SepsisPRESENCE REGIONAL EMS SYSTEM

In the movie Independence Day

Will Smith and Jeff Goldblum destroy the alien invaders by inserting a “virus” into their system.

Sepsis

Overwhelming infection in the blood

10th leading cause of death 50 deaths per 100,000 Americans 1/3 arrive in ED by EMS

Objectives Outline the physiology of the immune

system Describe the pathophysiology of sepsis

on the cell level and how it presents on the systemic level.

Discuss the signs and symptoms of sepsis

List the appropriate PPE for EMS providers caring for patients with sepsis

 

Outline the assessment and management of the septic patient

Discuss the rationale for Advanced treatment measures for the septic patient

Review the Presence Health Code Sepsis protocol

Immune System

“If you ain’t for us, you’re against us”

It’s a jungle out there. . .

Immune system Leukocytes – white blood cells Natural barriers Inflammation

What makes you sick?

Bacteria Viruses Prions Fungi Parasites

Natural Immunity

Anatomical Barriers Inflammation

Anatomical Barriers/ Castle Walls

Epithelium Sebaceous glands Sweat, tears, saliva Mechanical responses—

respiratory, urinary,

gastrointestinal

Functions of Inflammation

Destroy and remove unwanted substances.

Wall off infected and inflamed area.

Stimulate the immune response. Promote healing.

Biochemical Agents of Inflammation

Vasoactive amines.Histamine

Chemotactic factorsAttraction of WBC

So what happens

Vascular response.

Increased permeability.

Exudation of white cells.

Fever.

Leukocytosis.

Increased circulating plasma proteins

Leukocytes

Phagocytes

Inflammation

Hallmarks of Acute Inflammation

Redness Pain Heat Swelling

Sepsis Bacterial infection in blood Inflammation system wide

Too much of a good thingHeat = feverCapillary leaking = distributive

shockSystemic edema

Who Gets Sepsis?

Elderly Infants Immunosuppression Hospitalized patients Preexisting conditions Severe trauma

Sources of Infection

Urinary Tract Infection Pneumonia Wounds – decubiti

Sepsis

Overwhelming systemic infection Hemodynamic instability

Systemic inflammationLeaking capillariesHypotensionTachycardia

Poor Perfusion on Cell Level

Normal Aerobic MetabolismBreaking down glucose with oxygenEnd products = CO2 and H2O

Hypoxic Anaerobic MetabolismBreaking down glucose without

oxygenEnd product = lactic acid

Lactate Production

Makes cells acidic Damages cells Damages vital organs Multi-organ failure

Septic Shock -- Distribuatory

Systemic vasodilation Container too big

Capillary LeakingLoss of fluid into interstitial

spacesCan’t get fluid back

Signs and Symptoms of Sepsis

Change in temperature (high or low) Hypo-perfusion – shock

MAP < 60 mm/HgMAP = (2X DP) + SP 3BP 88/40 (2 x 40) + 88 = 168 =

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3 3

Tachycardia Tachypnea –

Acute Respiratory Distress Syndrome

Altered mental state Elevated WBC Elevated lactate levels Skin: rashes, color changes,

lymph nodes

Complications with Elderly Poor temperature regulation

Relative hypotension (MAP <80)What is normal BP at this age

Relative bradycardiaDamaged baroreceptors in

carotid arteriesRx Beta Blockers

First Rule of EMSIf it is wet, and it’s not

yours, don’t touch it.

Second Rule of Sepsis BSI

If the patient is coughing, wear a mask.

Sepsis

Management100% OxygenVentilation supportFluid replacementBP/perfusion maintenance --

vasopresssors“Kill off the Bug”Outcome is frequently fatal

Code Sepsis

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Systemic Inflammatory Response Syndrome – SIRS is a widespread inflammatory response to a variety of severe clinical injuries. This syndrome is clinically indicated by the presence of two or more of the following:

Hypotension – systolic less than 90

Tachycardia – greater than 90

Temp - 101 or less than 96.8

Altered level of consciousness

Respiratory rate greater than 20

Definitions

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Sepsis – Clinical signs of SIRS are present together with evidence of infection.

Severe Sepsis – Sepsis associated with organ dysfuction, hypoperfusion, or hypotension.

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Why Do We Care? Every year, severe sepsis strikes more

than 1 million Americans (globally 20-30 million patients)

Estimated cost is more than $20 billion for sepsis care

Patients surviving sepsis have twice the risk of death in the following 5 years

The incidence of sepsis following surgery tripled between 1997 and 2006

Hospitalizations for sepsis have doubled in the last 10 years

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Where Did We Start?Baseline data: PCMC Sepsis Mortality

25.6%Baseline data: PUSMC Sepsis Mortality

17.8%Baseline data: PCMC Cost Per Patient

$22,191Baseline data: PUSMC Cost Per Patient

$17,073

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Why Do We Care?Patients receiving the sepsis bundle within the first hour have a mortality rate reduction of 14% and a reduction of 5.1 days in length of stay.

Early sepsis strategies are associated with 1 life being saved for every 7 treated.

The Genesis Project

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Why Do We Care?

We have the ability to save lives by using the appropriate tools to catch and treat sepsis.

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Definition of Code Sepsis Patient must be hypotensive with one

other SIRS criteria and a possible source of infection.

Hypotension – systolic less than 90

Tachycardia – greater than 90

Temp - 101 or less than 96.8

Altered level of consciousness

Respiratory rate greater than 20

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Code Sepsis Creates a Team Response

Code Sepsis will be paged overhead.Responders to include:

PhysicianHouse SupervisorPhlebotomyPrimary RNRadiology

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Procedure – EMS to Emergency Dept.

