Physiological vital signs, symptoms and matching ATS clinical descriptor category for the stages of sepsis with typical keywords used for identifying severe sepsis
| Stages of sepsis | Physiological vital signs and symptoms | ATS category | Typical keywords for identifying* severe sepsis |
|---|---|---|---|
| Suspected infection | Visual inspection or presenting history and pain: Cough/purulent sputum Wound infection Swollen hot painful joint Abdominal symptoms Urinary symptoms Fever excluding all other causes | ATS 5 ATS 5 ATS 4 ATS 3–4 ATS 3–4 ATS 3–5 | Suspected infection—from organ or location Examples include: Pneumonia UTI Cellulitis |
| SIRS syndrome | Two or more of the following: Body temperature >38.5°C or <35.0°C (ATS 4) ATS 3 if immunosuppressed or ATS 2 if fever with lethargy HR >90 bpm RR >20 breaths/min or arterial CO2 tension <32 mm Hg or need for mechanical ventilation White blood cell count >12 000 or <4000/mm3 or immature forms >10% | ATS 2–4 ATS 4–5 ATS 2 3 Not Applicable unless in referral | Fever or hypothermia HR elevated RR elevated From vital sign data or descriptive Documentation |
| Sepsis | SIRS syndrome and documented suspicion of infection: Visual inspection or presenting history and pain Cough/purulent sputum Wound Abdominal symptoms Urinary symptoms Fever excluding all other causes | ATS 2–4 | Suspected infection—from organ or location Examples include: Pneumonia UTI Cellulitis Plus SIRS signs |
| Severe sepsis | Sepsis and at least one sign of organ hypo-perfusion or organ dysfunction: Kidney—decreased urine output (<0.5 mL/kg for at least 1 h) Nervous system—abrupt change in mental status Gut—decreased motility, decreased bowel sounds and anorexia Blood—thrombocytopenia—bleeding and clotting issues Heart and circulation—hypotension, tachycardia, mottled skin and capillary refill >3 s Lungs—respiratory distress Skin and muscle—myalgia and mottled skin | ATS 4 ATS 2–3 ATS 3 ATS 3 ATS 2 ATS 2 ATS 2 | Keywords that describe the organ dysfunction Examples include Nervous system: Acute onset—obtunded, confused, agitated, disoriented Circulation: as per signs and symptoms Keywords ‘? Sepsis’ often used for ‘? severe sepsis’ |
| Septic shock | Severe sepsis and one of: Profound hypovolaemia, hypo-perfusion and hypoxia Hypovolaemia does not respond to fluid resuscitation Need for norepinephrine or epinephrine <0.25 μg/kg per min to maintain mean BP above 60 mm Hg (>80 mm Hg if previous hypertension) | ATS 1–2 ATS 1–2 Not applicable at triage | Shock or circulatory collapse or similar |
*Documentation containing keywords or similar were classified as ‘identified with severe sepsis’.
ATS, Australasian Triage Scale; SIRS, systemic inflammatory response syndrome; UTI, urinary tract infection.