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Any identified potential infection sources such as foreign bod- • If a soft tissue infection is suspected, inspect and monitor
ies, old indwelling catheters (to include IV/IO, urinary, etc.) the identified site (e.g., cellulitis) for improvement. Use a
and dead or dying tissue must be evaluated and attended to marker to outline any redness; time and date it. Monitor
immediately. All previously inserted urinary or other indwell- for any progression beyond the marked lines. If redness
ing catheters and IV/IO catheters should be removed and re- worsens after 24 hours or failure to improve within 48
placed if possible. Those that are not needed to immediately hours, consider changing antibiotics or the need for sur-
care for the patient should be considered for removal. All gical debridement after consulting telemedicine.
wound dressings should be removed, and any sign of infec- • Urine output (UOP) should be maintained at an average
tion requires surgical wound exploration. All dead infected of 0.3–0.5mL/kg/hr.
tissue must be removed, up to and including amputation when • Perform and repeat available labs as indicated. Diag-
needed. Any abscesses or infected spaces must be completely nostics: urine dipstick, malaria tests. Trend: i-STAT,
drained. Any suspected intrathoracic or intraperitoneal infec- lactate.
tion sources must be attended to by a surgeon urgently. Always • Initiate telemedicine early and often and report trends.
initiate antibiotics and fluid resuscitation prior to attempting • Monitor overall respiratory status. Many patients who
surgical interventions. are critically ill with sepsis will need ventilatory support
at some point in their management—see the Airway
 Aggressive and adequate surgical source control is essen- Management – PFC CPG, as well as the PFC reference
21
tial to the patient’s survival. Obtain telemedicine consultation paper: “MSMAID” Applying an Anesthesia Checklist to
from a surgeon. SOF Medicine. Always be prepared to manage a com-
22
plex airway with septic patients. Also, see the CCAT
Monitor the Patient Mechanical Ventilation CPG. 23
Monitor the patient for trend available vital signs, urine out-  Early Telemedicine
put, capillary refill, and adjuncts (ultrasound and/or labs if
available). GOAL: Gather appropriate and complete information and
enlist the help of a critical care and/or surgical expert early in
GOAL: Establish a baseline and measure response to your management. 24
interventions.
• Minimum: Serial vital signs measurement, mental status The following information, if obtainable, should be prioritized
assessment, and urine output. Vital signs trends and in- to enable the most effective telemedicine support: subjective
terventions recorded on flowsheet. comments; objective—vital signs (HR, RR, Systolic BP, MAP,
• Better: Add point-of-care lactate every 6 hours until urine output); mental status; skin exam, lactate (if available);
normal. treatments administered or available—antibiotics; any other
• Best: Add ultrasound monitoring to assess and trend in- drugs, and the amount and type of fluids given so far.
ferior vena cava (IVC) and left ventricular (LV) filling,
decrease in “hyperdynamic” cardiac physiology. • Ensure the complete medical history and documentation
of any preceding events.
Employing focused, goal-oriented interventions as early as • Communicate capabilities available where you are man-
possible has shown to decrease mortality. The following goals aging the patient (e.g., by completing the “capabilities
will direct treatment initiatives. Medical providers should checklist” on the PFC WG Telemedicine Template on
develop and prioritize a problem list with an accompanying prolongedfieldcare.org and emailing/texting if possible
treatment-solutions plan to meet the below therapy goals. before calling the consultant).
• Document any infected wounds, bites, or other poten-
• Systolic blood pressure (SBP) > 90mmHg and/or pal- tial sources of infection, etc. Send photographs or re-
pable radial pulse (if blood pressure monitoring is not al-time video if possible.
available). SBP is the most appropriate and feasible mo-
dality for monitoring a patient’s perfusion status. Evacuate to Definitive Care
• Mean Arterial Pressure (MAP) > 65mmHg. MAP is man-
ually calculated using the formula (SBP + (2 × DBP))/3. GOAL: Patients identified as being septic should be assigned
Most electronic monitors will automatically calculate the highest priority of evacuation to higher levels of medical
the MAP. At times, the MAP may be adequate even care.
when the SBP is low; however, SBP may be used when it
is easier to monitor. Patients with sepsis or with conditions concerning for the de-
• Capillary refill is an easy physical exam skill and im- terioration to sepsis will be best managed in a clinical setting
portant indicator of adequate perfusion as a high- conducive to monitoring and addressing multi-organ failure
fidelity marker for effective resuscitation. It should be and associated complications. Also, see the JTS Nursing Inter-
performed and recorded as a trend at least every 30 min- vention – PFC CPG and JTS Analgesia and Sedation Manage-
utes for the unstable septic patient. The proper way to ment – PFC CPG. 25
measure capillary refill is to apply pressure down on the
fingernail until it blanches (turns white), and after the Nutrition Considerations
removal of the pressure, time the nail’s return to normal
color compared to the other nails. Normal values are Septic patients are most often in a hypermetabolic state due to
a return to baseline color in 3 seconds or less. Longer the body’s efforts to fight off the infection. Nutrition is not the
times indicate normal perfusion has not been restored. most important consideration in the early treatment. However,

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