Escalation & the April 2026 update

SO-M-055 still describes contacting base for persistent systolic BP below 90 after 1 L, or CHF developing before 1 L with BP still below 90. The newer PR-230, implemented April 2026, explicitly removes the adult push-dose epinephrine base-contact/order requirement. Other required contact and destination rules still apply.
Fluid overload is a concern with CHF or renal disease. Absence of fever does not exclude infection, especially in older or immunosuppressed patients.

1. Check the criteria

Suspected or known infection, plus at least TWO findings:
GCS below 13; systolic BP below 100 mmHg; respiratory rate above 22/min; or reported/measured temperature above 100.4°F (38°C) or below 97°F (36°C).

Monitor cardiac rhythm and oxygen saturation. If SpO₂ is below 95%, give high-flow oxygen by mask or nasal cannula at 6 L/min, as tolerated.
Establish IV access. If systolic BP is below 100 and lungs are clear without CHF, give 250 mL normal saline.
Repeat only while lungs remain clear, up to 1 L, to improve perfusion.
Provide ALS transport to the nearest emergency receiving center. Notify the receiving team early of suspected sepsis.

For eligible shock under PR-230, use epinephrine diluted to 10 mcg/mL: 1 mL (10 mcg) IV/IO every 3 minutes, titrated to systolic BP above 90. Use the linked medication guide for preparation and the complete PR-230 exclusions.
Do not treat hemorrhage/dehydration with push-dose epinephrine before volume replacement. PR-230 also excludes a perfusing non-shock state and suspected stimulant intoxication.

Reassess pressure, perfusion, respiratory status, and lung sounds after each intervention. Stop repeating the clear-lung fluid pathway if congestion develops.
Communicate the suspected infection, qualifying findings, BP trend, fluid amount, treatment response, and early sepsis concern to the receiving team.