Eduovisual
Multisystem Processes & Disorders
Sepsis: SIRS to sepsis to septic shock and CCS-style bundle
— Operationalized as suspected/confirmed infection + acute rise in SOFA ≥2 points
— Septic shock: sepsis + vasopressor requirement to keep MAP ≥65 mmHg AND lactate >2 mmol/L despite adequate fluid resuscitation (mortality >40%)
— Sepsis-3 replaced "severe sepsis"; SIRS lacks specificity but high sensitivity for screening
— Better as a prognostic flag than a screening tool; do not delay workup waiting for qSOFA
— Fever or hypothermia + tachycardia + hypotension + any acute organ change (confusion, oliguria, AKI, transaminitis, thrombocytopenia, hyperbilirubinemia, hypoxia)
— Elderly patient with falls, delirium, or just "not acting right" — often afebrile; check lactate
— Post-op day 3–5 fevers, indwelling lines/catheters, recent chemo with neutropenia, asplenia, cirrhosis, immunosuppression
Step 3 management: the moment infection + organ dysfunction is suspected, start the clock — the Hour-1 bundle (lactate, cultures, broad-spectrum antibiotics, 30 mL/kg crystalloid if hypotensive or lactate ≥4, vasopressors for refractory hypotension) drives both the CCS case and SEP-1 compliance. Anchor every order on time-from-recognition, not time-from-arrival.
— Productive cough, pleuritic chest pain → pneumonia
— Dysuria, flank pain, CVA tenderness, indwelling Foley → urosepsis (most common in elderly women)
— Abdominal pain, distention, peritonitis, recent surgery → intra-abdominal (perforation, cholangitis, abscess)
— Erythema, induration, crepitus, pain out of proportion → SSTI / necrotizing fasciitis
— Indwelling central line + rigors with line flush → CLABSI
— Elderly: afebrile or hypothermic, isolated delirium, falls, generalized weakness, "failure to thrive"
— Neutropenic (ANC <500): fever may be the only sign; minimal inflammation, no pus
— Cirrhosis: decompensation (encephalopathy, ascites worsening) → think SBP — tap the belly
— Asplenic / post-splenectomy: rapid OPSI with encapsulated organisms (S. pneumoniae, H. flu, N. meningitidis)
— Diabetics: DKA precipitated by occult infection (foot ulcer, emphysematous pyelonephritis, mucormycosis)
— Onset, fevers, rigors, focal pain, urinary/GI/respiratory symptoms
— Exposures: recent hospitalization, antibiotics in last 90 days (risk MDR), travel, tick bites, animal contact, IVDU
— Devices/procedures: lines, catheters, prosthetic joints/valves, recent endoscopy
— Immune status: chemo, steroids ≥20 mg prednisone-equivalent, biologics, HIV, transplant
— Vaccination history (pneumococcal, meningococcal, influenza)
Board pearl: Two stem signals that mean sepsis until proven otherwise — (1) new confusion in an elderly patient with a Foley, and (2) fever + hypotension in a neutropenic chemo patient. Both demand the Hour-1 bundle before the differential is finalized.
CCS pearl: Order vitals q1h, finger-stick glucose, and a focused exam (lung, abdomen, skin, lines, CVA) in the same clock-advance as labs — CCS rewards parallel orders, not serial workup.
— Tachycardia (>90, often >110); blunted if on β-blocker or in late shock
— Tachypnea (RR >22) — earliest sign, driven by lactic acidosis (compensatory respiratory alkalosis)
— Fever >38°C or hypothermia <36°C — hypothermia carries worse prognosis
— Hypotension (SBP <90 or MAP <65, or ≥40 mmHg drop from baseline)
— SpO₂ falling — ARDS develops in ~25% of severe sepsis
— Mentation: confusion, agitation, lethargy → encephalopathy
— Skin: warm, flushed, bounding pulses early (distributive/"warm shock"); cool, mottled, prolonged capillary refill >3 sec late or in mixed/cardiogenic overlap
— Urine output <0.5 mL/kg/hr — early AKI marker
— Mottling score on knees (Ait-Oufella) correlates with mortality
— Lungs: crackles, bronchial breath sounds, dullness, egophony
— Abdomen: rigidity, rebound, Murphy sign, CVA tenderness, ostomy/wound inspection
— Skin: cellulitic borders, bullae, crepitus (necrotizing), pressure ulcers, IV/line sites — expose the patient fully, including back and perineum
— Pelvic/rectal exam if abdominal sepsis source unclear (tubo-ovarian abscess, prostatitis, perirectal abscess)
— Distributive: low SVR, normal-to-high CO, low filling pressures — the classic pattern
— Mixed: ~40% develop sepsis-induced cardiomyopathy (low EF, transient) → may behave cardiogenically
— Bedside POCUS: IVC collapsibility, LV function, B-lines, FAST for occult abdominal source
Key distinction: Warm extremities + wide pulse pressure + hypotension = distributive shock (septic, anaphylactic, neurogenic). Cool, clamped, narrow pulse pressure = cardiogenic or hypovolemic. Misreading this on a stem leads to wrong-fluid wrong-pressor answers.
