Septic shock in the elderly patient

Instructions

You are the ST4 in resus. A 78-year-old woman has been brought in by ambulance with a 2-day history of dysuria, fever and increasing confusion. She lives alone, normally independent, and was found drowsy by a neighbour this morning. Past history: hypertension, type 2 diabetes; no known respiratory disease.

Observations on arrival: HR 124, BP 84/46, RR 28, SpO₂ 91% on air, temp 38.9°C, GCS 14 (E4 V4 M6). Capillary glucose 6.8 mmol/L. Weight estimated at 65 kg.

A staff nurse and a healthcare assistant are present and will act on your instructions. Standard resus equipment, VBG machine and a fluid warmer are available. You have 8 minutes to assess, initiate management and verbalise your escalation plan. The examiner will not prompt you.

Equipment & setting

No equipment notes provided.

Actor / patient brief

No actor brief provided.

Finish your timed attempt before revealing the answer.

The tasks & expected progression

Lead a structured ABCDE assessment
Initiate the Sepsis 6 within the time available
Communicate clearly with your team using closed-loop instructions
Identify the likely source and verbalise your escalation plan

0-1 min Prime Read the stem. Form a working diagnosis (septic shock, likely urosepsis with associated delirium). Anticipate kit and team roles before approaching the patient.
1-2 min Team & A/B Take a brief handover. Allocate roles to the nurse and HCA by name. Airway patent. Controlled oxygen titrated to SpO₂ 94-98% (88-92% if COPD risk emerges on history); assess work of breathing and auscultate chest.
2-5 min C/D/E + Sepsis 6 Two large-bore cannulae. Deliver the Sepsis 6 (oxygen, blood cultures, IV broad-spectrum antibiotics per local pathway, 500 mL balanced crystalloid bolus over <15 min, lactate via VBG, urinary catheter for hourly output). State antibiotics target: within 1 hour of recognition. Send adjunctive bloods (FBC, U&E, CRP, coagulation) in parallel.
5-7 min Reassess Closed-loop check on what has been actioned. Repeat A-E and observations to assess response to the first bolus. Name the likely source (urinary); send urinalysis; consider further bolus to a cap of 30 mL/kg with reassessment between each.
7-8 min Escalate Verbalise the escalation plan: senior support, critical care referral for vasopressors if fluid-refractory after 30 mL/kg, and a definitive source-control plan including catheter sampling and antimicrobial review.

Mark scheme

Clinical reasoning

35%

Excellent Names septic shock and likely urinary source within the first minute; voices a prioritised differential (urosepsis vs. chest source vs. intra-abdominal); pre-empts deterioration by anticipating fluid-refractory shock and naming the vasopressor and critical-care trigger before BP collapses further.
Above standard Working diagnosis of septic shock named in the first two minutes with a tight differential; explicit antibiotic-within-1-hour target; explicit anticipation of fluid-refractory shock and the need for source identification.
Standard Correct working diagnosis of septic shock; appropriate investigations including lactate and cultures; safe, logical plan that follows the Sepsis 6 within the time available and reaches an escalation plan.
Borderline Reaches the diagnosis but with prompting gaps; one or two key investigations missed or mis-ordered; reasoning surfaces only when asked.
Below standard Disorganised reasoning; significant differentials (e.g. alternative source) or red flags (e.g. delirium as marker of severity) overlooked.
Unacceptable Fails to recognise shock or sepsis; pursues an unsafe plan such as withholding fluids or antibiotics.

Organisation / leadership

30%

Excellent Allocates the nurse and HCA to named tasks in the first 60 seconds; ABCDE completed without omission; delivers all six Sepsis 6 elements in parallel within 5 minutes; gives at least one explicit time-check (e.g. 'we are at 5 minutes').
Above standard Allocates roles by name to nurse and HCA early; ABCDE complete; Sepsis 6 delivered with parallel rather than sequential tasking; at least one verbal reassessment loop after intervention.
Standard Organised ABCDE with role allocation; Sepsis 6 completed within the 8 minutes; transitions between assessment and intervention are clear.
Borderline Some structure present but inefficient; minor omissions in sequence or timing; transitions occasionally rushed or duplicated.
Below standard Poor structure; performs tasks personally instead of delegating; loses track of time and the Sepsis 6 sequence.
Unacceptable No discernible structure; chaotic; team left without direction.

Communication

20%

Excellent At least three closed-loop instructions with named recipient and verbal read-back in the first three minutes; updates the team on the working diagnosis aloud; escalation handover follows SBAR structure and names the specific specialty (critical care).
Above standard Closed-loop instructions are the default throughout, including when ordering antibiotics and fluids; escalation handover is SBAR-structured.
Standard Mostly closed-loop with named recipients; handover communicates the salient points (problem, vitals, what has been done, what is needed).
Borderline Intermittent open-loop instructions; handover lacks structure or omits a key element such as the working diagnosis or vital trend.
Below standard Frequently open-loop; team unsure of tasks; handover disjointed.
Unacceptable Communication absent or actively confusing; no usable handover.

Practical

15%

Excellent Directs all six Sepsis 6 elements (oxygen titrated to SpO₂ 94-98%, blood cultures, IV broad-spectrum antibiotics within 1 hour, 500 mL balanced crystalloid bolus, lactate via VBG, urinary catheter for hourly output) in the correct sequence with cultures before antibiotics and explicit rationale.
Above standard All six Sepsis 6 elements directed (including IV antibiotics) with correct sequence and explicit timing checkpoints; cultures sent before the antibiotic dose.
Standard Directs the key practical steps of Sepsis 6 correctly within the time, including IV antibiotics and a defined fluid bolus.
Borderline Most practical steps directed but with one error in sequence or omission (e.g. cultures after antibiotics, or fluid given without a defined volume).
Below standard Several practical steps missed or wrongly sequenced; fluid type, route or volume inappropriate.
Unacceptable Practical management absent or unsafe.

— Self-mark each domain

Weighted across all domains · Day-1 consultant standard · pass mark 60%.

What good looks like

Delegates as the team leader — uses the nurse and HCA as a resource rather than doing tasks personally
Sends blood cultures and lactate before the antibiotic dose, and names the 1-hour antibiotic target
Reassesses after each 500 mL bolus rather than chasing a fixed total or running fluids open
Explicitly names a source (urinary) and a source-control plan, not just a drug list

Common pitfalls

Tunnel-vision on antibiotics; lactate or cultures forgotten or sent after the antibiotic dose
Open-loop instructions — orders into the air with no named recipient or read-back
Blanket high-flow oxygen with no titration to a saturation target
Fails to escalate to critical care for vasopressor support when shock persists after 30 mL/kg fluids