Jaundice may be present if the patient is experiencing liver failure. Physical exam findings associated with specific sources of gastrointestinal infection include rebound tenderness (peritonitis), left lower quadrant pain (diverticulitis), pain at McBurney’s point (appendicitis), Murphy’s sign (cholecystitis) and shifting dullness (ascites).
A musculoskeletal or cutaneous source of infection for sepsis may not seem obvious but is a legitimate risk. Ask the patient or caregiver about any pain or discomfort localizing to a specific joint. Assess each joint for swelling, redness, pain with palpation or movement, decrease of movement, or warmth. Check the patient’s skin for open wounds or sores, pressure ulcers (particularly in dependent areas such as the buttocks, heels and back), abscesses, cellulitis or any other source of infection. Localized pain to lymph nodes and swelling is also a sign of infection.
Patients with sepsis may or may not present with fever. This may seem counterintuitive; however, the profound vasodilation that occurs in sepsis can result in significant heat loss and the development of hypothermia. Patients may experience chills or shivering as they try to compensate for this loss of heat. A core temperature below 36°C (96°F) or above 38°C (100.4°F) indicates hypothermia or fever, respectively.
Patients progressing from sepsis to severe sepsis become profoundly dehydrated. Assess for signs of dehydration such as poor skin turgor, dry mucus membranes and decreased urine output.
A diagnostic tool that is presently uncommon but may be seen in the future is the lactate monitor. Looking and operating much like blood glucose monitors, lactate monitors are a reliable method for determining circulating blood lactate levels. Lactate is released by hypoxic tissues and is a reliable early indicator of hypoperfusion. Lactate levels above 4 mmol/L suggest hypoperfusion and sepsis. These meters have been effectively used in prehospital settings for identifying patients who have severe sepsis.8 Because early recognition of sepsis correlates with decreased mortality, it makes sense to consider using lactate meters for early sepsis recognition.
A New Approach
The prehospital treatment of sepsis has traditionally revolved around addressing issues related to airway, breathing and circulation, and unlike patients with, say, heart attack or stroke, the patient with severe sepsis or septic shock has traditionally been treated like a “routine” patient.
Let’s consider stroke. As prehospital care providers, we are trained to aggressively assess for, identify and treat stroke in the field. We obtain thorough histories to determine patients’ status regarding fibrinolytic therapy, and transport these patients to specialized stroke centers where they receive specialized care from a team of providers put together for that exact purpose. There is a specialized continuum of care from the prehospital environment to the ED to the ICU, all in an effort to improve outcomes by reducing time to treatment.
In 2001, a team led by Michigan emergency physician Emanuel Rivers published the results of a randomized, controlled trial in which patients presenting to the ED with severe sepsis or septic shock received either a new treatment called early goal-directed therapy or the usual treatment during the first 6 hours of care.9 The core components of early goal-directed therapy include: 1) early identification of patients with sepsis; 2) optimization of oxygenation, ventilation and circulation; 3) initiation of drug therapy, including vasopressors and antibiotics; and 4) controlling the source of infection. In this study, the mortality rate for patients receiving early goal-directed therapy was lower than for those receiving routine care.
Since publication of this data, early goal-directed therapy has been incorporated into the Surviving Sepsis Campaign’s most recent international guidelines for management of septic shock, published in 2008.10 Accordingly, the treatment of severe sepsis is now carried out in an organized, systemwide fashion in the hospital environment. Recently, a study from Colorado looked at the role of prehospital care providers in the treatment of sepsis. Paramedics were trained to recognize sepsis in the field through identification of SIRS criteria and alert the hospital in advance, similar to a STEMI notification. Patients whose caregivers provided those alerts had a median arrival-to-antibiotic time of 24 minutes less than those whose caregivers didn’t. While 24 minutes may seem unimpressive, in the context of previous research demonstrating a 7.6% increase in mortality for every one hour delay to antibiotics, it becomes more significant.11