- Category of patient
-
< 5 years old [Inclusion criteria: Child looks unwell, parental concern, abnormal temperature (< 36°C or > 38°C)]
-
Risk factors include:
– Impaired immunity (e.g. diabetes, steroids, chemotherapy, neutropenia, asplenia)
– Indwelling lines / IVDU / broken skin / indwelling devices
– Recent trauma / surgery / invasive procedure
– Rural, remote or low socioeconomic status
– Re-presentation or delayed presentation to a health service
– Infants < 3 months old -
Next
- Is there an obvious non-infective cause to the abnormal presentation?
-
Yes, the patient has an obvious non-infective cause.
- Sepsis unlikely. Consider other diagnosis
-
There is no obvious non-infective cause.
- Are there any red flags present?
– BSL < 3mmoL/L (note: < 2.6mmol/L for neonates)
– Doesn't wake when roused / won't stay awake
– Child looks unwell to healthcare professional
– Weak, high-pitched or continuous cry
– Tachypnoea (see chart)
– Tachycardia (see chart)
– Bradycardia (< 60 beats per minute)
– SpO2 < 91% on room air or oxygen requirements > 10 litres per minute
– Non-blanching rash / mottled / ashen / cyanotic
– Lactate > 4mmol/L (if available)
Note: These parameters are relative to sepsis assessment onlyTachypnoea Tachycardia Bradycardia Age Severe Moderate Severe Moderate Severe Moderate < 3 months ≥75 65–74 ≥180 170–179 ≤50 ≤60 3 – 12 months ≥75 65–74 ≥180 170–179 ≤60 ≤70 1 – <5 years ≥55 50–54 ≥170 160–169 ≤60 ≤70 -
Yes, the patient has red flags present.
-
Commence sepsis management
-
-
No, the patient does not have any red flags present.
- Are there any amber flags present?
– Family and/or clinical concern is continuning or increasing
– Not responding normally / no smile / reduced activity / very sleepy
– Unexplained pain, leg pain or cold extremities
– Tachypnoea (see chart)
– Tachycardia (see chart)
– SpO2 < 92% or increased oxygen requirements
– Temperature ≤ 36°C or ≥ 38°C
– Capillary refill time > 3 seconds, mottled or cold extremities
– Lactate 2–4 mmol/L (if available)
– Reduced urine output
– Nasal flaring
Note: These parameters are relative to sepsis assessment onlyTachypnoea Tachycardia Bradycardia Age Severe Moderate Severe Moderate Severe Moderate < 3 months ≥75 65–74 ≥180 170–179 ≤50 ≤60 3 – 12 months ≥75 65–74 ≥180 170–179 ≤60 ≤70 1 – <5 years ≥55 50–54 ≥170 160–169 ≤60 ≤70 -
Yes, the has amber warnings present
-
Further information and review required. Transfer to destination, communicate potential of sepsis at handover.
-
-
No amber warnings present
- Sepsis is unlikely.
Transport to appropriate ED.
- Sepsis is unlikely.
- Are there any amber flags present?
- Are there any red flags present?
-
Risk factors include:
-
5 – 11 years old [Inclusion criteria: Child looks unwell, parental concern, abnormal temperature (< 36°C or > 38°C)]
- Risk factors include:
– Impaired immunity (e.g. diabetes, steroids, neutropenia, chemotherapy, asplenia)
– Indwelling lines / IVDU / broken skin / indwelling devices
– Recent trauma / surgery / invasive procedure
– Rural, remote or low socioeconomic status
– Re-presentation or delayed presentation to a health service -
Next
- Is there an obvious non-infective cause to the abnormal presentation?
-
Yes, the patient has an obvious non-infective cause.
- Sepsis unlikely. Consider other diagnosis
-
There is no obvious non-infective cause.
- Are there any red flags present?
– BSL ≤ 3mmoL/L
– Doesn't wake when roused / won't stay awake
– Objective evidence of new or altered mental state
– Child looks unwell to healthcare professional
– Tachypnoea > 50 breaths per minute
– Tachycardia > 170 beats per minute
– Bradycardia < 60 beats per minute
– Needs oxygen to keep SPO2 ≥ 90%
– Non-blanching rash / mottled / ashen / cyanotic
– Lactate > 4mmol/L (if available) -
Yes, the patient has red flags present.
-
Commence sepsis management
-
-
No, the patient does not have any red flags present.
- Are there any amber flags present?
– Family and/or clinical concern is continuning or increasing
– Behaving abnormally / not wanting to play / drowsy / confused
– Unexplained pain, leg pain or cold extremities
– Tachypnoea (45 – 49 breaths per minute)
– Tachycardia (160 – 169 beats per minute)
– SpO2 ≤ 92% on room air
– Temperature ≤ 36degC or ≥ 38degC
– Capillary refill time > 3 seconds, mottled or cold extremities
– Lactate 2–4 mmol/L (if available)
– Reduced urine output (< 1mL/kg/hr if catheterised) -
Yes, the has amber warnings present
-
Further information and review required. Transfer to destination, communicate potential of sepsis at handover.
