fluid resuscitate aggressively; left lateral tilt after 20 weeks
— Safe antibiotics: beta-lactams, cephalosporins, vancomycin, clindamycin, azithromycin, metronidazole (after 1st trimester preferred), aztreonam
— Avoid: fluoroquinolones, tetracyclines, aminoglycosides (relative — use if life-threatening), TMP-SMX in 1st trimester and near term
— Vasopressors: norepinephrine still first-line; phenylephrine historically used in obstetric anesthesia
— Continuous fetal monitoring if viable (>23–24 wk); OB on board; delivery may be source control (chorio, septic abortion)
— Postpartum endometritis: clindamycin + gentamicin (classic), or ampicillin-sulbactam
— Tachycardia and tachypnea precede hypotension; hypotension is a late sign
— Fluid bolus 20 mL/kg (up to 60 mL/kg in first hour) — but recent data (FEAST) suggests caution in resource-limited settings
— Empiric ceftriaxone covers most community pathogens; add vancomycin for severe
— Neonates (<28 days): ampicillin + gentamicin (or cefotaxime) for Listeria, GBS, E. coli
Board pearl: Pyelonephritis in pregnancy → admit, IV antibiotics (ceftriaxone), monitor for ARDS (up to 10% develop pulmonary edema/ARDS from endotoxin).
Step 3 management: Suspect chorioamnionitis in any febrile gravida with uterine tenderness — empiric ampicillin + gentamicin and expedite delivery (definitive source control).
— ARDS: bilateral infiltrates, PaO2/FiO2 ≤300 within 7 days of insult; manage with lung-protective ventilation (Vt 6 mL/kg IBW, plateau ≤30, PEEP titration, prone if P/F <150)
— AKI: prerenal → ATN; may need CRRT
— DIC: ↑PT/PTT, ↓fibrinogen, ↓platelets, ↑D-dimer, schistocytes; treat underlying cause; transfuse only if bleeding or pre-procedure
— Septic cardiomyopathy: reversible LV dysfunction; supportive — add dobutamine for low CO
— Hepatic dysfunction: shock liver (transaminases in thousands), cholestasis
— Adrenal insufficiency (CIRCI): consider hydrocortisone in refractory shock
— GI: ileus, stress ulcer, acalculous cholecystitis, NOMI (non-occlusive mesenteric ischemia)
— Encephalopathy: delirium in 50–70%; minimize sedation, treat pain, sleep-wake cycle
— ICU-acquired weakness/critical illness myopathy/neuropathy: early mobilization, minimize NM blockers and steroids
— Over-resuscitation → pulmonary edema, abdominal compartment syndrome, ↑mortality
— Pressor extravasation → tissue necrosis (treat with phentolamine local injection)
— Central line complications: pneumothorax, CLABSI, arterial puncture
— Hyperchloremic metabolic acidosis from high-volume NS
— Antibiotic toxicity: C. diff, AKI, ototoxicity, drug fever
— Post-sepsis syndrome: cognitive impairment, PTSD, depression, persistent fatigue, sarcopenia — 1-year mortality 25–40% even after discharge
— Recurrent infection within 90 days common
— VTE despite prophylaxis
— Healthcare-associated infections (VAP, CAUTI, CLABSI)
Key distinction: DIC vs TTP/HUS — DIC has prolonged PT/PTT and low fibrinogen; TTP has normal coags + neuro symptoms + renal failure + MAHA + thrombocytopenia, and requires plasma exchange, not the DIC pathway.
Board pearl: Persistent or recurrent shock on adequate pressors → think undrained source, adrenal insufficiency, occult bleeding, cardiogenic component — order echo, cortisol, repeat imaging.
