Recognizing and managing severe sepsis in the pre-hospital environment

WHAT IS SEPSIS? Sepsis is a potentially dangerous or life- threatening medical condition, found in association with a known or suspected infection (usually caused by but not limited to bacteria) whose signs and symptoms fulfill at least two of the following criteria of a systemic inflammatory response syndrome (SIRS):

Elevated heart rate (tachycardia) >110 beats per minute Body temperature either high (>100.4 F ) or low (<96.8 F or 36 C) Increased respiratory rate of >24 breaths per minute or a reduced PaCO2 (partial pressure of carbon dioxide in arterial blood level) Abnormal white blood cell count

The challenge in the pre-hospital setting is that our understanding of the sepsis process is still developing. Traditionally, we've viewed sepsis as the body's response to infection. Therefore, patients who die from sepsis have seemingly lost the battle with the microorganisms invading their bodies. But the process is far more complex.

  At its core, sepsis is a problem with circulation. When the immune system senses a threat-- bacterial, fungal, viral or parasitic--it mounts a response. White blood cell production and localized inflammatory responses are standard immune system responses.

In severe sepsis, the body's balance between inflammatory and anti-inflammatory chemical responses gets out of whack. This systemic inflammatory response is known as SIRS (systemic inflammatory response syndrome). Systemic inflammation, vasodilatation and capillary leakage contribute to hypotension and the rapid slide into end-organ hypoxia and failure.

UNCOMPLICATED SEPSIS verses SEVERE SEPSIS Uncomplicated Experienced by millions of people each year, uncomplicated sepsis is caused by a wide variety of viral and bacterial infections, such as the common flu, gastroenteritis, bacteremia, pneumonia, dental abscesses and bladder infections. Severe Severe sepsis is identified when one or more end organs begin to show signs of failure.   Due to inhibited circulatory function, organs like the heart, kidneys, lungs and liver become oxygen-deprived and begin to fail. Core body temperature may rise, then fall. The heart rate will increase, and the blood pressure will fail, respirations increase. Many will receive oral antibiotics from their physicians. Most will recover without further intervention. This is the magic moment when recognition of the patient's condition can make a huge difference in their outcome. Intervention is the key.

Sepsis is commonly seen by EMS professionals and has an in-hospital mortality of almost 29%. It is extremely common and is the cause of 50% of deaths worldwide.It represents 2% of hospitalizations in the U.S., with over 200,000 associated deaths. Pneumonia is the cause of 61% of sepsis cases in the U.S. Urinary tract infections are also a very common cause of sepsis, particularly in the elderly.

With any infection, the body's immune response system will actively try to keep it controlled and will fight against it. Infections activate the body's inflammatory- immune response, activating several pathophysiologic pathways. This response results in leaky capillaries, vasodilation, and microthrombi (i.e. small clot formation). In some patients, this response can become uncontrolled and unregulated, resulting in hypoperfusion to the cells, tissue destruction, and organ death (i.e. septic shock).

Temperature is a very useful vital sign Temperature is a very useful vital sign. Confused patients with elevated temperature are much more likely to have an infection as the source for their altered mental status.

During the scene survey, look for medicine bottles and check the refrigerator to see if it contains an adequate food supply and refrigerated medications like insulin. Check the dates that medication bottles were filled and see if there are too many or not enough pills missing.

It is not uncommon for elderly patients with short-term memory problems or depression to take too much or too little of their medicine, which can each lead to problems. Malnutrition and dehydration are also possibilities, particularly in the homebound elderly patient with inadequate social support mechanisms in place.

Respiratory rate – tachypnea is an early sign of infection and septic shock. Peripheral pulses – strength of peripheral pulses is related to both stroke volume of the heart and pulse pressure. If the patient is not in shock, pulses should be easily palpable. Skin perfusion – in the normal individual, skin will be warm, dry, and pink. Shock may result in delayed capillary refill. Normal capillary refill is less than 2 seconds . Mental status – altered mental status is a late finding in septic shock, and it is an indicator of inadequate tissue perfusion. Temperature – hyperthermia and hypothermia can each be seen with septic shock.

