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