Background: Unrecognized and undertreated septic shock increases morbidity and mortality. Septic shock in children is defined as sepsis and cardiovascular organ dysfunction, not necessarily with hypotension. OBJECTIVE: Cases of unrecognized and undertreated septic shock in our emergency department (ED) were reviewed with a focus on (1) increased recognition at triage and (2) more aggressive treatment once recognized. We hypothesized that septic shock protocol and care guideline would expedite identification of septic shock, increase compliance with recommended therapy, and improve outcomes.