Though sepsis is the third leading cause of death inside hospitals and causes one death every three to four seconds around the globe, the medical community’s understanding of the condition remains lacking, resulting in a subpar ability to detect, diagnose and treat. Why is this? Mike McEvoy, PhD, NRP, RN, CCRN, drilled down on this issue Feb. 22 in National Harbor, Md. in his “Suspecting Sepsis” session at the EMS Today Conference and Exposition.
“We can’t detect sepsis very well because the signs and symptoms are difficult to pick up on and they vary patient to patient,” said McEvoy. Sepsis is an altered immune response that occurs when the body is under assault by bacterial or viral infections (though physical trauma can also be a factor), and “as a consequence, it starts to injure organs in an effort to respond to abnormal organisms in the body,” he said.
Sepsis is defined as a “life-threatening organ dysfunction caused by a dysregulated host response to infection.” Both sepsis and septic shock (“a subset of sepsis with circulatory and cellular/metabolic dysfunction associated with a higher risk of mortality”) are clinical diagnoses and are considered medical emergencies requiring immediate intervention to prevent death.
The body’s initial (innate) response begins within the first few hours, causing inflammation as it begins to fight off the infection. This prompts systemic vasodilation, increased capillary permeability, clotting issues and impaired perfusion. The secondary (adaptive) response occurrs four to seven days after exposure, at which time the body begins producing antibodies, or lymphocytes, to aid in the fight.
In a study analyzing the care and outcomes of septic patients, Seattle (Wash.) EMS reviewed a nine-year period of 407,176 runs to find cases of severe sepsis. They found approximately 3.3 cases of it per 100 EMS encounters, 40% of which resulted in transports to the ED. Care for these patients was found inadequate; EMS spent an average of 45 minutes with them despite the need for urgent treatment. It was reported only 54% of patients with sepsis were transported by ALS, resulting in only 37% receiving IVs. In response to this study, Seattle added sepsis alerts to the repertoire of stroke and AMI alerts to deliver better care when received at the hospital.
To help providers identify sepsis in the field, McEvoy explained the quick Sequential Organ Failure Assessment (qSOFA), which is the prehospital care version of calculating a patient’s severity score (the assessment is much more comprehensive in the ICU). If coupled with an infection, the following signs suggest the presence of sepsis:
Hypotension – systolic BP of <100 mmHg
Altered mental status
Tachypnea – RR <22/min
If the patient presents with two or more of these criteria, there is a greater risk of a poor outcome for them. McEvoy said other notable indications of sepsis can be observed based on the condition’s order of events:
Stroke volume drops: The heart rate increases so cardiac output can be maintained (McEvoy notes that there are multiple reasons why the heart rate may increase, though).
Cardiac output decreases: The increased heart rate fails to compensate, leading to vasoconstriction, which helps maintain normal blood pressure.
Increased oxygen extraction: Initially peripheral (StO2 ), then central (ScvO2, SvO2)
Blood pressure decreases, urine output drops
If a patient is severely hypotensive, you’re already behind the ball, said McEvoy. If you get 30mL of fluid in them, their survivability increases. Aggressively treat the patient with fluids, vasopressors and antibiotics, and while our ability to understand and diagnose sepsis is still poor, one thing remains certain to be helpful in the prehospital environment: do not delay treatment!
Valerie Amato is assistant editor of EMS World. Reach her at firstname.lastname@example.org.