Clinical Commander

All dossiers
critical.sepsis_bridge.v1

Sepsis bridge (recognition + Hour-1 bundle)

critical_careacuteadultpregnancygeriatricacuteinpatient
Start encounter →Print handoutPRODUCTION

Manifest is fully authored against SSC 2026 + Sepsis-3 + ANDROMEDA-SHOCK + CLOVERS + 2025 ATS CAP + KDIGO 2026. Atoms split across .atoms.ts / .atoms.assessment.ts / .atoms.treatment.ts (3 files). INTEGRATED status justification: ≥1 protocol (protocol.septic_shock), ≥6 calculators, evidence + guideline label + last_reconciled, all acute phase requirements met (RED_FLAGS, INITIAL_WORKUP, TREATMENT, DISPOSITION). Bridge engine: routes downstream to disease-specific infection engines (id.cap.core.v1, id.uti.core.v1, id.meningitis.core.v1, etc.); workups[] intentionally empty here. evidence.pmids populated 2026-05-12 (B.5 ID/CC lane): 12 verified-landmark RCT/guideline anchors (SSC 2021, Sepsis-3, SEPSISPAM, OVATION-65, ANDROMEDA-SHOCK, CLOVERS, SMART/PLUS/BaSICS, APROCCHSS, ADRENAL, VASST). Removed boilerplate non-sepsis PMIDs (DELIVER 36027571 / ProMISe 25776532 / POINT 29766750 / REDUCE 23900119) that were scaffolding residue. No engine-specific test_files declared — sepsis logic exercised via protocol.sepsis_hour1_bundle.v1 tests in shared protocols suite. PRODUCTION blockers: PMIDs, RxNav-validated empiric abx + pressor regimen seeds, dedicated tests, bridge-routing tests for downstream infection engines. Deepened 2026-04-27: Hour-1 bundle regimen ladder (lactate+cultures → empiric abx within 1h → 30 mL/kg fluid → MAP ≥65 with norepi → vaso → hydrocort → epi/dobutamine → source control), ED + ICU playbooks, 7 severity triggers (qSOFA ≥2, lactate >4, septic shock, refractory shock, neutropenic fever, pregnancy, atypical AMS), siblings vs id.sepsis (bridge vs full) / cardiogenic-shock / post-arrest. RxCUIs reused from manifest rxnorm_codes: 203220 pip-tazo, 20481 cefepime, 74169 meropenem, 11124 vanc, 2193 ceftriaxone, 7512 norepi, 8163 vaso, 5489 hydrocort, 309115 fluconazole, 20614 LR, 7407 NS.

Entry points (5)

  • symptom
    Fever + suspected source (cough, dysuria, abdominal pain, skin)
    fever_with_localizing_symptoms
  • symptom
    Acute AMS (especially elderly — atypical sepsis presentation)
    altered_mental_status_acute
  • vital_abnormality
    SBP <90 or MAP <65
    hypotension_sbp_lt_90
  • lab_abnormality
    Unexplained lactate >2 mmol/L
    lactate_elevated_unexplained
  • symptom
    qSOFA ≥2 (RR ≥22, AMS, SBP ≤100)
    qsofa_positive

Required inputs (22)

  • agerequired
    demographic • used at CONTEXT
    SSC 2026 conditional MAP target 60–65 in adults ≥65; atypical presentation in elderly
  • sbprequired
    vital • used at CONTEXT
    qSOFA + hypotension + MAP target
  • maprequired
    vital • used at CONTEXT
    Resuscitation target ≥65 (or ≥60 in elderly)
  • hrrequired
    vital • used at CONTEXT
    Tachycardia component of septic phenotype
  • rrrequired
    vital • used at CONTEXT
    qSOFA RR ≥22 component
  • temprequired
    vital • used at CONTEXT
    Fever or hypothermia (especially elderly/immunocompromised)
  • spo2required
    vital • used at CONTEXT
    Hypoxia drives oxygen + intubation decisions
  • mental_status_gcsrequired
    symptom • used at CONTEXT
    qSOFA AMS component + organ dysfunction marker
  • lactaterequired
    lab • used at INITIAL_WORKUP
    Hour-1 bundle; >2 with vasopressor = septic shock; clearance target
  • wbcrequired
    lab • used at INITIAL_WORKUP
    SOFA + diagnostic; leukopenia in immunocompromised
  • plateletsrequired
    lab • used at INITIAL_WORKUP
    SOFA coag axis; DIC screen
  • creatininerequired
    lab • used at INITIAL_WORKUP
    SOFA renal axis; sepsis-AKI; renal-dose abx
  • bilirubinrequired
    lab • used at INITIAL_WORKUP
    SOFA liver axis
  • inr
    lab • used at INITIAL_WORKUP
    Coagulopathy / DIC component
  • blood_cultures_2_setsrequired
    lab • used at INITIAL_WORKUP
    Hour-1 bundle — pre-antibiotic
  • urinalysisrequired
    lab • used at INITIAL_WORKUP
    UTI source identification
  • procalcitonin
    lab • used at INITIAL_WORKUP
    Bacterial vs viral; abx duration guidance
  • cxrrequired
    imaging • used at INITIAL_WORKUP
    Pneumonia source; ARDS evolution
  • allergiesrequired
    history • used at TREATMENT
    Penicillin/cephalosporin allergy → empiric abx selection
  • recent_antibiotic_exposure
    history • used at TREATMENT
    Drives broader vs narrower empiric coverage
  • immunocompromised_statusrequired
    history • used at CONTEXT
    Neutropenic → broader coverage + antifungal
  • pregnancy_statusrequired
    history • used at CONTEXT
    Pregnancy-safe abx + OB consult