CCS pearl: Recheck vitals after each intervention (fluid bolus, antibiotic, pressor titration). The grader tracks reassessment — advance the clock 30–60 min, then reorder vitals/lactate/exam.
— CBC with diff — leukocytosis with left shift, bandemia, leukopenia (worse prognosis), thrombocytopenia (DIC, organ dysfunction)
— CMP — Cr (AKI), bicarbonate (gap acidosis), LFTs (shock liver, cholestasis of sepsis), glucose
— Lactate — draw before antibiotics if possible; ≥2 = tissue hypoperfusion, ≥4 = high mortality; repeat within 2–4 hr if initial ≥2 to assess clearance
— VBG/ABG — anion gap metabolic acidosis with respiratory compensation
— Coags (PT/INR, aPTT, fibrinogen, D-dimer) — screen for DIC
— Procalcitonin — useful to support stopping antibiotics when trending down; not for ruling sepsis in/out at presentation
— Troponin, BNP — sepsis-induced myocardial dysfunction common
— 2 sets of blood cultures from separate sites (peripheral + line if CLABSI suspected — paired for differential time to positivity)
— Urine culture + UA
— Sputum Gram stain/culture, respiratory viral PCR (flu, COVID, RSV in season)
— Wound, CSF, paracentesis, thoracentesis, joint as indicated
— CXR universally
— CT abdomen/pelvis with contrast if abdominal source suspected (perforation, abscess, ischemia, obstructive cholangitis)
— RUQ ultrasound for cholangitis/cholecystitis
— CT head + LP if meningitis suspected — give antibiotics first, do not delay for imaging if signs are clear
— Bedside echo if cardiogenic overlap or endocarditis on the differential
Board pearl: A normal WBC does not rule out sepsis. Bandemia >10%, hypothermia, or thrombocytopenia <100k in a sick-looking patient are equally damning. Lactate >2 in a patient with infection = organ dysfunction by Sepsis-3 even without other SOFA points clearly documented.
Step 3 management: Procalcitonin's evidence-based role is antibiotic de-escalation (drop ≥80% from peak or <0.5 → consider stopping) — not initial diagnosis. Don't withhold empiric antibiotics for a low procalcitonin.
— Echocardiography: TTE first for suspected endocarditis, sepsis-induced cardiomyopathy, or assessing volume responsiveness; TEE if TTE non-diagnostic, prosthetic valve, or persistent S. aureus bacteremia
— Lumbar puncture: opening pressure, cell count/diff, glucose, protein, Gram stain, culture, lactate (CSF lactate >4 favors bacterial)
— Paracentesis in any cirrhotic with ascites + fever/AMS/abd pain → SBP if PMN ≥250/mm³ in ascitic fluid
— Thoracentesis for parapneumonic effusion → complicated/empyema if pH <7.2, glucose <40, or pus
— Arthrocentesis if monoarticular swelling — WBC >50k with neutrophil predominance suggests septic arthritis
— CT with IV contrast for intra-abdominal source (don't withhold contrast for mild AKI in sepsis — the diagnostic yield outweighs)
— MRI spine if back pain + fever (epidural abscess, vertebral osteomyelitis/discitis)
— HIDA if acalculous cholecystitis suspected in ICU patient
— Repeat blood cultures q48h for S. aureus, Candida until clearance documented
— Galactomannan, beta-D-glucan if invasive fungal suspected (neutropenic, prolonged steroids)
— HIV testing in any new severe infection
— Stool studies (C. diff, enteric pathogens) if diarrhea
— Multiplex PCR panels (BioFire) accelerate pathogen ID but do not replace cultures for susceptibilities
— Dynamic measures of fluid responsiveness preferred over static CVP: passive leg raise + cardiac output change, pulse pressure variation in mechanically ventilated, IVC ultrasound
— ScvO₂ from central line and lactate clearance guide resuscitation (EGDT-era targets relaxed but trends still useful)
CCS pearl: When the source isn't obvious by Hour 6, order CT abdomen/pelvis and an echo rather than continuing to recheck the same basic labs. CCS rewards source identification — undrained pus or unremoved infected hardware will not be cured by antibiotics alone.
