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Identification and Management of Sepsis in The Prehospital Environment

This document discusses identification and management of sepsis in the prehospital environment. It defines sepsis as a syndrome caused by an exaggerated immune response to infection that can damage organs. Early identification of sepsis and treatment with intravenous fluids and antibiotics in the prehospital setting has been shown to decrease time to treatment and reduce mortality compared to patients who receive treatment only after arriving at the hospital. Prehospital providers should monitor for signs of infection, risk factors for sepsis, and SIRS criteria to identify potential sepsis patients and alert receiving facilities so rapid treatment can begin. Treatment involves IV fluids, oxygen supplementation, and rapid transport to the hospital.

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Rutuja Umate
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115 views46 pages

Identification and Management of Sepsis in The Prehospital Environment

This document discusses identification and management of sepsis in the prehospital environment. It defines sepsis as a syndrome caused by an exaggerated immune response to infection that can damage organs. Early identification of sepsis and treatment with intravenous fluids and antibiotics in the prehospital setting has been shown to decrease time to treatment and reduce mortality compared to patients who receive treatment only after arriving at the hospital. Prehospital providers should monitor for signs of infection, risk factors for sepsis, and SIRS criteria to identify potential sepsis patients and alert receiving facilities so rapid treatment can begin. Treatment involves IV fluids, oxygen supplementation, and rapid transport to the hospital.

Uploaded by

Rutuja Umate
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd
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Identification and

Management of Sepsis in the


Prehospital Environment
Objectives
“Sepsis is caused when the body’s
immune system becomes
overactive in response to an
infection, causing inflammation which
can affect how well other tissues and
organs work.”
–National Institute for Health and Care Excellence Guidelines
Defining Sepsis
Sepsis is a syndrome
– A group of body dysfunctions found
together
– Dysfunctions that progress together in a
predictable way
– High mortality rate, variable clinical
presentations
Sepsis Mortality
Sepsis Spectrum

• HR>90
• RR>20
• T > 100.4 F or < 96.8 F
• Abnormal WBC count
• Low pCO2

SIRS
MORTALITY
Normal Response to Infection
• Local infection
• Non-specific inflammatory response
• 3 phases
– Vasodilation - increased blood flow to site, infusion of
antibodies and cells to fight infection
– Vessel permeability - antibodies and cells exit
bloodstream and enter infected tissue
– Once infection is controlled, tissue repairs itself
Pathophysiology of Sepsis
• Uncontrolled, exaggerated immune response
• Endothelium damage, cell mediator activation,
disruption of coagulation system homeostasis
• Vasodilation and capillary permeability
• Systemic inflammatory response
• End-organ damage, death
SIRS
• Systemic Inflammatory Response Syndrome
– A constellation of abnormal signs
– Many triggers, infection is most common
– EMS uses a version of SIRS that doesn’t rely
on blood test results (WBC count, ABG)
– Temp, HR, RR, glucose, mental status
Risk Factors for Sepsis
• Extremes of age (old and young)
– Can’t communicate, need careful assessment
– Patients with developmental delay
– Cerebral Palsy
• Recent surgery, invasive procedure, illness,
childbirth/pregnancy
termination/miscarriage
• Reduced immunity
Increased Risk for Sepsis
• DIABETES, DIABETES, DIABETES
• Liver cirrhosis
• Autoimmune diseases (lupus, rheumatoid arthritis)
• HIV/AIDS
• Para/quadriplegics
• Sickle cell disease
• Splenectomy patients
• Compromised skin (chronic wounds, burns, ulcers)
Increased Risk for Sepsis
• Chemotherapy
• Post-organ transplant (bone marrow, solid
organ)
• Chronic steroid use
• Recent antibiotic use
• Indwelling catheters of any kind (dialysis, Foley,
IV, PICC, PEG tubes, etc)
Signs/Symptoms of Sepsis
• Symptoms of sepsis are often nonspecific and include the
following:
– Fever = most common (elderly patients often do NOT
mount a febrile response)
– Flu-like symptoms
– Chills/shaking (mistaken for seizure)
– Nausea/vomiting
– Mental status changes/fatigue/lethargy

