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Pressure Injury Toolkit For Spinal Cord Injury and Spina Bifida

Beyond the wound - Bringing best practice to the bedside

Red Flag Screening: Sepsis


Sepsis occurs as the body’s systemic response to infection.

Sepsis can escalate rapidly and cause organ failure and death.

Early recognition of signs of infection and increased systemic response are crucial.

After SCI, symptoms such as pain or early indication of infection may be impaired due to reduced sensation.  

Infection may begin as localised infection of the pressure injury or wound, or other sites such as a bladder infection or chest infection/pneumonia.  

Risk of developing sepsis may be elevated after SCI particularly with immune compromise and / or extensive paralysis.

Clinical Presentation

  • Signs or symptoms of infection (e.g. wound infection or cellulitis, pneumonia, bladder infection).
  • Chills and/or rigors.
  • Rapid rise in temperature >38.3℃.
  • Raised respiratory rate > 20 breaths/minute / raised heart rate or bradycardia.
  • Confusion, anxiety, lethargy, clouded consciousness.
  • Severe hypotension.
  • Pale, cold, clammy (sluggish capillary return).
  • Elevated blood sugar (without diabetes).
  • Lowered temperature <36℃.


  • Referral for medical assessment urgently required if sepsis is suspected.
  • Refer to Sepsis Pathway, available on the Clinical Excellence Commission Sepsis Kills page.  
  • Assess vital signs: Temperature, Heart Rate, Blood Pressure, Respiratory Rate.


  • Blood tests (eg: FBC, ESR, C-RP, EUC, LFT). 
  • Wound swab.
  • If source of infection is not the wound, other investigations such as urine culture or sputum culture may be required.

Clinician Resources

Consumer Resources

  • Christopher and Dana Reeve Foundation - Paralysis Resource Centre. Sepsis.