Recognition, Prevention and Management of Sepsis

     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