Emergency Department Management of Septic Shock

Septic shock per Sepsis-3 criteria is a subset of sepsis with circulatory and cellular metabolic abnormalities profound enough to substantially increase mortality. Clinical criteria are vasopressor requirement to maintain MAP >=65 mmHg and serum lactate >2 mmol/L despite adequate volume resuscitation. Hospital mortality exceeds 40%.

Pathophysiology involves dysregulated host response to infection with vasoplegia, capillary leak, microcirculatory dysfunction, mitochondrial impairment, and immunosuppression. Common sources include pneumonia (35%), abdominal infection (21%), urinary tract (10%), bloodstream (15%), skin and soft tissue, and catheter-related infections.

The Surviving Sepsis Campaign Hour-1 bundle mandates immediate measurement of lactate (remeasure if >2), blood cultures before antibiotics, broad-spectrum antibiotics within 1 hour, rapid administration of 30 mL/kg balanced crystalloid for hypotension or lactate >=4, and vasopressor initiation if MAP <65 after fluids. Norepinephrine is first-line vasopressor (target MAP 65 mmHg), with vasopressin or epinephrine added for refractory shock. Source control (drainage, debridement, device removal) within 6-12 hours is critical. Ongoing care includes mechanical ventilation with lung-protective settings, glucose control, stress ulcer and DVT prophylaxis, and dynamic reassessment using point-of-care ultrasound and lactate clearance.