The nursing home calls for “weakness.” Your patient is an 82-year-old woman who has “been off” for a day or two. Blood pressure is 118/72. Heart rate is 96. She is alert, answers questions, and the staff says she is “always a little confused.”
Nothing screams emergency here. But she might be hours away from a rapid response.
The Compensation Trap
Sepsis does not announce itself with unstable vitals—at least not at first. Early sepsis is a master of disguise, hiding behind:
- A blood pressure that looks “fine” (but is actually 30 points below their normal)
- A heart rate that is “slightly elevated” (but compensating for everything falling apart inside)
- Mental status that is “baseline” (because no one asked the right questions)
By the time the blood pressure drops, you are behind. Way behind.
The Vitals That Matter More Than BP
When you suspect early sepsis, these findings often show up before hypotension:
- Respiratory rate over 22 — The body trying to blow off CO2 to compensate for acidosis
- Heart rate that does not match the picture — Tachycardia at rest without obvious cause
- Capillary refill over 3 seconds — Peripheral perfusion failing before central
- Temperature instability — Fever OR hypothermia (hypothermia is actually worse)
- New confusion or agitation — Often the first sign in elderly patients
- Mottled skin — Especially on the knees and elbows
If you have point-of-care lactate, a level over 2 mmol/L with any of these findings should raise your suspicion significantly.
The Right Questions for Facility Staff
Nursing home and care facility staff often have critical information, but you have to ask the right way:
- “What is her NORMAL blood pressure?” (118 might be a 40-point drop)
- “When did she last seem completely herself?”
- “Any new medications in the last week?”
- “Recent UTI, skin breakdown, or respiratory symptoms?”
- “When was her last bowel movement?” (Bowel obstruction can cause sepsis too)
- “Any recent procedures or hospitalizations?”
Trust Your Gut
Sepsis has a “look” that experienced medics recognize—the patient who just seems sicker than their vitals suggest. If your gut says something is wrong:
- Trend vitals frequently during transport
- Establish IV access early (you may need it)
- Communicate your concern clearly: “Vitals are currently stable, but I am concerned about early sepsis”
- Consider transport destination—does this patient need a higher level of care?
The Pearl
Normal blood pressure does not mean not septic. If they are compensating now, they will not be for long. Respiratory rate, mental status changes, and that “sick look” often show up before the blood pressure crashes—pay attention to them.
This clinical pearl is for educational discussion only. Sepsis recognition and treatment should always follow your local protocols and medical direction. Early recognition saves lives, but your protocols guide your interventions.