In which cases should I consider referring a patient with TSS to secondary care?

When considering referring a patient with suspected toxic shock syndrome (a form of sepsis) to secondary care, the decision is based on risk stratification using specific criteria ¹.

• Immediate Emergency Referral (High Risk Criteria):

  Refer people aged 16 or over with suspected sepsis who are or have recently been pregnant for emergency medical care immediately if they meet any high risk criteria ¹. This typically involves using a 999 ambulance, and secondary care should be pre-alerted ¹. For people under 16 with suspected sepsis, refer them for emergency medical care if they meet any high risk criteria ¹.

  High risk criteria include:

  • History: Objective evidence of new altered mental state ¹.
  • Respiratory: Raised respiratory rate of 25 breaths per minute or more, or new need for oxygen (40% FiO2 or more) to maintain saturation above 92% (or above 88% in known chronic obstructive pulmonary disease) ¹.
  • Blood Pressure: Systolic blood pressure 90 mmHg or less, or systolic blood pressure more than 40 mmHg below normal ¹.
  • Circulation and Hydration: Raised heart rate of more than 130 beats per minute, or not passed urine in the previous 18 hours (or less than 0.5 ml/kg of urine per hour for catheterised patients) ¹.
  • Skin: Mottled or ashen appearance, cyanosis of skin, lips or tongue, or a non-blanching petechial or purpuric rash ¹.
• Urgent Referral (Moderate to High Risk Criteria):

  For people aged 16 or over with suspected sepsis who are or have recently been pregnant and meet any moderate to high risk criteria, assess them to make a definitive diagnosis and decide if their condition can be treated safely outside hospital ¹. If a definitive diagnosis is not reached or the condition cannot be treated safely outside an acute hospital setting, refer them urgently for emergency care ¹. For people under 16 whose immunity is impaired by drugs or illness, refer them for emergency medical care if they meet any moderate to high risk criteria ¹.

  Moderate to high risk criteria include:

  • History: New onset of altered behaviour or mental state (reported by patient, friend, or relative), acute deterioration of functional ability, impaired immune system (due to illness or drugs including oral steroids), or trauma, surgery, or invasive procedures in the last 6 weeks ¹.
  • Respiratory: Raised respiratory rate of 21 to 24 breaths per minute ¹.
  • Blood Pressure: Systolic blood pressure 91 to 100 mmHg ¹.
  • Circulation and Hydration: Raised heart rate of 91 to 130 beats per minute (100 to 130 beats per minute in pregnancy) or new-onset arrhythmia, or not passed urine in the past 12 to 18 hours (or 0.5 ml/kg to 1 ml/kg of urine per hour for catheterised patients) ¹.
  • Temperature: Tympanic temperature less than 36°C ¹.
  • Skin: Signs of potential infection, including redness, swelling, or discharge at a surgical site or breakdown of a wound ¹.