Key distinction: Persistent fever + bacteremia despite appropriate antibiotics = source control failure (abscess, infected device, endocarditis) until proven otherwise — escalate imaging, repeat cultures, get ID and surgical consults.
— 1. Measure lactate; remeasure if initial >2 mmol/L within 2–4 hr
— 2. Obtain blood cultures before antibiotics (don't delay antibiotics >45 min for cultures)
— 3. Administer broad-spectrum antibiotics within 1 hour of recognition
— 4. Begin rapid crystalloid 30 mL/kg for hypotension or lactate ≥4 mmol/L (complete within 3 hr)
— 5. Start vasopressors if hypotensive during or after fluids to keep MAP ≥65 mmHg
— Balanced crystalloids (LR, Plasma-Lyte) preferred over normal saline (SMART, SALT-ED trials — less AKI, less hyperchloremic acidosis)
— 30 mL/kg over first 3 hr is the default starting point; reassess for responsiveness afterwards rather than continuing fixed volumes
— Albumin reasonable as adjunct after large crystalloid volumes, especially in cirrhosis (1.5 g/kg day 1, 1 g/kg day 3 for SBP)
— Avoid hydroxyethyl starches (increased AKI, mortality)
— SOFA (organ dysfunction tracking), APACHE II (ICU prognosis), MEDS (ED sepsis mortality)
— Lactate trajectory is the most actionable single number — failure to clear ≥10%/hr correlates with mortality
Step 3 management: If after 30 mL/kg the patient is still hypotensive (MAP <65), do not chase with endless fluid — start norepinephrine via peripheral large-bore IV while central access is being placed. Over-resuscitation worsens outcomes (pulmonary edema, abdominal compartment syndrome, AKI from venous congestion).
CCS pearl: Document the bundle elements on the CCS clock — lactate, cultures, antibiotic, IVF bolus, reassessment — each as a distinct order with timestamps. This mirrors how SEP-1 compliance is audited in the real hospital.
— Piperacillin-tazobactam 4.5 g IV (covers gram-positives, gram-negatives including Pseudomonas, anaerobes)
— OR cefepime + metronidazole if abdominal/anaerobic concern
— Add vancomycin for MRSA coverage if: skin/soft tissue, indwelling lines, prior MRSA, severe illness, hospital exposure
— Carbapenem (meropenem) if prior ESBL or high local resistance
— CAP severe / ICU: ceftriaxone + azithromycin (or respiratory fluoroquinolone); add vanco if MRSA risk, add antipseudomonal if structural lung disease
— HAP/VAP: cefepime or pip-tazo + vancomycin ± aminoglycoside if MDR risk
— Urosepsis: ceftriaxone if community; pip-tazo or carbapenem if healthcare-associated/prior ESBL
— Intra-abdominal: pip-tazo OR ceftriaxone + metronidazole; carbapenem if severe/healthcare-associated
— Meningitis (adult): ceftriaxone + vancomycin + dexamethasone 0.15 mg/kg q6h (start before/with first antibiotic dose for pneumococcal); add ampicillin if >50 yr, immunocompromised, alcoholism (Listeria)
— Neutropenic fever: cefepime monotherapy, OR pip-tazo, OR carbapenem; add vanco for line, SSTI, mucositis, MRSA history
— Necrotizing fasciitis: vancomycin + pip-tazo + clindamycin (toxin suppression) + emergent surgical debridement
— Toxic shock (Staph/Strep): vanco + clindamycin ± IVIG
— Asplenic patient: ceftriaxone empirically
Board pearl: Every hour of antibiotic delay in septic shock increases mortality ~7%. Empiric coverage is the right answer even when the question stem dangles "wait for cultures."
Step 3 management: De-escalate by day 2–3 based on cultures and clinical trajectory. Treatment duration: 7 days for most sources (PCT-guided trials support shorter courses); 4–6 wk for endocarditis/osteomyelitis; 14 days for S. aureus bacteremia minimum (uncomplicated).
