Time of presentation is defined as the time of triage in the emergency department
Measure lactate level
Obtain blood cultures prior to administration of antibiotics
Administer broad spectrum antibiotics
Administer 30ml/kg crystalloid for hypotension or lactate ≥4mmol/L
Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation) to maintain a mean arterial pressure (MAP) ≥65mmHg
If persistent hypotension after initial fluid administration (MAP < 65 mm Hg) or if initial lactate was ≥4 mmol/L, reassess volume status and tissue perfusion:
Option 1: Focused Exam
Vital signs
Cardiopulmonary Exam
Capillary Refill
Peripheral Pulse
Skin Exam
Option 2: Two of the following
Measure CVP (IVC ultrasound) with following goals:
>8 cmH2O, not intubated
>12 cmH2O, intubated
Measure ScvO
Bedside cardiovascular ultrasound
Dynamic assessment of fluid responsiveness with passive leg raise or fluid challenge
Option 1: Focused Exam
Vital signs
Cardiopulmonary Exam
Capillary Refill
Peripheral Pulse
Skin Exam
Option 2: Two of the following
Measure CVP (IVC ultrasound) with following goals:
>8 cmH2O, not intubated
>12 cmH2O, intubated
Measure ScvO
Bedside cardiovascular ultrasound
Dynamic assessment of fluid responsiveness with passive leg raise or fluid challenge
Vital signs
Cardiopulmonary Exam
Capillary Refill
Peripheral Pulse
Skin Exam
Measure CVP (IVC ultrasound) with following goals:
>8 cmH2O, not intubated
>12 cmH2O, intubated
Measure ScvO
Bedside cardiovascular ultrasound
Dynamic assessment of fluid responsiveness with passive leg raise or fluid challenge
>8 cmH2O, not intubated
>12 cmH2O, intubated
A central line and measurement of ScvO2 is not required and does not impact mortality
Sepsis 
Adrenal Insufficiency
Tumor lysis syndrome
Salicylate Toxicity
Hemorrhagic shock
Anticholinergic Toxicity
Toxic shock syndrome
Neuroleptic Malignant Syndrome