Sepsis-What is it?

Sepsis-What is it?

Sepsis is defined as a systemic reaction to an infection.  As you fight the infection in your lungs, bladder, or leg, your immune system reacts by activating white blood cells and antibodies to attack locally.  At some point, in some cases, the inflammatory response becomes systemic which initiates a system wide cascade of effects.  Sepsis is the cause of death for over 250,000 people every year.  Patients of age extremes and those with weakened immune systems are more susceptible to having an infection turn into sepsis.

We often use sepsis and septic shock interchangeably but they are different stages of the disease process.

  • Sepsis – life threatening response to an infection with life threatening organ dysfunction
  • Septic Shock – sepsis with hypotension and hypoperfusion

As the patient becomes hypoxic and develops poor perfusion, lactic acidosis occurs due to anaerobic metabolism.  These levels can be measured in the blood with and ABG and lactate.

End tidal CO2 can also be used as an adjunct to assist in determining sepsis.  End Tidal CO2 is affected by ventilation, cardiac output and metabolism.  A low reading (normal is considered 35-45) can mean the respiratory rate is too fast and the patient is breathing off too much carbon dioxide or cardiac output is low causing anaerobic metabolism and metabolic acidosis.

Assessment

EMS providers can indicate a high index of suspicion that the patient has sepsis or septic shock.  If the patient has a known infection or strongly suspected one AND two or more Systemic Inflammatory Response Syndrome (SIRS) criteria, they may have sepsis.

SIRS Criteria

Systolic BP less than 90
Heart Rate greater than 90
Altered mental status
Respiratory rate greater than 20
Temperature greater than 100.4 F  or less than 96.0 F

 

In addition, perform a physical exam and obtain vital signs including pulse, blood pressure, respiratory rate, blood glucose, pulse oximetry and end tidal CO2.  Some of these “vitals” and readings will be higher or lower than normal based on the patient and the progression of sepsis.

EMS Treatment

We need to manage the patient’s airway, breathing, and circulation as well as provide other supportive care (like blood glucose, keeping warm, positioning, oxygen, etc.).  While we “fix” those things such as hypoventilation and hypoperfusion, we will also be working towards correcting the process of sepsis.

When gaining access for fluids and medications, crews should pay close attention so as not to use a limb with a current infection or an existing port that could be the source of the infection.

Patients with suspected sepsis (known or suspected infection and 2 or more SIRS criteria) should receive IV fluids when their blood pressure is less than 90 mmHg systolic and especially if their ETCO2 is less than 26.  We can give up to 30mg/kg of normal saline to keep the systolic BP at least 90.  These should be given in 250 mL boluses with frequent breath sound checks.  If the patient is not responding to fluid challenges, Paramedics may start a norepinephrine (Levophed) drip at 0.1-0.5 mcg/kg/min on standing order.  Intermediates can call for orders for a norepi drip.

Crews should not delay transport and indicate on the radio report and during face to face turnover that sepsis is suspected.

Hospital Treatment

Sepsis and Septic Shock are treated with antibiotics and supportive care including fluids but patients often require much more aggressive treatments such as vasopressors, corticosteroids (not solumedrol), blood products, glucose management, dialysis, and other electrolyte corrections.  The true correction is locating the source of the infection, determining the bacteria and treating that specific process.

Unless the specific bacteria and source is already known to the physician, they will start with broad spectrum antimicrobials immediately after obtaining blood cultures, and work on locating the source of the infection with other lab work and treatments.  Once the cultures return with results in 48-72 hours, the antimicrobial can be adjusted for that specific bacteria.  Some tests can take up to 10 or more days.

Some facilities have instituted an overhead “sepsis alert” process much like Stroke or STEMI alerts.  Other facilities are more subtle with timers and alerts built into the chart.  Every hospital tracks that the right procedures are performed and that they meet their timelines and goals.

For more information, visit:

http://tidewater.vaems.org/regional-protocols/current-tidewater-ems-regional-protocols

https://www.cdc.gov/sepsis/index.html

http://www.survivingsepsis.org/Guidelines/Pages/default.aspx