Recognition, Prevention and Management of Sepsis

You are dispatched to a long-term nursing facility for a general illness call. Upon arrival, you find your patient lying in bed, soaked in sweat and responsive to pain only. The nursing staff tell you that Gerald is 76 years old, had a major stroke two years ago and is now nonverbal, but normally opens his eyes when his name is called. They also tell you he broke out with a fever of 101°F this morning and has had diarrhea for two days. You notice that he has a urinary catheter and a feeding tube.

     You begin a physical exam while your partner applies oxygen and obtains a set of vitals. As you inspect the patient's abdomen and examine the site where the feeding tube enters, you note that it is red and swollen, with pus seeping out around the tube. Your partner tells you that Gerald's pulse is 104, blood pressure 84/50, and his respirations are 28. After performing routine management, you alert the hospital that you are transporting a patient with suspected sepsis.

Introduction
     More than 750,000 patients are diagnosed with severe sepsis annually in the United States. Diagnoses have increased by over 90% in the last 10 years.1 One of the main reasons for this increase is the continual rise of drug-resistant bacteria.2 Further, 25 U.S. citizens die each hour from severe sepsis, making it more deadly than breast, colon/rectal, pancreatic and prostate cancer combined.1 Although most commonly seen in the hospital, sepsis often strikes patients in the prehospital setting.

Demographics
     Anyone can be stricken with sepsis; however, some people are more at risk than others.

Elderly population
     As people age, the effectiveness of their immune system begins to decrease, and it becomes much more difficult to fight off infections before they spread to the entire body.

     Dementia may impair a patient's ability to communicate illnesses. Additionally, many elderly patients have conditions, such as diabetes and cancer, that further impair their immune systems.4

Infants
     Premature babies and neonates have underdeveloped immune systems, making it very difficult for them to fight off infections. Infants born before 37 weeks gestation, as well as those born with meconium staining, are at high risk for developing sepsis. Mortality for septic infants is 50%.5

Surgical patients
     High-risk surgical procedures, such as heart or abdominal surgery, organ transplant and splenectomy, put patients at greater risk for sepsis. These patients often receive immunosuppressant drugs that impair their immune systems.4 These drugs are given to protect any transplanted organs or artificial organ parts, such as a heart valve, from being rejected by the recipient's body.

Pre-Existing Conditions
     Many conditions put patients at greater risk for infection. Chronically ill patients have already-stressed immune systems that are often too weak to fight off systemic infections. Chemotherapy administered to cancer patients impairs the immune system.4 Diabetics suffer from decreased peripheral circulation, which makes wound healing more difficult.

     Patients with gastrointestinal and gastrourinary problems are also at risk for infection, as are morbidly obese patients, who are generally less ambulatory, often bedridden and may develop bedsores, which are prime locations for infection development. Additionally, obese patients usually wait longer before seeking medical attention, delaying the recognition of infections. Major trauma and burns also put patients at risk for infections by destroying the body's natural protective barrier-the skin. However, sepsis may occur in an otherwise healthy person and can strike very quickly.

The following wounds carry a high potential for infection:

  • Impaled objects
  • Puncture wounds (e.g., dog bites)
  • Burns
  • Complex wounds (e.g., open fractures)
  • Crush injuries
  • Dirty wounds (full of debris).

     These wounds damage large areas of the skin and introduce impurities deep into the body. Prehospital providers must learn to recognize them and treat them aggressively.

Mortality
     When an otherwise healthy individual develops sepsis, there is a 95% chance of recovery; however, mortality rises quickly for those who are already sick or develop severe sepsis.2 If hypotension, the signal of severe sepsis, sets in, mortality jumps to 50%.3 As stated before, infant mortality from sepsis is also near 50%.5 The longer it takes for treatment to begin, the higher the mortality.

Definitions of Sepsis
     You are dispatched to a nonemergency medical center for a patient with a fever. Upon arrival, the treating physician informs you that your 74-year-old male patient likely has a nasty flu virus; however, while you assess the patient, a nurse remarks that he looks septic. As you give your report to the emergency department, the receiving nurse observes that "it is probably septicemia."