Patient often does NOT


appear acutely ill
Multiple Organ System Dysfunction

CNS Cardiovascular
Altered mental status Tachycardia
Hypotension
Respiratory
Tachypnea Renal
Hypoxia Oliguria
Anuria
Hepatic Renal failure
Jaundice
Liver inflammation
Hematologic
Coagulopathy
Consumptive coagulopathy
Petechiae
Metabolic Purpura
Lactic acidosis
Causes of Sepsis
United Effort to Improve Survival from Sepsis

• Research from past 20 years is saving lives


– Rapid identification, fluids, antibiotics
• Education to all physicians, nurses, technicians
• “Care bundles” monitored by Feds
• Sepsis alert teams in hospitals
• Chart review
• Administrative support at all levels
(Crit Care Med 2006;34[6]:1589.)
EMS and Sepsis
Emerg Med J. 2009

• “In time critical conditions such as AMI or stroke,


specific interventions by prehospital practitioners
make a significant difference to mortality.”
• 45,394 EMS encounters in King County, Washington
• 1350 met criteria for severe sepsis
• Administration of prehospital fluid was associated
with decreased odds of hospital mortality
• 34% of patients presenting to the ED with a serious
infection arrived by EMS
• In these patients, mortality was higher for EMS
patients (8%) than non-EMS patients (2%)
• EMS cares for the “sickest” sepsis patients
• Compared severe sepsis patients arriving by EMS to
those that did not
• 35 minute reduction to initiation of antibiotics
• 41 minute reduction to targeted sepsis resuscitation
EMS Role in Sepsis

• Decreased time to intravenous fluids


• Decreased time to antibiotics
• Decreased mortality
• Shorter hospital stay
Identifying the Sepsis Patient
• Look for and ask about infection
– Did you look at all the skin???
• Look for and ask about risk factors for infection
• Check a temperature accurately
– > 38°C (100.4°F)
– < 36°C (96°F) more dangerous
Identifying the Sepsis Patient
• Look for SIRS criteria in the vital signs
• Look for shock/dehydration
• Check end-tidal CO2
Treating the Sepsis Patient
• Airway/breathing
– Get sats > 92%
– NRB, CPAP, invasive airway
• Circulation
– 2 large bore IV, consider IO
– 20 cc/kg NS bolus
– May repeat if lungs remain clear
Sepsis Alert

• Communicate your suspicion early!


• It doesn’t matter if accepting facility has a
formal sepsis alert response process
• Explicitly communicate abnormal vitals
(especially temp) just as you would in trauma
What about Dopamine?
• Dopamine traditionally used for shock in EMS
• Studies show that survival is worse when
dopamine is used to treat septic shock
• Probably better to stick with fluids and rapid
transport
• Hospitals and other EMS use norepinephrine
for best survival in septic shock
Respiratory Component of Sepsis
• Mismatch of oxygen availability to
changing needs of organs (ie. Increased
oxygen demand)
• Keep sats ≥ 92 % (NRB, CPAP, intubation)
• Respiratory failure can happen quickly
• Acute Respiratory Distress Syndrome
Severe Sepsis/Septic Shock
A story of imbalance…

Oxygen Oxygen
Consumption Delivery

As sepsis progresses, circulatory abnormalities lead to an imbalance of systemic


oxygen delivery and demand, resulting in global tissue hypoxia.
Global tissue hypoxia is a key development preceding multi-organ failure and death.
Sepsis Pitfalls

• Beta blockers block tachycardia response


• Altered mentation not recognized as
“end-organ failure”
• Temperatures not checked
• EtCO2 not checked or recognized
• Discouragement due to hospital response
EtCO2 and Lactate

• Low EtCO2 associated with high lactic acid


• Low EtCO2 predicts mortality
• EtCO2 of 25 mmHg = lactate up to 6.1 mm/L
Identification and Management of
Sepsis in the Prehospital Environment
THANK YOU
Presenter Name | Title
[email protected] | 602-542-1025

azhealth.gov
@azdhs
facebook.com/azdhs

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