— Vasopressor requirement
— Lactate ≥4 or not clearing
— Mechanical ventilation or high-flow O2
— Multi-organ dysfunction (≥2 systems)
— Need for invasive monitoring (arterial line, central line)
— Inadequate response to initial bundle
— Stable vitals after resuscitation, single-organ involvement, MAP maintained without pressors, decreasing lactate
— Telemetry for ongoing monitoring
— At T=1h: if MAP <65 after 30 mL/kg → norepi + central line + arterial line + ICU transfer
— At T=3h: if escalating pressors >0.25 mcg/kg/min norepi → add vasopressin, start hydrocortisone, recheck lactate, echo
— At T=6h: if persistent lactate >4 or pressor escalation → reimage for occult source, consider CRRT prep, broaden antibiotics
— ICU/Critical care — all shock patients
— Infectious disease — resistant organisms, persistent bacteremia, unclear source, immunocompromised
— Surgery / IR — source control (any drainable collection, nec fasc, perforation)
— GI/Hepatology — cirrhotic, ERCP for cholangitis
— Nephrology — RRT decisions
— Cardiology — endocarditis, septic cardiomyopathy
— OB — pregnant patient
— Palliative care — goals of care, especially elderly/frail/MOF
CCS pearl: "Move patient to ICU" is a discrete order — enter it once stabilization measures are initiated; the case clock continues, so don't wait for "perfect" stability before transferring.
Step 3 management: Document code status before intubation/central line — Step 3 ethics points reward conversations done proactively, not after a crisis.
— Anaphylactic shock: acute onset post-exposure, urticaria, angioedema, bronchospasm; treat IM epinephrine 0.3–0.5 mg, fluids, H1/H2 blockers, steroids
— Neurogenic shock: spinal cord injury above T6; bradycardia + hypotension (key distinction — sepsis tachycardic); fluids + norepi/phenylephrine, atropine for HR
— Adrenal crisis: hyperpigmentation, hyperK, hypoNa, hypoglycemia, prior steroid use; hydrocortisone 100 mg IV + fluids; can coexist with sepsis (CIRCI)
— Toxic shock syndrome (TSS): staph (tampon, packing, surgical wound) or strep (nec fasc); diffuse erythroderma, desquamation later, multi-organ; clindamycin + vancomycin + source removal + IVIG
— Drug-induced/anaphylactoid: vanc red man (slow infusion, not true anaphylaxis), contrast reactions
— Mimics sepsis but blood cultures negative; ferritin >10,000, hypertriglyceridemia, hypofibrinogenemia, cytopenias, splenomegaly
— Treat underlying trigger; HLH protocol with steroids, etoposide
Key distinction: Adrenal crisis vs septic shock — both hypotensive and febrile, but adrenal crisis has hyperkalemia, hyponatremia, hypoglycemia, eosinophilia, and dramatic response to hydrocortisone. Always check cortisol if shock refractory.
Board pearl: Bradycardia + hypotension in a trauma patient → neurogenic shock (cord injury) until proven otherwise, not hemorrhagic (which causes tachycardia).
Step 3 management: When etiology unclear, you can empirically treat for both sepsis and adrenal insufficiency — draw random cortisol, then give hydrocortisone 100 mg IV + antibiotics + fluids simultaneously.
— Hemorrhage (GI bleed, ruptured AAA, ectopic pregnancy, trauma, retroperitoneal bleed on anticoagulants), severe dehydration, burns
— Cool, clamped, tachycardic, low CVP, flat IVC; Hgb may be normal acutely
— Manage: control bleeding source, massive transfusion protocol (1:1:1 RBC:FFP:platelets), TXA in trauma <3h
— MI (LAD, RV infarct), acute valve failure, myocarditis, tamponade
— Pulmonary edema, JVD, S3, cool extremities, ↑lactate; ECG, troponin, echo
— Manage: revascularize STEMI, inotropes (dobutamine, milrinone), mechanical support (IABP, Impella, ECMO); avoid aggressive fluids
— Massive PE: sudden dyspnea, ↑RV strain on echo, S1Q3T3; tPA if hemodynamic instability
— Tamponade: Beck triad, pulsus paradoxus, electrical alternans; pericardiocentesis
— Tension pneumothorax: absent breath sounds, tracheal deviation, JVD; needle decompression then chest tube
— Septic + cardiogenic (septic cardiomyopathy), septic + hypovolemic (GI losses, third spacing), septic + obstructive (PE in immobile septic patient)
— DKA/HHS — glucose, ketones, anion gap
— Thyroid storm — hyperthyroid signs, ↓TSH, ↑T4
— Myxedema coma — hypothermia, bradycardia, hyporeflexia
— Drug overdose/toxidromes — opioids (Narcan), CCB/BB overdose (calcium, glucagon, high-dose insulin)
— Heat stroke vs sepsis — environmental history; both can have fever + MOF
Key distinction: POCUS in 5 minutes classifies shock — hyperdynamic LV + flat IVC = septic/hypovolemic; depressed LV + dilated IVC = cardiogenic; large RV = PE; pericardial effusion = tamponade.