     Are these medical providers using different names for the same condition, or are they each thinking about different conditions? Following are terms used when dealing with sepsis.

Pathogen
     A pathogen is any agent that causes a disease or infection in a host. Pathogens can be bacteria, viruses, parasites or fungi. More than 90% of sepsis cases are caused by bacteria.3

Systemic Inflammatory Response Syndrome
     Systemic inflammatory response syndrome, or SIRS, is the term given to a bodywide immune response, no matter what triggers it.1 SIRS may be triggered by a pathogen, antigen or toxin. A patient has SIRS when two or more of the following are present:

  • Temperature above 100.4°F or below 96.8°F
  • Heart rate above 90 beats per minute
  • Respiratory rate above 20 breaths per minute or PaCO2 below 32 mmHg
  • An extremely high or low white blood cell count.

Sepsis
     Sepsis is a broad term, and many struggle with its correct definition. Contrary to many beliefs, sepsis is not a single type of infection. Sepsis is defined as a SIRS response in the body that is triggered by an infection. Sepsis is only one place on a continuum of events for patients suffering an infection. If untreated, patients will continue to deteriorate, progressing into severe sepsis, septic shock and eventually into multiple organ dysfunction syndrome.

Septicemia
     Sepsis, septic shock and septicemia are not the same thing. Septicemia is a form of sepsis where the infection originates in the bloodstream.

Infection Pathology
     While I was performing hospital time during paramedic school, a man entered the ED with his hand wrapped in several towels. He had avulsed the skin on the top of his hand in a construction accident. The ED physician performed deep wound cleansing, closed the injury and prescribed antibiotics before discharging the patient. The next day, I saw the man in the ICU. His hand was five times its normal size, and he was febrile. I discovered he had been brought in by ambulance during the night and admitted with sepsis.

     Pathogens are all around us and are constantly trying to enter our bodies. Our body normally defends itself against infection through our largest defense mechanism, which is the skin. Intact skin keeps out most pathogens we encounter. However, pathogens can enter through any of the openings in our body, such as the respiratory tract or anywhere the skin's surface is compromised.

     Medical professionals put patients at risk for infection whenever they perform invasive medical procedures, such as IV cannulation, dental work, urinary catheter placement, any surgical drain insertion or chest tube insertion, and fail to maintain as sterile an environment as possible. The sites of these procedures open pathways from the environment directly into the body for pathogens to follow, and they need to be monitored carefully for any sign of infection.

     All infections, even the worst system-wide infections, begin locally; therefore, recognizing a local infection is critical to preventing sepsis. A local infection will appear warm to the touch, flushed, swollen, and may have pus draining from the site. The inflammation that occurs is part of the body's natural attempt to restrict the infection to the local site.3

     When a local infection occurs, the cells in the infected area respond as they do anywhere in the body for every type of infection. This is called a non-specific inflammatory cell response. Response occurs in three phases:

  • Vasodilation occurs, allowing for more blood to enter the infected area. Greater blood flow enhances the immune response by facilitating movement of antibodies and phagocytes into the infected area to fight off infection.
  • Local vessel permeability increases, which permits antibodies and phagocytes to move out of the bloodstream and into the infected cells.
  • Once the infection is controlled, tissue repair begins. Blood flow remains increased during this stage to bring additional oxygen and nutrients to the cells needing repair.

Influenza
     The influenza virus is a common form of infection that is naturally systemic. Between 250,000 and 500,000 cases occur annually in the United States. The infection first settles in the respiratory tract, then spreads throughout the body.6

     Patients with influenza often present with high fever, chills, headache, fatigue, sore throat, nonproductive cough, and nausea and vomiting. Although influenza often mimics sepsis, they are not the same. Influenza often causes a fever well above 102°F. Fevers caused by sepsis are usually between 99°F and 101°F. Additionally, influenza generally fails to cause a SIRS response.

Systemic Infection
     When the immune system fails to control a local infection, there is risk of it spreading throughout the body. Red streaks may be seen running from the local infection site toward the body's core, which is a sign the infection has entered the bloodstream.

