Septic shock is sepsis in which the blood vessels dilate and leak so much that pressure stays low despite fluids, and vasopressors are needed to keep the mean arterial pressure at 65 or more. Organs stop getting enough oxygen, and every hour of delay in antibiotics raises the risk of death.
Key symptoms
- Fever and chills, or a low temperature in older or frail patients
- Confusion, agitation or unusual sleepiness
- Fast breathing and feeling very unwell
- Little or no urine output
- Symptoms of the source: cough, painful urination, abdominal pain, red skin
What you find on exam
- Low blood pressure and fast heart rate
- Warm flushed skin early, then cold, mottled skin and slow capillary refill
- Altered mental status and fast breathing
- Head-to-toe search for the source, including lines, wounds and the abdomen
Tests
- Lactate; repeat if above 2
- Two sets of blood cultures before antibiotics, if this does not delay them
- Blood count, metabolic panel, liver tests, coagulation tests
- Urinalysis, chest X-ray and imaging to find the source
Treatment basics
- Broad-spectrum IV antibiotics within 1 hour, for example vancomycin plus piperacillin-tazobactam
- IV crystalloid, about 30 mL/kg, reassessing response often
- Norepinephrine as the first vasopressor to keep mean arterial pressure at 65 or more
- Source control: drain abscesses, remove infected lines
- Hydrocortisone if vasopressor needs keep rising
Red flags
- Mean arterial pressure below 65 despite fluids
- Lactate of 4 or more, or one that is not falling
- New confusion, no urine output or mottled skin
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Sources: NASEMSO National Model EMS Clinical Guidelines; NCCPA PANCE Content Blueprint; NCSBN 2026 NCLEX-RN Test Plan. Written by Making Synapses. Making Synapses is not affiliated with these organizations.