Board pearl: Always ECG + troponin + lactate + lipase + glucose in unexplained shock — these 5 tests catch most occult diagnoses in <30 minutes.
— Total course tailored to source: uncomplicated UTI 7–10 d, pneumonia 5–7 d, intra-abdominal 4–7 d post-source-control, bacteremia (uncomplicated GNR) 7–14 d, S. aureus bacteremia 14 d (uncomplicated) to 4–6 wk (complicated/endocarditis)
— Procalcitonin-guided de-escalation acceptable
— Transition to oral therapy when: afebrile 24–48 h, hemodynamically stable, tolerating PO, source controlled
— OPAT (outpatient parenteral antibiotic therapy) for prolonged IV courses (endocarditis, osteomyelitis): PICC line, weekly labs (CBC, CMP, drug level)
— Restart ACEi/ARB once Cr stable and BP tolerates
— Restart beta-blocker before discharge if held
— Reassess statin, anticoagulation
— Hold SGLT2i during acute illness (DKA risk); resume when fully recovered
— Insulin/oral hypoglycemics: recalibrate doses
— Pneumococcal (PCV20 or PCV15+PPSV23) for all adults ≥65 and high-risk
— Influenza (annually, in season)
— COVID-19 updated booster
— Meningococcal + Hib if asplenic or complement deficient
— Tdap if not current
— PT/OT consult; early mobilization started in ICU
— Skilled nursing facility vs home with home health
— Nutrition: address sarcopenia, protein intake
— Pressure ulcer prevention, DVT prophylaxis transition
Step 3 management: Every sepsis discharge → pneumococcal + influenza vaccines ordered before leaving the hospital. Don't defer to "outpatient" — completion rates drop sharply.
Board pearl: Asplenic patients need lifelong daily penicillin VK or amoxicillin prophylaxis (especially children, first 5 years post-splenectomy in adults) plus a stand-by emergency antibiotic course.
— PCP within 7 days (ideally 48–72 h for high-risk) — readmission rates 20–25% in first 30 days
— ID follow-up at 2 weeks if complicated infection, OPAT, or resistant organism
— Surgical follow-up at 1–2 weeks for source-control procedures
— Nephrology at 1–2 weeks if AKI required RRT or persistent CKD
— Cardiology at 2–4 weeks if septic cardiomyopathy or new AF
— Pulmonary at 4–6 weeks if ARDS (PFTs, 6-minute walk)
— CBC, CMP at 1 week (renal recovery, leukocytosis resolution)
— Vancomycin levels weekly if on OPAT
— CRP/procalcitonin trends if ongoing concern
— Repeat blood cultures only if ongoing fever/bacteremia concern (S. aureus, Candida — clearance documentation needed)
— Cognitive: MoCA at 3 months — up to 30% have new cognitive impairment
— Mental health: PHQ-9, GAD-7, PTSD screen — depression in 30%, PTSD in 20%
— Functional status: ADL/IADL assessment
— Sleep, fatigue, appetite
— Refer to post-ICU clinic if available
— Outpatient PT for deconditioning, ICU-acquired weakness
— Pulmonary rehab if persistent dyspnea
— Cardiac rehab if cardiac involvement
— Smoking cessation, alcohol counseling
— Diabetes/hypertension optimization (sepsis often a wake-up moment)
— Recognize early signs of recurrent infection (fever, rigors, new pain)
— Seek care promptly — return precautions written
— Medication reconciliation; teach back
Step 3 management: Schedule the PCP visit before discharge with an actual date — written, on paper or via portal — and arrange transportation. This is a tested transitions-of-care intervention.