All types of shock, including septic shock, are characterized by reduced cardiac output, circulatory insufficiency, and tachycardia. Low blood pressure, although sometimes seen in late shock, is an ominous finding. With compensated shock, systolic blood pressure is normal. In decompensated shock, systolic blood pressure is low.

One of the most common reasons for altered mental status in the field is hypoglycemia. Hypoglycemia is easily diagnosed with a blood glucose check. Stroke is another large category that can explain altered mental status, particularly in the elderly. Infection/sepsis is another common reason for altered mental status. Temperature is a very important vital sign to obtain, particularly in the older patient with altered mental status. The patient with altered mental status and a fever is much more likely to have an infection as the reason for altered mental status. Common infections in the elderly are pneumonia and urinary tract infections. These patients should be asked careful history questions looking for possible infections.

Do not make assumptions about the confused elderly patient Do not make assumptions about the confused elderly patient. The patient you think may be having a stroke may actually be hypoglycemic or postictal from a recent seizure, or even intoxicated. Keep in mind sepsis is a very common condition and often presents with confusion. Be thorough, perform a thorough history and physical exam

As sepsis progresses, additional findings are, grunting, altered mental status, and irritability. hypotension, respiratory depression or failure, cyanosis, cool extremities, decreased pulses, lethargy, and coma can be seen. (These are all late findings of sepsis in children.)

Glasgow Coma Scale: standardized method using a scale from 3-15 to assess a patient's level of consciousness by evaluating best eye opening, verbal, and motor responses. This scale should be done on all patients with altered mental status, and repeat evaluations are useful. Repeat evaluations should be recorded with the times that these were performed. This is helpful to the personnel at the hospital, and is also extremely helpful if the case is ever later reviewed in a court of law.

The elderly, very young, and immunocompromised patients can present with sepsis with atypical presentations (i.e. afebrile). Do not assume sepsis is ruled out in these patient populations just because a patient is afebrile.

More than 40,000 children in the U. S. develop severe sepsis each year More than 40,000 children in the U.S. develop severe sepsis each year. Incidence of severe sepsis is highest in infants. 1/2 of all patients had chronic medical conditions (i.e. malignancy, HIV, immunosuppression, absent spleen, chronic antibiotic therapy, malnutrition, sickle cell disease). Increased risk for presence of invasive devices (i.e. indwelling catheters), burns, urinary tract abnormalities, and neonates. More than 40% of cases due to respiratory infections and primary bacteremia. Initial presentation will often be widened pulse pressure (systolic pressure minus the diastolic pressure, warm and dry extremities), with tachycardia, tachypnea, bounding pulses, normal capillary refill, and fever.

PRE-HOSPITAL TREATMENT ABCs – aggressively support the airway and provide supplemental oxygen. Support circulation with IV/IO of normal saline • If SBP < 90 mmHg, initiate a fluid bolus of normal saline: 1 liter (PEDS 20 ml/kg) Repeat boluses (Max 3 boluses) to maintain a SBP of 90 mmHg Contraindicated in patients with signs or symptoms of pulmonary edema Contact Medical Control for ANY additional fluid boluses

Obtain and interpret 12-lead EKG. Transmit to receiving facility. Identify possible septic shock Contact hospital and relay suspected sepsis, including ALL signs of hypoperfusion AND presence of 2 or more Systemic Inflammatory response Syndrome (SIRS) criteria: HR > 110 RR > 24 Temp > 100.4° or < 96.8° F Contact Medical Control for ANY additional orders Constant re-evaluations and Quick transport

Key points Patients with severe sepsis have a high mortality rate in the absence of early treatment. Pre-hospital recognition of severe sepsis and early aggressive treatment along with goal directed therapy has been proven to significantly reduce mortality. Pre-hospital recognition and management of the septic patient can result improvements to the patient with severe sepsis.

In Conclusion Severe sepsis is a complex illness with a high mortality in the absence of early aggressive treatment. Early goal directed therapy is shown to significantly reduce mortality The use of a pre-hospital screening tool may help all EMR to identify these septic patients and provide early treatment