— Norepinephrine first-line (α + modest β, balanced vasoconstriction with preserved cardiac output)
— Add vasopressin 0.03 U/min when norepi reaches ~15–20 mcg/min — catecholamine-sparing, helps achieve MAP target (VASST)
— Epinephrine as third agent or if myocardial dysfunction (added β1 inotropy)
— Phenylephrine rarely (pure α; useful in tachyarrhythmia)
— Dopamine largely abandoned — more arrhythmias, no mortality benefit (SOAP II)
— Angiotensin II (Giapreza) for refractory vasodilatory shock as rescue
— Dobutamine if sepsis-induced cardiomyopathy with low cardiac output despite adequate MAP and volume (cold extremities, low ScvO₂, elevated lactate)
— Hydrocortisone 200 mg/day IV (50 mg q6h or continuous) if vasopressor-refractory shock (norepi >0.25 mcg/kg/min for >4 hr) — ADRENAL, APROCCHSS
— Glucose control: target 140–180 mg/dL with insulin infusion (avoid <110, NICE-SUGAR)
— VTE prophylaxis (LMWH preferred unless contraindicated)
— Stress-ulcer prophylaxis (PPI/H2RA) if mechanical ventilation, coagulopathy, or other risks
— Lung-protective ventilation if ARDS: Vt 6 mL/kg IBW, plateau <30, PEEP per ARDSnet, prone if P/F <150
— Transfuse RBC at Hgb <7 g/dL (TRISS) unless active ischemia/bleeding
— Bicarbonate only if pH <7.2 with AKI (BICAR-ICU)
— Drain abscesses (percutaneous or surgical) within 6–12 hr
— Remove infected lines/catheters/hardware
— Decompress obstructed urinary tract (ureteral stent, percutaneous nephrostomy) — emergent in obstructive pyelonephritis
— ERCP for cholangitis, cholecystectomy/cholecystostomy for cholecystitis
— Surgical debridement for necrotizing infections (within hours)
CCS pearl: "Source control" is a CCS-recognizable phrase — order the imaging that identifies it AND consult the relevant service (IR, urology, general surgery, ID) in the same clock advance.
— Often afebrile or hypothermic; delirium, falls, anorexia, incontinence may be sole presentation
— Baseline frailty worsens outcomes — discuss goals of care early
— Polypharmacy → β-blockers blunt tachycardia, ACEi/ARB exaggerate hypotension, diuretics complicate volume status
— Higher MDR risk if from SNF; consider broader empiric coverage (pseudomonas, MRSA)
— Avoid nephrotoxic combinations (vanc + pip-tazo controversial — some data suggest increased AKI; cefepime alternative if MRSA not needed)
— AKI in ~50% of septic shock; multifactorial (perfusion, inflammation, nephrotoxins)
— Do not under-dose initial antibiotics — give full loading dose, then renally adjust subsequent doses
— Vancomycin: target AUC 400–600 mg·hr/L (preferred over trough monitoring)
— Aminoglycosides: avoid if possible; once-daily dosing if needed
— RRT indications: refractory hyperkalemia, acidosis, volume overload, uremia, certain toxins — timing of RRT initiation does not improve mortality (STARRT-AKI, AKIKI) — start for indications, not prophylactically
— Contrast for CT when needed — do not delay source identification over modest AKI risk
— SBP in any cirrhotic with ascites + fever/AMS/abd pain → paracentesis BEFORE antibiotics
— Empiric ceftriaxone for community-acquired SBP; albumin 1.5 g/kg day 1, 1 g/kg day 3 reduces hepatorenal syndrome and mortality
— Avoid nephrotoxins, NSAIDs, aminoglycosides
— Beta-blockers held in shock (paradoxical worsening in advanced cirrhosis with SBP)
— Adjust hepatically cleared drugs (some β-lactams require no change; tigecycline, metronidazole adjust)
Step 3 management: In an elderly nursing-home resident with altered mentation and a Foley, treat as urosepsis with healthcare-associated coverage (pip-tazo ± vanco), check post-void residual, replace or remove the Foley (source control of the colonized device), and assess goals of care within 24 hr.
Board pearl: Cirrhotic + ascites + any clinical change = tap the belly before any other empiric move. PMN ≥250 in ascitic fluid = SBP, treat even if culture negative.
— Physiologic tachycardia (HR up to 100) and lower baseline BP (SBP ~100) may mask sepsis — MAP <65 is still abnormal
— Common sources: chorioamnionitis, endometritis, septic abortion, pyelonephritis (3× more common), mastitis with abscess
— Empiric: ampicillin + gentamicin + clindamycin for chorio/endometritis; ceftriaxone for pyelonephritis
— Avoid: fluoroquinolones, tetracyclines (after 1st trimester), aminoglycosides if alternatives exist (limited course OK)
— Left lateral decubitus position to optimize uteroplacental perfusion in 3rd trimester
— Continuous fetal monitoring if viable gestation; delivery may be source control
— OB/MFM consult early
— Pediatric SIRS/sepsis criteria differ — age-specific HR, RR, BP
— Hypotension is a late finding in children (preserved cardiac index masks shock)
— Capillary refill, mental status, urine output are earlier markers
— Empiric: ceftriaxone for community; add vancomycin if toxic-appearing/severe; ampicillin if <1 month (Listeria, GBS)
— 20 mL/kg crystalloid boluses, reassess after each; avoid >60 mL/kg total in resource-limited settings (FEAST)
— Single temp ≥38.3°C or sustained ≥38°C for 1 hr = emergency
— MASCC score ≥21 = low risk (outpatient oral cipro + amox-clav possible); <21 = inpatient IV
— Empiric: cefepime, pip-tazo, or meropenem monotherapy; add vancomycin only for specific indications (line infection, SSTI, hemodynamic instability, mucositis, prior MRSA)
— Add antifungal if fever persists ≥4 days on antibiotics
— Encapsulated organisms — empiric ceftriaxone; vaccinate (pneumococcal, meningococcal, Hib) and consider standby amoxicillin
CCS pearl: In a pregnant patient, order continuous fetal monitoring and OB consult as standing items alongside the sepsis bundle — both are graded interventions in the CCS scoring algorithm.