     Systemic infections generally trigger a SIRS response, manifested with fever, tachycardia, tachypnea and alteration in the white blood cell count.4 When a patient's infection triggers a SIRS response, the patient has sepsis. If the immune system could not control the local infection, it will also not be able to control the systemic infection, and medical intervention will be required.

Symptoms of Sepsis
     Although fever is the most common symptom in sepsis, many other symptoms are also present but are commonly mistaken for other conditions. Symptoms include: chills and shaking, body aches, nausea and vomiting, vertigo and other flu-like symptoms.2,7 Occasionally, there are mild mental state changes, such as confusion, as well as lethargy and increased fatigue.4 Patients with sepsis often do not appear acutely ill and their nonspecific symptoms are misattributed as another illness because the infection is not recognized. When sepsis is not recognized and treated early, patients progress into severe sepsis.

     Low-grade fever, usually no higher than 102°F, is the most common symptom of sepsis. Infection-based fever results from a resetting of the hypothalamus (caused by pyrogens circulating in the bloodstream) meant to maintain heat production and loss at a higher temperature. The more quickly the fever develops, the more serious the infection.

     Chills develop early during an illness and signal that the body is fighting. Chills are caused by muscle activity trying to maintain body temperature at the temporary level set by the hypothalamus. Sweating, a natural antipyretic measure, is a late sign that occurs when the body is trying to return itself to normal temperatures.

     Patients progress into severe sepsis when they develop organ dysfunction, poor perfusion or hypotension. This condition is highly unstable and requires immediate aggressive treatment. Severe sepsis is characterized by: hypotension below 90 systolic, altered mental state, hyperglycemia without history of diabetes, hypoxemia and low urine output.3

     Physiologically, severe sepsis is dangerous. The body responds to the systemic infection by releasing histamines, prostaglandins and cytokines, which results in body-wide vasodilation and increased capillary permeability. As a result, fluid shifts out from blood vessels into the intravascular space, leading to body-wide inflammation and hypotension. Due to the fluid shift, the circulatory system becomes relatively hypovolemic.3

     When aggressive fluid replacement and administration of vasopressors fail to raise systolic blood pressure to at least 90, and signs of severe sepsis continue, patients are in septic shock.4 Treatment becomes extremely difficult in septic shock; mortality is over 50%.3

Multiple Organ Dysfunction Syndrome
     Multiple organ dysfunction syndrome, or MODS, occurs when two or more organs fail to function properly and homeostasis cannot be maintained without aggressive interventions.8 Generally, this state is only seen in the hospital, but it signals that the body is beginning to die.

     When septic shock cannot be corrected, MODS develops within three to five days. This is the ultimate final stage of an infection that has overtaken a body. Remember, as infections progress further, they become much more difficult to manage. The easiest infection management is prevention.

PPE and Prevention
     The first step to preventing infections is use of personal protective equipment, or PPE. PPE not only protects you from the patient, but also protects the patient from any pathogens you may be carrying. Use disposable gloves on every call. Coughs, sneezes, saliva and vomit can all spread airborne pathogens, so use face masks and safety goggles for your protection. Gowns may be indicated when treating patients with known immunosuppressant diseases or heavy bleeding.

     Arguably, the best treatment for sepsis is preventing an infectious pathogen from ever entering the body. Always clean the ambulance thoroughly between calls so pathogens are not passed from one patient to the next. Never reuse equipment on different patients without proper cleaning. This includes stethoscopes, blood pressure cuffs, EKG electrodes and stretchers.

     Patients are also exposed to infectious pathogens in other ways. Consider the last time you covered a wound in the field: Did you clean it first? Did you remove any debris? By the time a wound is cleaned at the hospital, a pathogen may have already entered the patient's body.

Wound Cleaning
     Providing some early wound cleaning drastically decreases a patient's chances of acquiring an infection. Once bleeding is controlled, inspect the wound for any debris. Flush loose debris with sterile water or normal saline, spraying water on the wound with a needleless syringe. Based on previous experience, we recommend using a 50 or 100cc syringe.

