Sepsis is a far too common medical condition with a mortality rate that warrants your attention. I bet if you were to tour your local ICU this week - you would find at least one (1) patient diagnosed with this life-threatening medical emergency. The clinical cascade of events that comes from a systemic infection usually develops swiftly and as a pre-hospital provider, this is something you should be able to pick up on. Early identification and proactive hospital telemetry calls can positively affect the alarming mortality associated with this disease process. EMS has the ability to directly influence these patient outcomes. Contrary to what you may think, you don't need a lot of sophisticated diagnostic equipment to identify the likelihood of sepsis with some decent accuracy.
Why do we care? -- These patients are sick, and they cost the healthcare systems a lot of money. With bundles of care having influence over reimbursement + with many entities having to share from the same pot of money; as stated before, sepsis deserves this attention.
Let's dive in (we have the ability to do more than we think in this arena):
Recognize SIRS (systemic inflammatory response syndrome) - this can be done, even in our out of hospital setting. You only need 2 of the 4 items below to qualify.
+ Temp > 100.4 or < 95 F (YES, some septic patients are hypothermic and YES, they historically do worse) - we can do this
+ RR > 20 or PaCO2 < 32mm HG (ETCO2 has many implications for NON-intubated patients) - we can do this
+ HR> 90 - we can do this
WBC > 12 or < 4 or bands (immature neutrophils) >10% - we need to leverage a laboratory for this one
In recent years, some EMS systems are deploying point of care systems that measure electrolytes, H&H, and of relevance to this blog Lactic Acid... this blood test can be another indicator that sepsis is lurking -- even before the patient's hemodynamics change.
NEXT consider if there can be a source of infection - (think indwelling catheters, broken skin, recent surgery, or hospital discharge)
If you can gather a decent history of present illness and pinpoint a potential cause for infection -- the likelihood for sepsis is high. SIRS + microbial source = SEPSIS
NEXT, look for organ dysfunction - our role here may be more limited, but look for obvious things like:
+Altered Mental Status (GCS <15)
+Profound hypotension (HR > SBP)
If the answer here is yes based on a further clinical evaluation in the back of the rig, you may have a severe case of sepsis on your hands and if they are unresponsive to you fluid challenges -- then this is the worst case scenario where SEVERE SEPTIC SHOCK is present and if interventions are initiated towards the root cause they multi-organ dysfunction syndrome is likely to happen next -- a great number of these patients do not get discharged from hospital without some form of disability -- and many will actually die.
If you get to these patients late one of you targeted goals should be to keep them oxygenating well and keep their MAP above 65. Remember the MAP dictates how end organ perfusion is going. This reading is captured during every automated BP reading. In fact, the cuff is measuring MAP directly and then simply using an algorithm in the background to compute the patient SBP and DBP.
Causes of sepsis can vary widely and depend on the specific organ system involved, (is it PNA, meningitis, or a UTI??) Some of the more common pathogens include: Group B Strep, Neisseria meningitidis (meningitis), Staphylococcus aureus (skin related infections), E.coli (UTI), Streptococcus pneumoniae (community acquired pna). Some our cocci shaped, others are bacillus or rod shaped on microscopy. Some stain pink, others stain purple.
Other microorganisms can also cause sepsis - they include yeast, fungi, and/or viruses. They are not as prevalent though.
To ensure you improve around management of these critically ill patients -
+ Converse regularly with your local hospitals. Your sustained successes depend on it.
+ Invest in technology to make pre-notifications for sepsis more streamlined. This should be treated like other time sensitive emergencies (STEMI, Stroke).
+ Look closely at the metrics and the discharge data. Health systems should be sharing this with you. The technology to automate this has been out there for nearly 15 years.
+ Consider updating your protocols and altering next year's training schedule.
October 9, 2023
Author: Joshua Ishmael, MBA, MLS(ASCP)CM, NRP
Pass with PASS, LLC.