Managing Sepsis in the Adult Patient

Additional treatment for the patient with sepsis or septic shock includes maintaining body temperature. Recall that patients with sepsis can present hyper- or hypothermic. Regardless of presenting core temperature, patients with sepsis are susceptible to heat loss. Protect them by employing warming measures such as blankets and turning up the heat in the patient compartment.

Monitor the blood sugar of patients with suspected sepsis closely. During the cascade of events that occurs systemically during severe sepsis, profound hyperglycemia becomes common—even in patients without prior histories of diabetes. Most hospitals use insulin to keep blood sugars below 180 mg/dL during sepsis.

The prehospital administration of antibiotics is beyond the scope of paramedics in essentially all EMS systems. However, it is well documented that the earlier sepsis is recognized and managed, the lower its mortality. Intravenous antibiotics may be appropriate to consider in some paramedic systems where lactate levels can be used to confirm the presence of sepsis and ED transport times are greater than 30 minutes.

The administration of intravenous antibiotics is common during interfacility transport of sepsis patients. Typically, once sepsis is confirmed, two different antibiotics are initiated simultaneously. A broad-spectrum antibiotic is given, as well as one specific to the local infection source. Vancomycin and Zosyn are commonly given as first-line antibiotics for sepsis. If you work in an environment where transport times are long (greater than 30 minutes), consider working with your medical director to implement a sepsis recognition and management plan.

References

1. Bone R. American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference: Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Crit Care Med 1992; 20: 864.

2. Bone RC, Grodzin CJ, Balk RA. Sepsis: A new hypothesis for pathogenesis of the disease process. Chest 1997; 112: 235–243.

3. Jui J. “Septic Shock.” In Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 7th ed. McGraw-Hill, 2011.

4. Wang HE, Shapiro NI, Angus DC, Yealy DM. National estimates of severe sepsis in United States emergency departments. Crit Care Med 2007; 35: 1,928.

5. Hall MJ, Williams SN, et al. Inpatient Care for Septicemia or Sepsis: A Challenge for Patients and Hospitals. NCHS Data Brief No. 62, June 2011.

6. Murphy ML, Xu J, Kochanek KD. Deaths: Preliminary Data for 2010. National Vital Statistics Report. Hyattsville, MD: National Center for Health Statistics, 2012.

7. Angus DC, Linde-Zwirble WT, Lidicker J, et al. Epidemiology of severe sepsis in the United States: Analysis of incidence, outcome, and associated costs of care. Crit Care Med 2001; 29: 1,303–10.

8. Spotlight on sepsis. J Emerg Med Serv www.jems.com/article/administration-and-leadership/spotlight-sepsis.

9. Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001; 345(19): 1,368–77.

10. Dellinger RP, Levy MM, Carlet JM, et al. Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock. Crit Care Med 2008; 36: 296.

11. Mayfield TR, Meyers M, Guerra W. Decreasing door to antibiotic time in septic shock patients using an EMS sepsis alert. J Emerg Med Serv, www.jems.com/article/training/prehospital-care-research-forum-presents-0.

12. The Acute Respiratory Distress Syndrome Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med 2000; 342: 1,301–08.

13. Shapiro NI, Zimmer GD, Barkin AZ. “Sepsis Syndromes.” In Marx, ed., Rosen’s Emergency Medicine, 7th ed. Mosby, 2009.

Scott R. Snyder, BS, NREMT-P, is EMT program director for the San Francisco Paramedic Association. Contact him at scottrsnyder@me.com.

Sean M. Kivlehan, MD, MPH, NREMT-P, is an emergency medicine resident at the University of California, San Francisco and a former New York City paramedic. Contact him at sean.kivlehan@gmail.com.

Kevin T. Collopy, BA, FP-C, CCEMT-P, NREMT-P, WEMT, is the performance improvement coordinator for Vitalink/Airlink in Wilmington, NC, and a lead instructor for Wilderness Medical Associates. Contact him at kcollopy@colgatealumni.org.