     Once the wound has been flushed free of debris, rinse with a povidone iodine solution. A 1% iodine solution, which looks like Coca-Cola, will help clean the wound.

     Iodine is preferred over an alcohol solution, as alcohol is much more harsh and can kill skin cells as well. After cleaning a wound, cover it with a sterile dressing and secure it in place with a bandage. Covering wounds keeps them clean and prevents pathogens from entering.

     Burns require special consideration, because the skin-the body's protective barrier-is destroyed. As soon as the burning process is stopped, cover the entire extent of the burned area with sterile dressings. Burn cleaning is not recommended. These patients need transport to an appropriate facility.

Invasive Procedures
     Pathogens like bacteria are always present on our skin; intact skin prevents them from entering our body. However, invasive procedures through the skin break this barrier, potentially allowing pathogens to enter. This is why proper skin cleaning is so important prior to starting an IV or performing needle chest decompression.

     If you are in a particularly dirty environment, wash the skin by multiple means including alcohol swabs, povidone iodine swabs, and soap and water. Practice aseptic techniques with your equipment, and never reuse needles, even on the same patient. Be sure intubation equipment, the laryngoscope blade and handle, is always properly cleaned. Small crevasses in the equipment, such as around the bulb, are often missed. After cleaning, laryngoscope blades should be sterilized.

Assessment and Management
     Don't expect to diagnose sepsis in the field. Definitive diagnosis requires blood tests to measure white blood cell count (high or low).2 The cause of sepsis determines the treatment course. Maintaining a high index of suspicion, identifying local infections and recognizing signs of a systemic infection speeds hospital diagnosis. This requires a complete physical examination and thorough history-taking.

     Begin assessing your patient with the dispatch information. Does anything alert you to a risk factor for sepsis? As you arrive on the scene, always begin by assessing the critical systems. Be sure the patient has a patent airway and is breathing adequately. Check the condition of the circulatory system and determine the patient's mental state. Ascertain if there is a history of trauma.

     After managing any critical system problems, obtain a complete history: Why did the patient call EMS? How long has he been ill? Is there any history of infections? Does the patient hurt anywhere? What prior medical conditions has he had? Any previous surgeries? Complete a SAMPLE history.

     Perform a complete physical exam. Start by asking "does the patient otherwise look healthy?" If the patient's complaint makes you suspect sepsis, look for any signs of local infection. Expose the body, paying special attention to any high-risk areas, such as the feet and sites of recent injuries and surgical procedures, as well as any location that is prone to bedsores. Take a complete set of vitals, paying special attention to signs of hypovolemia.

     Core body temperature is essential in assessing a potential case of sepsis. Since most patients will not allow you to take a rectal temperature, which is the ideal, be aware that core temperature is usually one degree warmer than axillary temperature and two degrees warmer than an oral temperature. Determine the patient's blood glucose level. Remember, hyperglycemia without a history of diabetes is an indicator of severe sepsis.

     If local protocols allow, take initial blood draws for in-hospital analysis. Many EMS systems now perform this assessment in the field. Having blood drawn prior to ED arrival speeds pathogen identification and assessment of white blood cell counts.

     Continue to reevaluate your patient. Patients with sepsis can deteriorate rapidly.

     Maintain your high index of suspicion and anticipate problems before they occur. Patients with sepsis are inherently unstable and prone to rapid deterioration.

     Once you successfully locate or otherwise suspect an infection, consider administering IV antibiotics. Studies have shown that early recognition of sepsis and initiation of antibiotic therapy improve patient outcome.9 Many EMS regions have begun providing antibiotics like Rocephin.