— ARDS (~25% of severe sepsis): bilateral infiltrates, P/F <300, non-cardiogenic edema — manage with lung-protective ventilation, prone positioning, conservative fluids
— AKI (~50%): ATN from hypoperfusion and inflammation; may require RRT
— DIC: prolonged PT/PTT, low fibrinogen, elevated D-dimer, thrombocytopenia, schistocytes; treat underlying sepsis; transfuse only for bleeding or pre-procedure
— Septic cardiomyopathy: transient global LV dysfunction, usually reversible by 7–10 days
— Sepsis-associated encephalopathy: delirium, often without focal findings; rule out meningitis, ICH
— Adrenal insufficiency (critical illness–related corticosteroid insufficiency): consider hydrocortisone
— Stress hyperglycemia, ileus, acalculous cholecystitis, GI bleeding
— Refractory shock (>0.5 mcg/kg/min norepi equivalents) — consider hydrocortisone, vasopressin, angiotensin II, mechanical support if cardiogenic overlap
— Cardiac arrest — PEA most common; address H's and T's (Hypovolemia, Hypoxia, H+, Hypo/Hyperkalemia, Hypothermia; Tamponade, Tension PTX, Toxins, Thrombosis, Trauma)
— VAP, CLABSI, CAUTI, C. difficile (broad-spectrum antibiotic sequela), pressure ulcers, ICU-acquired weakness
— VTE despite prophylaxis — high index of suspicion for PE in unexplained decompensation
— 30–50% of survivors have new cognitive, physical, or psychiatric impairment at 1 yr
— Higher 1-yr mortality even after discharge (~30%)
— Recurrent infections (immune dysregulation persists for months)
— Cardiovascular events increased in 1st year
— PICS (Post-Intensive Care Syndrome): muscle weakness, PTSD, depression, cognitive decline
— Sepsis: ~10–20%
— Septic shock: ~30–50%
— Time-to-antibiotic and source control are the strongest modifiable factors
Board pearl: Acute new-onset atrial fibrillation in sepsis is a marker of severity, not a primary cardiac disease — treat the sepsis, achieve rate control with amiodarone (β-blockers/CCBs poorly tolerated in shock), and most cases resolve.
Step 3 management: Anticipate post-sepsis syndrome at discharge — arrange PCP follow-up within 1 week, screen for depression/PTSD, reconcile meds (many home meds were held), and counsel on signs of recurrent infection.
— Vasopressor requirement (septic shock by definition is ICU-level)
— Mechanical ventilation or rapidly worsening respiratory failure
— Lactate ≥4 despite resuscitation, or rising lactate
— Persistent hypotension after 30 mL/kg fluids
— AMS, GCS ≤13, or rapidly deteriorating mentation
— New AKI requiring RRT, severe acidosis (pH <7.2)
— DIC with bleeding, severe thrombocytopenia
— Need for invasive monitoring (arterial line, central line)
— Sepsis without shock, lactate normalizing, stable vitals, source controlled, on oral or de-escalated IV antibiotics — but early-warning scores (MEWS, NEWS) trended at minimum q4h
— Infectious Diseases: S. aureus bacteremia, candidemia, unusual organisms, no clear source by 24 hr, treatment failure, immunocompromised
— Surgery / IR: any drainable collection, necrotizing infection, perforation, cholangitis (GI/IR), ischemic bowel
— Urology: obstructive pyelo, prostatic abscess, emphysematous pyelo
— OB: pregnant or peripartum
— Critical care / pulmonology: vent management, ARDS
— Nephrology: RRT, complex electrolytes, drug dosing
— Palliative care: poor prognosis, high frailty, prolonged ICU course — early integration improves goal-concordant care
— Document active issues, antibiotic day #, planned duration, pending cultures, source-control status, code status
— Handoffs are a high-risk moment — use I-PASS or SBAR; missed positive cultures and missed de-escalations are common errors
— Boarding in ED >6 hr increases mortality — push for timely admission
Step 3 management: Patients with septic shock or lactate ≥4 belong in the ICU regardless of how they "look" after fluids — physiologic compensation is unreliable, and decompensation tends to be sudden. CCS expects ICU placement as an order, not just a note.
