Option 1: Septic shock

The patient is flushed, breathing hard, and only able to get out a few words between gasps. Her skin is mottled, which the nurse says is a change compared to just one hour ago. The nurse quickly repeats the patient's vital signs, which are now: blood pressure 90/68 mm Hg, heart rate 115 beats/minute, respiratory rate 32 breaths/minute, and SpO₂ 89% on room air. It’s clear this patient is in shock.

Question: What do you do next?

Make your choices, then click the explanation bubbles for more information.

• Take a few minutes to build a comprehensive differential.
• Call for help.
• Perform a full physical examination.
• Stabilize the patient.
• Start an initial workup.

Calling for backup

It can be challenging to know who to call for help, especially in the middle of the night. Familiarize yourself with the backup teams at your hospital early on, before a crisis arises. The available backup may include the following:

• Code team: Call via a “code blue” if a patient has stopped breathing or lost their pulse.
• Rapid response team: Call to proactively intervene and prevent a patient's condition from becoming critical.
• Airway response team : Call to assist with difficult airways if intubation or other advanced airway management is needed.
• Critical care fellow: Call to evaluate a patient who likely needs transfer to the ICU; in addition to securing an ICU bed, they can often help initiate the first steps of critical care.
• House chief : Call to assist with managing codes and rapid responses, triaging admissions from the emergency department, and/or assessing patients who appear unstable.
• Senior resident and/or attending: Call for all important updates on their patients ; they can help with seeing the “big picture,” ensuring all appropriate next steps are considered, and advising about specifics (e.g., whether to call a consult now).

If managing septic shock feels like a race against time, that's because it is. But you've called for a backup, and now you can move through the first steps in management and hopefully prevent a full-on wipeout.

Question: Backup is on the way! Now what?

After an ABCDE survey, perform the following steps concurrently. Click on the explanation bubbles for more information.

First steps

• Perform an ABCDE survey.
• Begin continuous cardiac and respiratory monitoring.
• Provide oxygen therapy and respiratory support as needed.
• Establish IV access.

Initiate sepsis workup

• Laboratory tests
  • Serum lactate
  • CBC
  • CMP
  • CRP and procalcitonin
  • Coagulation panel
  • Blood gas
  • Consider amylase and lipase.
• Microbiology
  • Blood cultures
  • Urine studies: Urinalysis and urine culture
  • Additional cultures as indicated by clinical evaluation (e.g., sputum, CSF, pleural fluid, ascitic fluid)
• Imaging studies
  • Chest x-ray (most patients)
  • Additional imaging based on clinical presentation (e.g., abdominal CT or abdominal ultrasound for an acute abdomen)

Pancultures are generally not indicated as an initial approach to sepsis.

Begin resuscitation

• Start fluid resuscitation with 30 mL/kg of isotonic crystalloid (e.g., lactated Ringer’s solution or normal saline) bolus.
• Add vasopressors to maintain MAP ≥ 65 mm Hg if hypotension persists despite adequate fluid resuscitation.

Begin resuscitation if there are signs of poor peripheral perfusion or MAP < 65 mm Hg.

Next steps

• Start empiric broad-spectrum IV antibiotics.
• Consider invasive blood pressure monitoring and central venous line insertion if patient is not responding to fluids or needs vasopressors.
• Consider a Foley catheter to measure urine output.

Question: Which vasopressor support should you choose?

Decide what you would use for the following, then click the explanation bubbles for more information.

• First-line vasopressor
• Add-on vasopressors

Norepinephrine can be safely started through a secure peripheral IV while awaiting central access. When shock is progressing, delaying vasopressor therapy to obtain central access can be life-threatening.

Your patient eventually requires both IV fluids and vasopressors. Norepinephrine is delivered via peripheral IV until central access can be established. Because of your excellent care of the patient up to this point, you get to do the honors of placing the central venous catheter. Are you up to the task?

Question: What are the initial steps for placing a central venous catheter?

Make your choices, then click on the explanation bubbles to reveal the answers.

• Obtain informed consent.
• Select a CVL insertion site.
• Prepare yourself and the patient for the procedure.
• Review the technique and steps.

That's right—all of the above!

Ultrasound guidance reduces complications and increases the success of central line insertion. Use it whenever available.

You and your senior resident have determined that the internal jugular vein is the most appropriate site for a central venous line. After gathering all the essential equipment, review the key procedural steps (listed below) to maximize your chance of successful placement.

IJ line insertion in adults ^[1][2]

This approach uses a thin-wall introducer needle (TWN) and the Seldinger technique.

1. Center the probe above the IJV.
2. Place the TWN beneath the center of the probe at a 45° angle to the skin.
3. Apply negative pressure to the syringe plunger and advance the TWN until blood flashback occurs.
4. Hold the TWN firmly and remove the syringe.
5. Feed 15–20 cm of guidewire through the TWN. ^[2]
6. Remove the TWN while holding the guidewire in place.
7. Make a small skin incision over the guidewire.
8. Thread the vascular dilator over the guidewire and advance 5–7 cm in a spiral motion into the vein.
9. Remove the dilator and advance the catheter ∼ 16 cm (right IJV) or ∼ 20 cm (left IJV) over the guidewire. ^[1][2][3]
10. Remove the guidewire, aspirate blood from all ports, and flush each port with saline.
11. Secure the catheter to the skin and apply a sterile dressing.
12. Order a chest x-ray to evaluate catheter position.

Hold the guidewire at all times when using the Seldinger technique. ^[1]

Many common procedures are performed infrequently. Use the AMBOSS Knowledge App to quickly refresh your memory about the key steps, maximizing your chance of success and minimizing the risk of complications.

Up for a bonus lap?

Related resources

• Fever
• Sepsis
• Shock

Want to explore the other scenario? Jump over to “Option 2: Postoperative fever with stable vital signs.” You can also return to the main module; see “Burning up wrap-up.”