12-phase flow (12)

  1. 1FRAME
    Recognize sepsis early; bridge to disease-specific infection engine
    inputs: age
    advance: Sepsis suspected and engine activated
  2. 2ENTRY
    Capture trigger (qSOFA, lactate, hypotension, fever, AMS)
    inputs: sbp, map, hr, rr, temp, spo2, mental_status_gcs
    advance: Vitals + qSOFA documented
  3. 3CONTEXT
    Capture localizing symptoms, recent procedures/lines, immunocompromise, pregnancy, allergies, advance directives
    inputs: immunocompromised_status, pregnancy_status, allergies
    advance: Risk modifiers + GOC documented
  4. 4RED_FLAGS
    qSOFA ≥2, lactate >4, MAP <65, SpO2 <90, AMS, oliguria, DIC petechiae, neutropenic fever
    inputs: lactate, map, spo2
    actions: protocol.septic_shock
    advance: Hour-1 bundle initiated
  5. 5INITIAL_WORKUP
    Hour-1 bundle: lactate, blood cultures × 2 pre-abx, broad-spectrum abx, IVF if hypoperfusing; CBC/CMP/coag/ABG; urinalysis + culture; CXR; source-specific imaging
    inputs: lactate, wbc, platelets, creatinine, bilirubin, blood_cultures_2_sets, urinalysis, cxr
    actions: panel.abg, panel.cardiac, panel.renal, panel.inflammation
    advance: Hour-1 bundle elements documented
  6. 6BRANCHING_WORKUP
    Source identification → route to disease-specific engine: CAP, UTI/pyelo, intra-abd, meningitis, SST, endocarditis, CLABSI
    advance: Suspected source identified or unknown-source pathway selected
  7. 7DIFFERENTIAL
    Distinguish sepsis from PE, anaphylaxis, adrenal crisis, pancreatitis SIRS-mimic, cardiogenic vs distributive
    advance: Sepsis confirmed as principal physiology
  8. 8RISK_STRATIFICATION
    qSOFA, NEWS2, SOFA at presentation and after labs return; classify sepsis vs septic shock
    inputs: lactate, platelets, creatinine, bilirubin, mental_status_gcs, spo2
    actions: calc.qsofa, calc.sirs, calc.sofa, calc.anion_gap, calc.ckd_epi_2021, calc.map
    advance: Severity tier assigned
  9. 9TREATMENT
    30 mL/kg crystalloid initial bolus then re-evaluate (CLOVERS-aware restrictive after); norepinephrine first-line vasopressor titrated to MAP ≥65 (≥60 elderly); vasopressin add-on at norepi >0.25 mcg/kg/min; hydrocortisone if persistent vasopressor; lactate clearance + capillary refill (ANDROMEDA-SHOCK); source control; de-escalate by culture
    inputs: map, lactate, allergies
    actions: protocol.septic_shock
    advance: Bundle complete; pressors active if needed; source control planned
  10. 10DISPOSITION
    ICU for septic shock or ≥2-organ failure; ward/step-down for uncomplicated sepsis; OB if pregnant; surgery if source control needed
    advance: Disposition assigned
  11. 11MONITORING
    Lactate q2–4h until clearance; continuous vitals; arterial line if shock; daily SOFA; q1–2h glucose 140–180; serial CBC/CMP; culture-result window for de-escalation
    inputs: lactate, creatinine
    actions: panel.renal, panel.cardiac, panel.abg
    advance: Lactate clearing + vitals improving + culture data driving de-escalation
  12. 12FOLLOWUP
    Post-sepsis 2-week visit (post-sepsis syndrome / PICS screening); AKI 3-month recovery check; PCP med reconciliation; ID specialist if complex/resistant
    advance: Outpatient follow-up + PICS screening booked