Board pearl: Sepsis survivors have 2–3× baseline mortality at 1 year — aggressive longitudinal follow-up, vaccination, and chronic disease optimization save lives downstream.
— Address before intubation/CPR when possible; document POLST/MOLST, healthcare proxy, advance directive
— Surrogate decision-making hierarchy varies by state — generally spouse → adult children → parents → siblings
— Time-limited trials of aggressive therapy are ethically appropriate when prognosis uncertain
— Palliative care consult does NOT mean withdrawal — integrates symptom control with active treatment
— Emergency exception: life-saving interventions (intubation, central line, emergent surgery) in an unconscious patient without surrogate available — proceed under presumed consent
— Capacity assessment in delirium/encephalopathy: patient lacks capacity if cannot understand, appreciate, reason, or express a choice — defer to surrogate
— Jehovah's Witness: document specific blood products refused (whole blood, RBC, FFP, platelets, albumin, factor concentrates often acceptable); explore alternatives (cell saver, EPO, IV iron)
— Suspected elder abuse/neglect contributing to presentation (decubiti, poor hygiene from neglect)
— Certain infections (meningococcal disease, TB, syphilis, HIV — state-dependent) reported to public health
— Suspected child abuse (rare in adult sepsis but possible)
— Gunshot/stab wounds with infection — law enforcement
— Medication reconciliation 3 times: admission, transfer (ICU↔floor), discharge — sepsis discharges have >50% med errors without structured rec
— Pending labs/cultures at discharge — communicate clearly to PCP with explicit follow-up plan and contingency ("if MRSA on culture, switch to…")
— Read-back, structured handoff (I-PASS, SBAR)
— Discharge summary to PCP within 48 hours
— CLABSI bundle (chlorhexidine, full barrier, daily line necessity review)
— CAUTI bundle (remove Foley ASAP)
— VAP bundle (HOB ≥30°, oral chlorhexidine, sedation holidays, SBT)
— Pressure injury prevention
Step 3 management: When the family insists on "do everything" despite poor prognosis, the answer is family meeting with palliative care, not unilateral DNR or capitulation — shared decision-making with prognostic information.
Board pearl: Mandatory reporting of suspicion of elder abuse — you do not need to prove it; reporting in good faith is legally protected.
— UTI/pyelo: E. coli (most common), Klebsiella, Proteus, Enterococcus
— Pneumonia (CAP): S. pneumoniae, H. flu, atypicals (Legionella in severe)
— HAP/VAP: Pseudomonas, MRSA, Acinetobacter, ESBL Enterobacterales
— Intra-abdominal: E. coli, Bacteroides, Enterococcus, Klebsiella
— Skin/soft tissue: Staph aureus (MSSA/MRSA), Strep pyogenes
— Nec fasc type I (polymicrobial, diabetic) vs type II (GAS, healthy host)
— IVDU endocarditis: S. aureus → tricuspid valve
— Cirrhosis SBP: E. coli, Klebsiella, S. pneumoniae
— Asplenia: encapsulated — S. pneumo, H. flu, N. meningitidis (OPSI)
— Catheter-related: coag-neg staph, S. aureus, Candida
— Neutropenia: gram-negatives + Pseudomonas; consider Aspergillus, Candida
— TSS (staph) — tampons, packing, post-surgical
— Strep TSS — nec fasc, postpartum
— Add clindamycin for toxin suppression
— MAP target ≥65, UOP ≥0.5 mL/kg/h, lactate clearance >10%/h
— Initial fluid 30 mL/kg crystalloid in first 3 hours
— Antibiotics within 1 hour
— Septic shock mortality ~30–40%
— Each hour antibiotic delay → 4–7% ↑ mortality
— Norepi starting dose 0.05 mcg/kg/min, vasopressin fixed 0.03 U/min
— Hydrocortisone 200 mg/day in refractory shock
— Glucose target 140–180 mg/dL
— Lung-protective Vt 6 mL/kg IBW, plateau ≤30
— Dopamine (use norepi), HES starches, etomidate (single dose for intubation OK but adrenal suppression), routine high-dose steroids without indication, aminoglycoside monotherapy
Board pearl: S. aureus bacteremia ALWAYS gets: repeat blood cultures to document clearance, TTE (TEE if prosthetic valve or persistent bacteremia), ID consult, and minimum 14 days IV therapy.
