St Emlyn’s Lesson Plans
Recognising and responding to suspected sepsis
Compare high- and lower-risk presentations of possible sepsis, including treatment timing, fluids and reassessment.
New to Emergency Medicine / Induction / Early-career Emergency Medicine · 45-minute session
For learners
Before: Allow about 18 minutes in total.
When we meet: We will discuss a seriously unwell patient without fever and another whose initial observations are less concerning.
For facilitators
Send: the learner preparation link before teaching.
Bring: Observation chart, local antimicrobial guide and blank fluid record.
Before the session
If you are attending this session, complete the core preparation below before you come. Allow about 18 minutes in total.
Core preparation
NICE NG253: Managing suspected sepsis · About 10 minutes
Read NG253’s high- and moderate-risk management sections. Note antibiotic timing, the 250 ml fluid bolus recommendation and the required reassessment.
https://www.nice.org.uk/guidance/ng253/chapter/Managing-suspected-sepsis
NICE NG253: Why the recommendations changed · About 5 minutes
Read only “When to give fluids” and “Fluid volume” in the rationale. Compare the reasons for reassessment with the management recommendations above.
https://www.nice.org.uk/guidance/ng253/chapter/Rationale-and-impact
Think about (allow 3 minutes): Which changes after the first intervention would make you reassess the treatment plan?
Picture the scene
An older patient treated for a chest infection is newly confused and breathless. They have no fever. The nurse asks whether they need a resuscitation space.
By the end of the session
- Recognise organ dysfunction and serious illness even without fever.
- Use NEWS2 alongside clinical judgement to choose urgency and initial actions.
- Describe how response, fluid tolerance and source control shape escalation.
After the session
- On your next suspected-sepsis case, write down what response you expect from the first intervention.
- Check whether your department’s fluid chart reflects the 2025 guidance.
Facilitator guide
Send learners the preparation link several days before teaching. Allow about 18 minutes in total.
Before learners arrive
- Bring the current sepsis pathway, antibiotic formulary and NEWS2 chart.
- Confirm antibiotic access and senior/critical-care escalation routes.
- Identify how cumulative fluids and reassessment are recorded.
Equipment: Observation chart, local antimicrobial guide and blank fluid record.
Setup: Pairs identify the concerning features in each case and the observations still needed for a complete NEWS2. Do not calculate a score from the incomplete case data. Reveal the change in physiology and ask another pair whether the proposed action and reassessment still fit.
If the preparation has not been completed
Replace risk recognition and the guidance comparison (13 minutes). Spend eight minutes comparing the linked NG253 high-risk recommendations with the local sepsis pathway supplied by the facilitator. Use five minutes to identify treatment timing, fluid reassessment and who to call. Begin the cases at minute 13. For the 30-minute version, replace the first ten minutes with a six-minute shared read and four-minute discussion of those decisions.
Suggested session plan
- 0–5 min — Notice the risk. Ask which features concern learners before naming sepsis.
- 5–13 min — Compare current guidance. Identify differences from the remembered Sepsis Six approach.
- 13–35 min — Run two evolving cases. Reveal physiology changes and ask for the next action and reassessment.
- 35–40 min — Consolidate. Contrast high-risk urgency with lower-risk diagnostic review.
- 40–45 min — Choose a follow-up action. Identify one local barrier to timely reassessment.
Start the discussion
Read the opening scenario together. Give everyone a moment to think, then ask what concerns them and what they need to know next.
Cases and discussion
Use these cases, or invite an anonymised case from the group that addresses the same questions.
Afebrile but seriously unwell
A normally independent 78-year-old has cough, new confusion, respiratory rate 32 and a new oxygen requirement despite community antibiotics.
Add this information as the discussion develops:
- Lactate is 3.2 mmol/L and imaging supports pneumonia.
- After an initial intervention, confusion and oxygen requirement persist.
Ask the group:
- What makes this urgent before the blood results return?
- What will you do in parallel rather than sequentially?
- What would improvement or harm look like?
Discussion notes
Points to draw out:
- Escalate promptly, assess ABCDE and calculate NEWS2 in context; absence of fever is not reassurance.
