ER Basics for Rookies

Sepsis is one of the most time-sensitive emergencies in the ED. Every hour of delay in treatment increases mortality. For rookies, the first 60 minutes are critical: this is where you either turn the tide — or watch the patient spiral.

What Is Sepsis?

• A life-threatening organ dysfunction caused by a dysregulated response to infection.
• In the ED, you don’t need perfect definitions — you need to recognize it fast.

Think: infection + abnormal vitals + organ dysfunction.

Step 1: Recognition (Minutes 0–5)

• Suspect sepsis in any patient with:
  • Fever or hypothermia.
  • Tachycardia, tachypnea.
  • Hypotension or narrow pulse pressure.
  • Altered mental status.
  • Hypoxia, oliguria, mottled skin.
• Use bedside tools (qSOFA, pediatric sepsis criteria) but don’t delay for scoring.

Rookie pearl: If the patient “just looks sick,” trust your gut and act.

Step 2: Immediate Actions (Minutes 5–15)

1. IV/IO access ×2 large-bore (or central line if necessary).
2. Labs & cultures: CBC, electrolytes, lactate, blood cultures ×2, urine, others as needed.
3. Monitor: cardiac, SpO₂, BP, urine output.
4. Oxygen: give supplemental O₂ if hypoxic.
5. Start fluids:
   • Adults: 30 mL/kg isotonic crystalloids (NS or LR).
   • Children: 20 mL/kg bolus, reassess, repeat as needed.

Step 3: Antibiotics (Minutes 15–30)

• Give broad-spectrum antibiotics within 1 hour of recognition.
• Choice depends on source:
  • Pneumonia: ceftriaxone + azithromycin or cefepime + vancomycin if HAP.
  • Intra-abdominal: piperacillin-tazobactam or meropenem.
  • Sepsis unknown source: broad (e.g., vancomycin + cefepime).
• Adjust when cultures return.

Step 4: Reassessment (Minutes 30–45)

• Repeat vitals, exam, cap refill.
• Lactate trend: if elevated, repeat in 2–4 hrs.
• Look for signs of fluid overload (lungs, JVP, CXR).

Step 5: Vasopressors (Minutes 45–60)

• If hypotension persists after fluids → start pressors.
• First-line: norepinephrine (adults), epinephrine (children).
• Can be started peripherally while central line arranged.
• Goal:
  • Adults: MAP ≥65 mmHg.
  • Children: age-appropriate BP or good perfusion.

Adjuncts

• Source control (drain abscess, remove infected line).
• Correct hypoglycemia or electrolyte abnormalities.
• Stress-dose steroids if adrenal crisis or refractory shock.

Common Rookie Mistakes

• Waiting for hypotension before treating — sepsis can exist with normal BP.
• Delaying antibiotics while waiting for cultures.
• Giving maintenance fluids instead of aggressive resuscitation.
• Forgetting to reassess after fluid bolus.
• Not starting pressors early enough.

Rookie Pearls

• The first hour is golden.
• Cultures before antibiotics — but never delay antibiotics if unstable.
• 30 mL/kg in adults, 20 mL/kg in kids — reassess frequently.
• Pressors peripherally are safe — don’t wait for central line.
• Reassess, repeat lactate, escalate early.

Take-Home Message

For rookies:

• Sepsis resuscitation is about speed and structure.
• In the first hour: fluids, cultures, antibiotics, reassessment, pressors if needed.
• Admit all to ICU or monitored unit.

Remember: In sepsis, every minute counts — don’t lose the first hour.