One-Pager

Prehospital Sepsis

Field screening, sepsis alert, fluids, pressors and antibiotics en route under SSC 2026, for EMT, paramedic and critical care transport

Reviewed by Alex G, BSN, RN, CEN, CCRN, CMC, NREMT-P · Checked against current sources October 2026

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Recognize it

Sepsis-3: infection plus life-threatening organ dysfunction from a dysregulated host response. Septic shock: sepsis needing a vasopressor to keep MAP ≥65 mmHg, with lactate >2 mmol/L, despite adequate fluid.

• Source: lungs, urine, skin, abdomen, lines or devices
• New confusion, often the only sign in older adults
• Temp >38 °C or <36 °C; no fever does not rule it out
• HR >90, RR ≥22, SBP ≤100 or MAP <65
• Mottled skin, delayed or flash capillary refill, falling SpO₂
• High risk: older, immunocompromised, recent surgery

Supporting findings: ETCO₂ ≤25 mmHg suggests metabolic acidosis and poor perfusion; it falls as lactate rises. Point-of-care lactate >2 mmol/L is abnormal.

Sepsis alert and antibiotics

• Pre-notify early: screen result, vitals, source, fluid given, ETA
• Hospital goal: antibiotics within 1 hr of recognizing shock or probable sepsis
• SSC 2026 (new, conditional): antibiotics in the ambulance or aircraft for probable or definite sepsis with hypotension when hospital evaluation is over 60 min away
• Only with a structured en route screening process (SSC); agent chosen with receiving hospitals (NASEMSO)
• Draw blood cultures first when it does not delay the dose

Fluids

• Balanced crystalloid (lactated Ringer's, Plasma-Lyte) over 0.9% saline
• Hypotension or lactate ≥4 mmol/L: at least 30 mL/kg in the first 3 hr (80 kg ≈ 2.4 L)
• Field: rapid boluses (e.g., 500 mL); after each, recheck MAP, mentation, capillary refill, lungs, SpO₂
• Albumin: SSC 2026 suggests crystalloid alone; case by case after large volumes or in cirrhosis; avoid in TBI

Vasopressors in transport

• SSC 2026: start peripherally rather than delay for a central line
• Large vein, ideally at or above the antecubital fossa and short term (SSC 2021); avoid leg veins; check the site often
• Extravasation: stop the infusion and treat per protocol (phentolamine)
• Dopamine only if norepinephrine and epinephrine are unavailable; push-dose epinephrine per protocol

Children

Phoenix (2024): suspected infection plus a Phoenix Sepsis Score ≥2 (respiratory, cardiovascular, coagulation or neurologic); SIRS is retired. Septic shock adds ≥1 cardiovascular point: severe hypotension for age, lactate ≥5 mmol/L, or a vasoactive drug. The score needs labs, so field recognition rests on perfusion and mental status.

• Tachycardia, tachypnea, abnormal capillary refill, cool or mottled skin, lethargy; infants may be hypothermic
• Hypotension is late (decompensated shock): SBP <60 in neonates, <70 in infants, <70 + (2 × age) at 1–10 yr, <90 over 10 yr
• Septic shock: 10–20 mL/kg boluses of balanced crystalloid, up to 40–60 mL/kg in hour 1 where ICU care is available
• Reassess after every bolus; stop for crackles, hepatomegaly or worse breathing
• Vasoactive drug peripherally rather than waiting; no epinephrine vs norepinephrine preference
• Antibiotics within 1 hr for septic shock, ideally within 3 hr for sepsis without shock

Who does what

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Calculators for this topic

• Mean Arterial Pressure (MAP)
• Push-Dose Epinephrine

Sources

1. Society of Critical Care Medicine. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2026 (guideline page listing each recommendation with strength and certainty). Link
2. Prescott HC, Antonelli M, Alhazzani W, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2026. Crit Care Med. 2026;54(4):725-812. doi:10.1097/CCM.0000000000007075 Link
3. Prescott HC, Antonelli M, et al. Surviving Sepsis Campaign: international guidelines for management of sepsis and septic shock 2026. Intensive Care Med. 2026;52(5):863-936. doi:10.1007/s00134-026-08361-1 Link
4. SCCM/ESICM. Quick Guide for Resuscitation and Hemodynamic Support in Adults With Sepsis and Septic Shock (SSC 2026 infographic). Link
5. SCCM/ESICM. Hour-1 Bundle: Initial Resuscitation for Sepsis and Septic Shock (2019). Link
6. Clinical-database.com. SSC 2026 summary, Part 1: Screening and Early Management. Link
7. Clinical-database.com. SSC 2026 summary, Part 2: Infection, Antimicrobial Therapy and Source Control. Link
8. Clinical-database.com. SSC 2026 summary, Part 3: Hemodynamic Management. Link
9. Clinical-database.com. SSC 2026 summary, Part 5: Adjunctive and Supportive Therapies. Link
10. Society of Critical Care Medicine. Surviving Sepsis Campaign International Guidelines for the Management of Sepsis and Septic Shock in Children 2026 (guideline page). Link
11. Weiss SL, Peters MJ, Oczkowski SJW, et al. Surviving Sepsis Campaign International Guidelines for the Management of Sepsis and Septic Shock in Children 2026. Pediatr Crit Care Med. 2026;27(4):379-434. doi:10.1097/PCC.0000000000003927 Link
12. Schlapbach LJ, Watson RS, Sorce LR, et al. International Consensus Criteria for Pediatric Sepsis and Septic Shock. JAMA. 2024;331(8):665-674. doi:10.1001/jama.2024.0179 Link
13. Singer M, Deutschman CS, Seymour CW, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):801-810. Link
14. NASEMSO Medical Directors Council. National Model EMS Clinical Guidelines, Version 3.0, March 2022 (Shock guideline; pediatric hypotension values). Link
15. NASEMSO. Clinical and Evidence-Based Guidelines page (current edition listing). Link
16. Hunter CL, Silvestri S, Ralls G, et al. A prehospital screening tool utilizing end-tidal carbon dioxide predicts sepsis and severe sepsis. Am J Emerg Med. 2016;34(5):813-819. Link
17. Royal College of Physicians. National Early Warning Score (NEWS) 2. Link
18. Evans L, Rhodes A, Alhazzani W, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021. Intensive Care Med. 2021;47:1181-1247. Link
19. NHTSA/NASEMSO. National EMS Scope of Practice Model 2019, including Change Notices 1.0 and 2.0 (August 2021). Link
20. Levophed (norepinephrine bitartrate) prescribing information, Hospira. Revised 6/2023 (DailyMed SPL version 5, published June 13, 2025). Link
21. Munroe ES. 2026 Surviving Sepsis Campaign: Applying guidelines at the bedside. CHEST Physician. September 16, 2026. Link
22. Gebhart F. Updated sepsis guidelines balance rapid treatment initiation, antibiotic stewardship. CHEST Physician. May 20, 2026. Link
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24. Kim G, Kim WY. Prioritizing the patient through a continuum of personalized care: insights from the 2026 Surviving Sepsis Campaign guidelines. Acute Crit Care. 2026;41(2):419-427. Link