- For high-risk suspected sepsis, NG253 calls for IV antibiotics within one hour of the first ED NEWS2 calculation; obtain relevant cultures without creating harmful treatment delay.
- If fluid resuscitation is indicated, use 250 ml isotonic crystalloid boluses, ideally over 10–15 minutes, and reassess each time; account for fluid already given.
- Reassess breathing, circulation, mentation and urine output; persistent non-response demands senior and critical-care discussion.
Common misconceptions:
- Calling NEWS2 a diagnostic test for sepsis.
- Automatically giving repeated litres without checking tolerance.
For a more experienced group: Ask what would prompt early vasopressor discussion and who can make that decision locally.
Infection is possible, shock is not established
A 30-year-old with fever, cough and mild tachycardia is alert, normotensive and drinking. The first NEWS2 is low.
Add this information as the discussion develops:
- Their respiratory rate rises while awaiting investigation.
Ask the group:
- Does every possible infection need the same one-hour bundle?
- What review and observation are needed while clarifying the cause?
- What changes the risk category?
Discussion notes
Points to draw out:
- Assess the person and alternative diagnoses, not just a score.
- Lower-risk pathways allow qualified clinical assessment and time-limited diagnostic clarification; they do not permit unattended delay.
- Recalculate risk after change and escalate treatment promptly if the clinical picture worsens.
Common misconceptions:
- Applying the high-risk pathway to every febrile patient.
- Assuming a low first NEWS2 guarantees safe discharge.
For a more experienced group: Discuss how immune suppression or abnormal baseline physiology changes interpretation.
Important clinical points
- Follow NG253 risk-specific timing; do not delay antibiotics once the decision to treat is made.
- Reassess every fluid bolus; seek senior advice if improvement is inadequate after a cumulative 1,000 ml, or earlier if clinically concerning.
- Consider source control and alternative diagnoses throughout.
Closing the session
Use these questions to check what the group will take away. Go back over any clinical points that remain unclear.
- Why can an afebrile person need immediate escalation?
- What would make you stop giving fluid?
- How can a low-risk presentation become high risk?
Key teaching points:
- Severe infection can occur without fever.
- Use NEWS2 alongside the clinical history, examination and changes over time.
- Check the response and fluid tolerance after each intervention, then revise the plan.
Before leaving, ask each person to choose one action from After the session and say when they will try it. They complete that follow-up in practice, with supervision where needed.
Adapting the discussion
Uncertainty and local practice
Antibiotic choice, fluid tolerance and escalation depend on the source, comorbidity and response. This adult pathway does not cover pregnancy or children.
If the discussion drifts
What changed after the last intervention, and what is our next decision?
For a more experienced group
Debate a patient with heart failure, raised lactate and uncertain infection; articulate both undertreatment and overtreatment risks.
A 30-minute version
30 minutes: risk recognition 4; guidance reset 6; first case 15; consolidation and reflection 5. Use the second case as a two-sentence comparison within consolidation.
Evidence and guidance
- NICE NG253: Managing suspected sepsis — 2025 guidance for people aged 16 or over who are not, and have not recently been, pregnant.https://www.nice.org.uk/guidance/ng253/chapter/Managing-suspected-sepsis
- NICE NG253: Why the recommendations changed — Rationale, particularly the sections on when to give fluids and fluid volume.https://www.nice.org.uk/guidance/ng253/chapter/Rationale-and-impact
Suggested curriculum links
RCEM 2021 curriculum (2025 update): SLO1 Care for physiologically stable adults with acute presentations
Safe assessment, differential diagnosis and disposition.
RCEM 2021 curriculum (2025 update): SLO3 Resuscitate and stabilise adults
Recognition, prioritisation and team escalation.
Check these links against the learner’s stage and programme. Attendance at a teaching session does not establish competence.
Clinical review: awaiting clinician sign-off
The references have been checked during editing. A named clinician has not yet signed off the revised lesson collection. Use current local guidance when preparing to teach; editorial updates do not constitute clinical approval.
First published 2020-06-25 · Natasha Chatham-Zvelebil.