ER NOTE
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General ER Note
Sepsis
Trauma
Mammalian Bite
Chest Pain
Abdominal Pain
Eye Injury
Sepsis Risk
Low
SIRS
0/4
NEWS2
0
MEWS
0
HN
ER Note — Sepsis
1
Vital Signs & Lactate
T° (°C)
HR (/min)
RR (/min)
BP (mmHg)
SpO₂ (%)
Lactate (mmol/L)
2
Screening & Early Warning Scores
SIRS criteria
Temp >38 or <36
HR >90
RR >20 or PaCO₂ <32
WBC >12k or <4k or >10% bands
SIRS:
0
/4
NEWS2 — RR (/min)
≤8
9–11
12–20
21–24
≥25
NEWS2 — SpO₂ (%)
≤91
92–93
94–95
≥96
NEWS2 — Air / O₂
Room air
Supplemental O₂
NEWS2 — SBP (mmHg)
≤90
91–100
101–110
111–219
≥220
NEWS2 — Pulse (/min)
≤40
41–50
51–90
91–110
111–130
≥131
NEWS2 — Consciousness
Alert
New confusion / CVPU
NEWS2 — Temp (°C)
≤35.0
35.1–36.0
36.1–38.0
38.1–39.0
≥39.1
NEWS2:
0
—
low
MEWS — SBP (mmHg)
≤70
71–80
81–100
101–199
≥200
MEWS — HR (/min)
≤40
41–50
51–100
101–110
111–129
≥130
MEWS — RR (/min)
<9
9–14
15–20
21–29
≥30
MEWS — Temp (°C)
<35
35–38.4
≥38.5
MEWS — AVPU
Alert
Voice
Pain
Unresponsive
MEWS:
0
—
low
3
ตำแหน่งการติดเชื้อและแหล่ง (Infection & Source)
แหล่งที่สงสัยของการติดเชื้อ (Presumed source)
UTI
Pneumonia
Skin / Soft tissue
Intra-abdominal
CNS
Line / Device-related
Unknown
Other
ระบุแหล่งอื่นๆ (Other source detail)
ปัจจัยเสี่ยง (Risk factors)
DM
CKD
Malignancy
Steroid / immunosuppressant
None
4
HPI · PMH · Allergies · PE
5
Antibiotics & Source Control
ABx timing
Shock / probable-definite → 1h
Possible, no shock → 3h
Low likelihood → defer, monitor
Antibiotic regimen
Stewardship
No anaerobic coverage — no risk factor (Rec 28)
Prolonged β-lactam infusion after loading dose (Rec 33)
De-escalate when pathogen identified (Rec 36)
No empiric antifungal (Rec 27)
6
Fluids, Hemodynamics & Respiratory Support
Fluid type
Balanced crystalloid (preferred)
0.9% NS (TBI exception)
Fluid volume / rate
MAP target
MAP ≥65 mmHg
MAP 60–65 mmHg (age ≥65)
Vasopressor
Adjuncts
IV corticosteroid — septic shock (Rec 79)
No beta-blocker given (Rec 64)
Active fluid removal post-acute phase (Rec 89)
Respiratory support
HFNC — P/F<200 or SpO₂/FiO₂<235 (Rec 67)
Awake proning trial (Rec 70)
Invasive ventilation
7
Cultures & Investigations
Cultures sent
Blood
Urine
Sputum
Wound / other
Sent before ABx (Rec 7)
8
Supportive Treatment
9
Post-Sepsis Care & Disposition
Post-sepsis care
Transition care program initiated
Structured handoff completed
Medication reconciliation
Rehab referral
Patient & family education
Disposition
— select —
ICU
Ward
Step-down / HDU
Discharge with OPD f/u
F/U
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