Key distinction: Procalcitonin guides duration, lactate guides resuscitation — don't mix them up.
— "78yo nursing home resident with confusion, T 38.5, HR 112, BP 86/54, foul urine" → septic shock from pyelo, fluids + ceftriaxone
— "Cirrhotic with ascites, fever, abdominal pain" → paracentesis (PMN >250), ceftriaxone + albumin
— "Post-op day 5, indurated wound, pain out of proportion, crepitus" → necrotizing fasciitis: surgery + vanc + pip-tazo + clindamycin
— "Chemo patient ANC 200, fever 38.5" → febrile neutropenia: cefepime monotherapy
— "IVDU with fever, new murmur, tricuspid vegetation" → S. aureus endocarditis, vancomycin + cardiology consult
— "Pregnant with pyelo, dyspnea, bilateral infiltrates" → ARDS complication, supportive ventilation
— Patient on 30 mL/kg fluids, MAP still 58 → start norepinephrine, place central + arterial lines, transfer to ICU
— On norepi 0.3 + vasopressin 0.03, MAP 60 → add hydrocortisone 200 mg/day, echo, recheck cortisol
— Lactate not clearing → reassess for source control (image again, surgery consult)
— Persistent S. aureus bacteremia day 5 → repeat TEE for endocarditis/abscess, ID consult
— Before LP in AMS + papilledema → CT head first
— Before contrast in AKI → balance risk/benefit; don't withhold for critical Dx
— In refractory shock → echo + cortisol + reimage for source
— Septic shock survivor → pneumococcal + flu vaccines, PCP in 7 days, screen for post-sepsis syndrome
— Asplenic post-pneumococcal sepsis → lifelong penicillin prophylaxis + emergency standby antibiotics
— Family disagrees with patient's prior advance directive → honor the directive; family meeting with palliative care
— Unconscious, no surrogate, life-threatening → emergency exception, proceed
— Jehovah's Witness with hemorrhagic shock → document refusal, use alternatives, respect autonomy
Step 3 management: When the stem says "MAP <65 despite 30 mL/kg" — the answer is norepinephrine, not more fluids. Memorize this trigger.
Board pearl: When two answers seem right, choose the one that does both diagnosis and treatment simultaneously (e.g., cultures + antibiotics, not cultures then antibiotics).
Septic shock = sepsis + vasopressor requirement to maintain MAP ≥65 + lactate >2 despite adequate fluid resuscitation — recognize early, deliver the Hour-1 bundle (lactate, cultures, broad-spectrum antibiotics, 30 mL/kg crystalloid, norepinephrine for refractory hypotension), achieve source control, and escalate to ICU while planning longitudinal post-sepsis recovery.
Board pearl: The three exam-winning behaviors in any CCS sepsis case are (1) simultaneous orders at T=0 (cultures + antibiotics + fluids + labs + imaging together, not sequentially), (2) explicit source-control consultation when indicated, and (3) proactive code-status and goals-of-care documentation before crisis-driven intubation. Master these and the case grades itself.