CCS pearl: "Code status discussion" is a recognized order — discuss within 24 hr in any high-mortality sepsis case, document, and re-discuss if trajectory changes.
— Pneumonia vs aspiration pneumonitis: pneumonitis is chemical, fever lower, often improves in 24–48 hr without antibiotics; consolidation typically dependent (RLL); treat empirically if doesn't improve
— Pyelonephritis vs uncomplicated UTI: flank pain, CVA tenderness, fever ≥38, nausea/vomiting distinguish pyelo — needs IV antibiotics if septic; imaging if no improvement at 48–72 hr (abscess, obstruction)
— Cholangitis vs cholecystitis: Charcot triad (fever, jaundice, RUQ pain) ± Reynolds pentad (+ hypotension, AMS) → cholangitis needs emergent ERCP; cholecystitis treated with antibiotics + cholecystectomy within 1 week
— SBP vs secondary bacterial peritonitis: SBP is monomicrobial, low protein; secondary has polymicrobial growth, high protein, glucose <50, LDH >ULN serum → needs surgical eval
— Cellulitis vs necrotizing fasciitis: nec fasc has pain out of proportion, rapid progression, crepitus, bullae, systemic toxicity — LRINEC score ≥6 suggests; surgical exploration is diagnostic and therapeutic
— Endocarditis vs bacteremia from another source: persistent bacteremia, new murmur, vascular/embolic phenomena, IVDU, prosthetic valve → echo, Duke criteria
— Toxic shock syndrome: fever, rash (diffuse macular erythema), hypotension, multi-organ involvement; Staph (tampon, wound) or Strep (skin, necrotizing); add clindamycin for toxin suppression
— Meningococcemia: petechial/purpuric rash + hypotension + DIC → emergent ceftriaxone, droplet precautions, chemoprophylaxis for close contacts
— Rickettsial (RMSF): fever + rash starting on wrists/ankles + tick exposure → empiric doxycycline even in children
— Malaria: travel, fever paroxysms → thick/thin smears, treat per species
— Viral sepsis-mimic: influenza, COVID-19, dengue, hemorrhagic fevers
Key distinction: Persistent fever and bacteremia >48–72 hr on appropriate antibiotics = source control failure (abscess, infected hardware, endovascular focus). Don't just broaden antibiotics — hunt the source with imaging and TEE.
Board pearl: Pain out of proportion to exam findings + rapid progression of erythema = necrotizing fasciitis until surgically excluded; CT can support but should not delay the OR.
— Pulmonary embolism: tachycardia, hypotension, hypoxia, lactic acidosis — look for right heart strain on echo, elevated troponin/BNP, sudden onset, risk factors (immobilization, malignancy, OCP)
— MI / cardiogenic shock: cold extremities, narrow pulse pressure, elevated JVP, S3, pulmonary edema — ECG and troponin
— Adrenal crisis: hypotension refractory to fluids/pressors, hyponatremia, hyperkalemia, hypoglycemia, hyperpigmentation, known steroid use stopped abruptly — give hydrocortisone 100 mg IV empirically
— Anaphylaxis: urticaria, angioedema, bronchospasm, exposure history — IM epinephrine first
— DKA / HHS: infection often the trigger; treat both
— Thyroid storm: fever, tachycardia, AMS, GI symptoms — β-blocker, PTU/methimazole, steroids, iodine
— Pancreatitis: epigastric pain, lipase, can cause SIRS without infection
— Massive GI bleed: hypotension, tachycardia — Hgb may initially be normal
— Heat stroke / NMS / serotonin syndrome / malignant hyperthermia: drug exposure history, rigidity, hyperthermia
— Aortic dissection / ruptured AAA: tearing pain, pulse differential, mediastinal widening
— Pulmonary edema / acute decompensated HF: crackles, elevated JVP, BNP — distinguishing from sepsis is critical because 30 mL/kg fluids will worsen HF
— TTP/HUS: thrombocytopenia, MAHA, fever, AMS, AKI — plasma exchange emergently
— DIC from malignancy (APL): check fibrinogen, smear
— Tumor lysis syndrome, febrile reactions to chemo
— Sympathomimetic toxidromes, salicylates, metformin (lactic acidosis), iron, cyanide/CO
Step 3 management: Before slamming 30 mL/kg into every hypotensive febrile patient, take 60 seconds for bedside echo and lung ultrasound — full RV with septal bowing = PE; B-lines and dilated cardiomyopathy = cardiogenic; flat IVC + small hyperdynamic LV = sepsis/hypovolemia. Wrong fluid in wrong shock kills.
