Lcems sepsis summary

SEPSIS

Dominick C. Watts, MS, NREMT-P, FP-C

Lee County EMS

What is Sepsis?

• Sepsis is a systemic response to an infection

• word means- the state of decay

• Sepsis is SIRS with an infection

• It does not discriminate by age, sex or race

• A patient does not have to be immunocompromised to become septic

What is Sepsis?

Overview

SIRSSIRSSIRSSIRS + InfectionInfectionInfectionInfection = SepsisSepsisSepsisSepsis

SepsisSepsisSepsisSepsis Severe SepsisSevere SepsisSevere SepsisSevere Sepsis Septic ShockSeptic ShockSeptic ShockSeptic Shock

SIRS• Systemic Inflammatory Response Syndrome

• Term that was developed in an attempt to describe the clinical manifestations that result from the systemic response to infection.

• Criteria (At least two)

• Temp ≥ 100.4 or ≤ 96 F

• Heart Rate ≥ 90

• Respiratory Rate ≥ 20

• WBC ≥ 12 or ≤ 4

Sepsis

• Meets SIRS +

• Infection (documented or suspected)

• Be suspicious of recent hospital discharge or ED admission

Severe Sepsis• Meets SIRS + Infection +

• Organ dysfunction

• AMS

• Oliguria

• Mottling

• Delayed cap refill

Septic Shock

• Meets SIRS + Infection + Organ dysfunction +

• Hypotension

• SBP ≤ 90 mmHg and/ or MAP ≤ 65 mmHg

Why is this important?

• Early Goal Directed Therapy (EGDT)

• Studies show significantly reduces mortality

• EMS influences ED triage

• Sepsis identification and prompt treatment is a health care wide problem

Little Pathophysiology

• Sepsis effects mitrochonidal oxygen utilization

• clinical research shows these patients have adequate cellular oxygen

• Coagulopathy

• microthrombosis

• Vasodilation and capillary leaking

Challenges• Diagnosis requires strong assessment skills

• Some patients may not have two signs of SIRS (even when they are septic)

• beta blockers, pacemakers

• elderly patients

• immunosupressed patients

• Some septic patients have a good general appearance and are not hypotensive

• referred to occult or cryptic shock

History

• Recent infection

• Recent hospital admission

• Including EDs and Urgent Cares

• Worsening viral-like symptoms

• General malaise

History

• Body aches

• Decreased appetite

• Taking antibiotics

• Immunocompromised

• Elderly

Signs• Temp ≤ 96 or ≥ 100.4 F

• SBP ≤ 90 mmHg or hypoperfused

• MAP ≤ 65 mmHg

• HR ≥ 90 bpm

• RR ≥ 20 bpm

• EtCO2 ≤ 37 mmHg

Alternative EtCO2 Uses

• Kartal, Eray, Rinnert, Goksu, Beka, & Eken (2011)

• demonstrated a statistical significant correlation with EtCO2 values ≥ 37 mmHg as not having acidosis (100% sensitivity)

• also reported correlation with values ≤ 25 mmHg as being a STRONG indicator of acidosis (84% sensitivity)

Differentials

• CHF

• Simple bacteria infection

• Viral infection

• Allergic reaction

• Toxi shock syndrome

Prehospital Treatment

• Early recognition

• Aggressive fluid resuscitation

• Low-flow oxygen (unless hypoxic)

• Hemodynamic support

• Effective communication

• Do NOT use Lactated Ringers! (remember the patho sides?)

• If septic shock start fluids and Dopamine together• Dopamine doses need to start at 20

mcg/kg/min for alpha affects

Reminders• Use low tidal volumes (6 ml/ kg of ideal

body weight)

• Do NOT suppress a compensatory respiratory rate!

• Do NOT treat a compensatory heart rate unless affecting preload!

• Increase PEEP to improve oxygenation unless the patient is hypotensive

References• Guranni, P. K., Patel, G. P., Crank, C. W., Vais, D., Lateef, O., Akimov, S., et al. (2010).

Impact of the Implementation of a Sepsis Protocol for the Management of Fluid-Refractory Septic Shock: A Single-Center, Before-and-After Study. Clinical Therapeutics , 32 (7), 1285-1293.

• Kartal, M., Eray, O., Rinnert, S., Goksu, E., Bekas, F., & Eken, C. (2011). ETCO2: a predictive tool for excluding metabolic disturbances in nonintubated patients. American Journal of Emergency Medicine , 29, 65-69.

• Marino, P. L. (2007). The ICU Book (3rd ed). Lippincott Williams & Wilkins. Philadelphia, PA.

• Nguyen, H. B., Rivers, E. P., Abrahamian, F. M., Moran, G. J., Abraham, E., Trzeciak, S., et al. (2006). Severe Sepsis and Septic Shock: Review of the Literature and Emergency Department Management Guidelines. Annals of Emergency Medicine , 48 (1), 28-54.

• Seymour, C. W., Band, R. A., Cooke, C. R., Mikkelsen, M. E., Hylton, J., Rea, T. D., et al. (2010). Out-of-hospital characteristics and care of patients with severe sepsis: A cohort study. Journal of Critical Care , 25, 553-562.

• Seymour, C. W., Cooke, C. R., Mikkelsen, M. E., Hylton, J., Rea, T. D., Goss, C. H., et al. (2010). Out-of-hospital fluid in severe sepsis: effect on early resuscitation in the emergency department. Prehosp Emerg Care , 14 (2), 145-152. 

References

• Surviving Sepsis Campaign

• Studnek, J. R., Artho, M. R., Garner, C. L., & Jones, A. E. (2010). The impact of emergency medical services on the ED care of severe sepsis. American Journal of Emergency Medicine , 1-6.

• Townsed, S., McMullan, C., & Jacobsen, D. (2011). Sepsis Detection & Initial Management. IHI Expedition- Session 1.

• Tromp, M., Hulscher, M., Bleeker-Rovers, C. P., Peters, L., van den Berg, D. T., Borm, G. F., et al. (2010). The role of nurses in the recognition and treatment of patients with sepsis in the emergency department: A prospective before-and-after intervention study. International Journal of Nursing Studies , 47, 1464-1473.

• Wang, H. E., Weaver, M. D., Shapiro, N. I., & Yealy, D. M. (2010). Opportunities for Emergency Medical Services care of sepsis. Resuscitation , 81, 193-197.