Clinical Criteria for Systemic Inflammatory Response Syndrome (SIRS)

Are any 2 of the following SIRS criteria present and new to your patient?

  • Heart Rate > 90 BPM
  • Respiratory Rate > 20
  • Temperature < 96.8 F (36 C) or > 100.4 F (38 C)

If not, follow local protocol and consider reassessing if changes occur.

Here are the next steps, if yes:

Do any of these apply?

  • Known or Suspected Infection (UTI, Wound, Cellulitis, PN)
  • Recent Antibiotic Therapy
  • History of Cancer or Transplant Candidate
  • Recent Medical/Surgical Procedure
  • Indwelling Catheter

Pre Hospital/Hospital Organ Assessment

Do any of these apply?

  • CNS - Altered Consciousness: Not related to drugs or alcohol; Glasgow Coma Scale: ≤ 12
  • Respiratory - worsening O2 saturation or requiring ventilation assistance
  • Cardiovascular – SBP < 90 or Shock Index (SI) > 0.7 as defined by HR/SBP
  • Renal - decreased urine output
  • Report of recent abnormal lab values
  • Maintain SPO2 > 92%
  • 2 Large Bore IV with Fluid bolus 30 mL/kg 0.9% Sodium chloride over 30 minutes, consider additional fluids if SBP < 90 or MAP < 65 after 3 liters 0.9% NS
  • Cardiac Monitor
  • Rapid transfer to facility with ICU capabilities