Key distinction: Hypotension + hyperkalemia + hyponatremia + hypoglycemia + history of chronic steroids → adrenal crisis, not sepsis. Hydrocortisone first; cultures and antibiotics still appropriate because infection may be the trigger.
— Most uncomplicated sepsis sources: 7-day course (pneumonia, urosepsis, intra-abdominal with source control)
— Procalcitonin-guided stopping reasonable in select cases
— Endocarditis: 4–6 wk; S. aureus bacteremia: minimum 14 days, longer if complicated; osteomyelitis: 6 wk; prosthetic joint infection: prolonged + ID guidance
— Transition IV → PO when clinically stable, tolerating oral, bioavailable agent available
— Document stop date in discharge summary
— Pneumococcal (PCV20 or PCV15+PPSV23) for adults ≥65, immunocompromised, asplenic, chronic disease
— Annual influenza
— COVID-19 per current CDC schedule
— Meningococcal for asplenic patients (MenACWY + MenB)
— Hib for asplenic
— Tdap if not current
— Live vaccines deferred in active immunosuppression
— Recurrent UTI → post-coital or low-dose suppressive antibiotics, vaginal estrogen in postmenopausal women, behavioral measures
— Recurrent cellulitis → treat tinea pedis, lymphedema management, suppressive penicillin if ≥3 episodes/yr
— Cirrhotic with prior SBP → lifelong norfloxacin or ciprofloxacin prophylaxis
— Aspiration risk → swallow eval, head of bed elevation, oral hygiene
— Asplenia → standby antibiotics (amoxicillin-clavulanate), MedicAlert bracelet
— Restart home antihypertensives, statins, anticoagulants thoughtfully; many were held
— Adjust diabetes meds (often need insulin briefly after stress hyperglycemia)
— Continue VTE prophylaxis post-discharge if mobility limited (consider extended prophylaxis in cancer)
— Educate patient/family on early signs of recurrent infection and when to seek care
— Address post-sepsis syndrome possibility, refer to PT/OT, screen for PTSD/depression at 2–4 wk
Step 3 management: Discharge bundle for sepsis survivors — vaccines updated, antibiotic stop date, PCP follow-up in 1 week, screen for cognitive/psychiatric symptoms, reconcile every med, and ensure transportation/social support. Skipping any of these is a board-style "wrong answer."
— PCP visit within 1 week of discharge — review symptoms, labs, med reconciliation
— ID follow-up at 2–4 wk if on extended antibiotics (endocarditis, osteo, complicated bacteremia)
— Specialist follow-up by source (urology for obstructive pyelo, CT surgery for valve, hepatology for SBP)
— Repeat imaging if drained abscess (US/CT at 2–4 wk) or to document resolution
— CBC, BMP, LFTs weekly for prolonged courses
— Vancomycin: AUC-guided dosing, trough/peak per protocol, renal function
— Aminoglycosides: levels, renal function, audiology if >7 days
— Daptomycin: weekly CK (myopathy)
— Linezolid: weekly CBC (thrombocytopenia, neuropathy if >2 wk)
— Repeat blood cultures to document clearance in S. aureus, candidemia, gram-negative bacteremia
— ICU-acquired weakness affects ~40% of ICU survivors — early mobilization in-hospital, PT/OT post-discharge
— Pulmonary rehab if prolonged ventilation or ARDS
— Cognitive screening (MoCA) at 1–3 months — sepsis-associated cognitive decline common
— Mental health: screen for depression (PHQ-9), PTSD, anxiety; refer to therapy
— Increased CV event risk in 1st year post-sepsis — optimize BP, lipids, glucose, smoking cessation
— Echo follow-up if septic cardiomyopathy was documented (usually resolves by 7–10 days, repeat at 4–6 wk)
— Hand hygiene, wound care, catheter care
— When to call: fever ≥38, new pain, dyspnea, confusion, decreased urine output, redness/drainage at wound
— Driving restrictions if cognitive impairment
— Return-to-work expectations (often weeks to months)
— Advance care planning conversation
Board pearl: Sepsis survivors have ~30% 1-year mortality even after discharge — the post-sepsis period is a high-risk window, not a recovery victory lap. Active outpatient management matters.
Step 3 management: Build follow-up appointments before discharge (PCP within 7 days, specialty within 2–4 weeks). "Patient will arrange follow-up" is a known transition-of-care failure point.