-
-
No amber warnings present
- Sepsis is unlikely.
Transport to appropriate ED
- Sepsis is unlikely.
- Are there any amber flags present?
- Are there any red flags present?
- Risk factors include:
-
12+ years [Inclusion criteria: NEWS2 ≥ 5]
- Risk factors include:
– Age > 75 years
– Impaired immunity (e.g. diabetes, neutropenia, steroids, chemotherapy)
– Recent trauma / surgery / invasive procedure
– Indwelling lines / IVDU / broken skin -
Next
- Could abnormal NEWS2 score be due to an infection in the:
– Respiratory tract
– Urinary system
– Skin / joint / wound
– Indwelling device
– Brain
– Surgical site
– Other -
No, the patient has no identified infections.
- Sepsis unlikely. Consider other diagnosis
-
Yes, the patient has identified infections.
- Are there any red flags present?
– Objective evidence of new or altered mental state
– Systolic BP ≤ 90mmHg (or drop of > 40mmHg from normal)
– Heart rate ≥ 130 per minute
– Temperature ≤ 35degC
– Respiratory rate ≥ 25 per minute
– Needs oxygen to keep SPO2 ≥ 94% (88% in COPD)
– Non-blanching rash / mottled / ashen / cyanotic
– No urine passed in 18 hours (< 0.5mL/kg/hr if catheterised)
– Lactate ≥ 2 (if available)
– Recent chemotherapy -
Yes the patient has red flags present.
-
Commence sepsis management
-
-
No, the patient does not have any red flags present.
- Are there any amber flags present?
– Relatives concenred about mental status
– Acute deterioration in functional ability
– Trauma / surgery / procedure in the past 8 weeks
– Immunosuppressed
– Respiratory rate 21–24 per minute
– Systolic BP 91–100mmHg
– Heart rate 91–130 per minute or new dysrhythmia
– Temperature range between 35.1°C–36°C or ≥ 38degC
– Clinical signs of wound infection -
Yes, the has amber warnings present
-
Further information and review required. Transfer to destination, communicate potential of sepsis at handover.
-
-
No amber warnings present
- Sepsis unlikely.
Routine care, consider other diagnoses.
- Sepsis unlikely.
- Are there any amber flags present?
- Are there any red flags present?
- Could abnormal NEWS2 score be due to an infection in the:
- Risk factors include:
-
Pregnant
- Risk factors include:
– Impaired immunity (e.g. diabetes, neutropenia, steroids, chemotherapy)
– Recent trauma / surgery / invasive procedure
– Indwelling lines / IVDU / broken skin -
Next
- Could abnormal NEWS2 score be due to an infection in the:
– Respiratory tract
– Breast abscess
– Abdominal pain / distension
– Urinary system
– Infected caesarean / perineal wound
– Chorioamnionitis / endometriosis -
No, the patient has no identified infections.
- Sepsis unlikely. Consider other diagnosis
-
Yes, the patient has identified infections.
- Are there any red flags present?
– Objective evidence of new or altered mental state
– Systolic BP ≤ 90mmHg (or from of > 40mmHg or more from normal)
– Heart rate ≥ 130 per minute
– Temperature ≤ 35degC
– Respiratory rate ≥ 25 per minute
– Needs oxygen to keep SPO2 ≥ 94% (88% in COPD)
– Non-blanching rash / mottled / ashen / cyanotic
– No urine passed in 18 hours ( < 0.5mL/kg/hr if catheterised)
– Lactate ≥ 2mmol/L (if available), noting that lactate may be raised in and immediately after normal delivery
– Immunity impaired -
Yes the patient has red flags present.
-
Commence sepsis management
-
-
No, the patient does not have any red flags present.
- Are there any amber flags present?
– Behavioural / mental state change
– Acute deterioration in functional ability
– Respiratory rate 21 – 24 per minute
– Systolic BP 91 – 100mmHg
– Heart rate 100 – 130 per minute or new dysrhythmia
– Invasive procedure in the last 6 weeks (e.g. cervical cerclage, forcepts delivery, ERPC, miscarriage, termination)
– Temperature range between 35.1 – 36degC or ≥ 39.1degC
– Has diabetes or gestational diabetes
– Close contact with Group A Streptococcus
– Prolonged rupture of membranes
– Bleeding or wound infection
– Offensive vaginal discharge
– Non-reassuring CTG / fetal tachycardia > 160 -
Yes, the has amber warnings present
-
Further information and review required. Transfer to destination, communicate potential of sepsis at handover.
-
-
No amber warnings present
- Routine care, consider other diagnoses.
- Are there any amber flags present?
- Are there any red flags present?
- Could abnormal NEWS2 score be due to an infection in the:
- Risk factors include:
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