Respiratory Support
     Septic patients have an increased oxygen demand. In severe sepsis, tissue cyanosis is common. Provide supplemental oxygen and use pulse oximetry to keep the patient's SpO2 above 90%. Monitor carefully and be prepared to assist with ventilations. Mechanical ventilation is frequently required for patients with severe sepsis.9

     Patients who have progressed to severe sepsis often fail to maintain adequate SpO2 levels, even with supplemental oxygen. Respiratory failure can develop very quickly; therefore, be prepared to intubate patients for definitive airway management. If local protocols allow, use capnography on all intubated septic patients. Respiratory alkalosis with a PaCO2 of less than 32 mmHg is common.10

     Adult respiratory distress syndrome (ARDS) often occurs as patients progress to septic shock. ARDS is the acute onset of pulmonary edema without heart failure or volume overload. Sepsis is considered a leading cause for ARDS. Patients in ARDS present with rales throughout their lung fields and often develop respiratory failure.11

     Monitor hypotension. Septic patients suffer relative hypovolemia due to fluid shifts in the body. The development of hypotension signals the beginning of severe sepsis. Position patients in the Trendelenburg position and keep them warm.

     Initiate IV access in all patients you suspect of having sepsis. Consider large-bore needles to facilitate aggressive fluid replacement. Provide patients with crystalloid solutions of normal saline or lactated Ringer's. Give hypotensive patients fluid replacement in 500 mL boluses and attempt to raise the systolic blood pressure to at least 90. Two to three liters of fluid are often required for patients with severe sepsis. Consider vasopressors like dopamine and norepinephrine for patients who don't respond to fluid boluses.3

Monitoring
     Patients with sepsis require careful monitoring. Frequently assess their vital signs and mental state and watch for changes in their hemodynamic stability. While EMS providers generally do not initiate urinary catheters, they often see them in nursing home patients and on interfacility transfers. If your patient has a urinary catheter, monitor urine output.

     Healthy kidneys produce about 1 mL/kg/hr of urine. Decreased urine output may signal hypovolemia or kidney dysfunction, which is common in septic shock.

Transport Considerations
     Septic patients are inherently unstable and prone to rapid deterioration; therefore, consider an ALS intercept as soon as possible. If the closest ALS is the hospital, expedite on-scene assessment. Rapid transport is indicated if the patient has a compromised airway or inadequate breathing; registers V, P or U on the AVPU scale; has unstable vital signs; or has an oral temperature above 100°F.

     Definitive care for all forms of sepsis is identification of the pathogen and aggressive, specific antibiotic therapy. This can only be accomplished in the hospital setting. Do not delay transport of septic patients. The earlier their pathogen is identified, the better their chances are for a positive outcome.

     If sepsis progresses to severe sepsis or septic shock, treatment is more difficult. Sepsis requires aggressive management through specific pathogen recognition and antibiotic therapy.

References

  1. Society of Critical Care Medicine. A Guide to Severe Sepsis; ICU Issues & Answers. Sepsis: What You Should Know. www.sccm.org.
  2. Lasker JS, Frey RJ. Gale Encyclopedia of Medicine, Thompson Gale, 2004.
  3. Robson W, Newell J. Assessing, treating and managing patients with sepsis. Standard 19(50):56-66, 2005. 4. Stapczynski JS. Shock: Septic. www.emedicine.com/emerg/topic533.htm.
  4. Bizzarro MJ, et al. Seventy-five years of neonatal sepsis at Yale: 1928-2003. Pediatrics 116(3):595-602, 2005.
  5. Leblebicioglu H. Influenza. www.emedicine.com/ped/topic3006.htm.
  6. Richards T. What is sepsis from infusion, injection or transfusion? Clinical Reference Systems, p. 2746, Jan 2004.
  7. Who is at risk for severe sepsis? www.sepsis.com.
  8. Dellinger RP, Carlet JM, Masur H, et al. Surviving sepsis campaign guidelines for management of severe sepsis and septic shock. Crit Care Med 32(3):858-873, 2004.
  9. Bone RC. Toward an epidemiology and natural history of SIRS (systemic inflammatory response syndrome). JAMA 268(8):3453-3455, 1992.
  10. Rothenhaus T. Adult Respiratory Distress Syndrome. www.emedicine.com/emerg/topic15.htm.

Kevin Thomas Collopy, BA, NREMT-P, WEMT, is a paramedic crew chief for Bell Ambulance in Milwaukee, WI. He currently writes for Mosby and www.emsed.com through Emergency Preparedness Systems. In addition, he is a lead instructor for Wilderness Medical Associates. Contact him at kcollopy@colgatealumni.org.

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