— Discuss within 24 hr in any septic shock case — mortality is high, decisions may need to be made quickly
— Use shared decision-making: explain prognosis honestly (mortality 30–50%, post-sepsis morbidity), elicit values, recommend rather than offer a menu
— POLST/MOLST forms travel with the patient; honor them, but verify validity (signed, current)
— Time-limited trials of aggressive therapy (e.g., "72 hr of full ICU support, then reassess") are ethically sound and useful when prognosis is uncertain
— Septic encephalopathy frequently impairs capacity → engage surrogate decision-maker per state hierarchy (spouse → adult children → parents → siblings)
— Emergency exception: life-saving treatment may proceed without consent when surrogate unreachable
— Document capacity assessment and surrogate identity
— Meningococcal disease, certain TB, novel pathogens → notify public health and provide chemoprophylaxis to close contacts
— Suspected abuse/neglect if presentation suggests (untreated decubitus sepsis in dependent adult, pediatric sepsis from neglect)
— Medication reconciliation at every transition (admission, transfer, discharge) — held home meds, new antibiotics with stop dates, anticoagulation changes
— Pending cultures at discharge must be assigned to a responsible follow-up clinician — this is a leading sentinel-event category (delayed positive blood culture missed)
— Closed-loop handoff with PCP; send discharge summary within 24–48 hr
— SEP-1 (CMS core measure) audits Hour-1 bundle compliance — affects hospital reimbursement
— Antibiotic stewardship: automatic stop orders, daily review, de-escalation by 48–72 hr reduce C. diff and resistance
— Central line bundle (CHG skin prep, full-barrier drapes, daily necessity review) to prevent CLABSI
— Foley necessity reviewed daily — leading source of healthcare-associated sepsis
— CUSP, hand hygiene, sepsis screening tools in EMR
Step 3 management: A patient with septic shock from a Foley UTI in a SNF needs (1) the bundle, (2) Foley removal/replacement, (3) capacity assessment and surrogate engagement, (4) a clear conversation about goals before escalating to intubation if it's not consistent with the patient's known wishes. All four are testable.
Board pearl: When the question stem describes a hypotensive patient with infection and asks "next best step," it is almost always (a) fluids if not yet given, (b) broad-spectrum antibiotics if not yet given, or (c) norepinephrine if still hypotensive after fluids. Identify which Hour-1 bundle element is missing and that's your answer.
— Best next step: broad-spectrum antibiotics + 30 mL/kg LR + blood cultures; replace the Foley
— Wrong answers: wait for urine culture; normal saline 1 L only; dopamine
— Best next step: IV antibiotics + fluids + emergent ERCP
— Reynolds pentad → don't wait, decompress the biliary tree
— Best next step: cefepime monotherapy (or pip-tazo); blood cultures from each lumen of port
— Wrong: vanc + cefepime (only if specific indications)
— Best next step: ceftriaxone + vanc + dexamethasone IMMEDIATELY, then LP/CT
— Don't delay antibiotics for imaging when signs are clear; droplet precautions, chemoprophylaxis to contacts
— Best next step: paracentesis + cultures; if PMN ≥250 → ceftriaxone + albumin
— Don't start antibiotics first — tap first when feasible
— Best next step: norepinephrine, start peripherally if needed while central line placed
— Not: more fluid, dopamine, phenylephrine
— Best next step: hydrocortisone 50 mg q6h ± add epinephrine
— Best next step: de-escalate to ceftriaxone; complete 7-day course
— Best next step: hydrocortisone 100 mg IV for adrenal crisis (still get cultures and antibiotics if infection suspected)
— Best next step: pneumococcal, meningococcal, Hib vaccines + counseling on standby antibiotics
Step 3 management: Recognize the bundle element being tested — the question is almost always probing one specific step (timing of antibiotics, choice of pressor, source control modality, de-escalation).
Sepsis is a life-threatening dysregulated host response to infection that demands recognition within minutes and execution of the Hour-1 bundle — lactate, cultures, broad-spectrum antibiotics, 30 mL/kg balanced crystalloid for hypotension or lactate ≥4, and norepinephrine for MAP ≥65 — alongside aggressive source control and disciplined de-escalation.
Board pearl: Every hour of antibiotic delay in septic shock costs roughly 7% of survival — when the stem describes an undifferentiated hypotensive febrile patient, the bundle element that hasn't happened yet is your answer.
CCS pearl: On the CCS case, run the bundle in parallel orders (lactate, cultures, antibiotic, fluid, pressor, vitals, ICU bed, consults) on the first clock advance — then reassess every 1–2 hr with repeat lactate, vitals, urine output, and exam until the patient stabilizes or escalates.