Paramedic unit follows established Region VI protocols and care guidelines for Sepsis Patients.

Paramedic unit calls report to the hospital prior to leaving the scene to initiate the Code Sepsis.

If the patient meets criteria then a Code Sepsis will be called.

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The RN receiving the radio report will notify the charge nurse and the emergency department physician. The designee will activate the Code Sepsis by dialing communication and giving the Location.Upon patient arrival, RN initiates sepsis protocol.Immediate evaluation per emergency room physician.

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Code Sepsis Protocol

1.Labs: CBC, CMP, PT/PTT, Procalcitonin, Blood cultures, UA/UC

2.RT: ABG (Lactic Acid), Oxygen to keep sat greater than 90%

3.Portable CXR, if not done previously4.IV: 2 Large bore PIVs

1 Liter 0.9% NS bolus via pressure bag. Notify physician for vasopressors if pt.

remains hypotensive despite fluid resuscitation.

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5. Cardiac monitor, Vital signs every 15 min. Undress pt. and place in gown, Insert Foley catheter – Strict I & O

6. Discuss with physician possible need for central line if patient remains hypotensive despite fluid resuscitation and vasopressors are needed.

7. Discuss with physician stat antibiotic orders.

 

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Surviving Sepsis Starts With YouBe aware of sepsis signs / symptomsComplete MEWS screens every 8 hoursComplete screening on all ED patients

age 18+ED physicians, assess all admissionsCall Code Sepsis when patient meets

criteriaFollow protocols

Case Study 1

You are called to an apartment for a 19 year old “man down”

You find Lou lying prone in bed. He is pale and looks to be sleeping. His chest is barely moving

His roommate says he came home from work and found Lou like this.

Lou moans when you stimulate him, He does not wake up and does not follow commands. He will not open his eyes

His airway is open and clear He is breathing 28 per minute

with rales and rhonchi in his lungs His skin is pale, hot and dry,

pulse is fast and weak

Lou’s roommate said he was complaining of a sore throat and a massive headache this morning and decided not to go to class at the community college. He has been studying and working 2 jobs.

He has no known allergies, no medical history. He has been taking Tylenol cold pills for 2 days for his symptoms

His roommate just found him and called 911

BP 88/60, P. 140, R. 28, Temp hot Pulse Oximetry 89% on room air Blood sugar 100 When you examine Lou you find a

fine petechial rash on his chest, back and arms. Lou cries out whenever you move him, particularly his neck and back

What is wrong with Lou? Does he meet Code Sepsis criteria? What body system is infected in this

case? What BSI should you have on? What can you guess his lactate

level is? High or low? How do you want to manage Lou?

Case Study 2

Dispatched at 1000 for elderly person sick for 2 days with a urinary tract infection.

You respond to a large assisted living center.

Your patient is 82 year old Mrs. Schmidt, who is sitting in a recliner in her apartment.

Initial Assessment

Mental Status: lethargic, moans when disturbed

Airway has large amounts of mucus in mouth and rattling in her throat

Breathing is labored and shallow. Skin is very pale and warm, moist

to touch, poor radial pulses, very weak and irregular

History

Allergies: None Medications: Capoten 25 mg TID,

Diabinese 100 mg daily, pyridium 200 mg TID, Gantrisin 1 gm. TID

Previous Illnesses: Breast cancer 7 years ago, completed radiation and chemotherapy, hypertension and type II diabetes

Current Health Status: Mrs. Schmidt has been in good health. She has been at this facility for 2 years. She is up and dressed every day and eats her meals in the dining room. She is very active in social activities.

Events: Mrs. Schmidt went to see her doctor 2 days ago for a urinary tract infection. He put her on pyridium and gantrisin, which she has been taking. Mrs. Schmidt told the staff that she did not feel well yesterday and that she ached all over. She wanted only tea for supper last night. They found her this morning in her recliner in this condition.

Focused Physical

BP 80/60 Pulse 88 irregular Respirations 20, she breathes fast,

then slows down to a period of apnea and then speeds up again

Blood sugar 190 Pulse oximetry: 86% on room air Montior shows atrial fibrillation

with unifocal PVC

Head to Toe

Responds only by moaning when spoken to

Jugular veins distended Breath sounds have soft crackles

in bases Abdomen soft and not tender Gross edema of legs, arms and

face

What is wrong with Mrs. Schmidt? Does she meet Code Sepsis

criteria? What is the source of the

infection? What BSI should you have on? What can you guess her lactate

level is? High or low?

How do you want to manage Mrs. Schmidt?

What do you do if she doesn’t tolerate fluid boluses?

Case Study 3

Dispatch: You are dispatched to transfer an 18 month old boy to Children’s Hospital in Chicago.

Initial Transfer History

Jason has been sick for 3 days. It started out as an ear infection, but he is much worse today.

Jason has been in the ED for 90 minutes.

Chief Complaint: Fever

Initial Assessment

Mental Status: Lethargic. Responds to pain only by whimpering and trying to draw away.

Airway: Open, but must be suctioned periodically for mucus

Breathing: Shallow and gasping 32 times/minute

Circulation: Skin is cool, pale and clammy. His arms and legs are mottled. He has purple blotches and petechiae on his trunk. He has peri-oral and peripheral cyanosis. His pulse is 150 and weak. His blood pressure is 70/50.

Focused History Events: Jason’s mother took him

to the doctor for an ear infection 3 days ago. He was much worse this morning.

Physical Illnesses: Frequent ear infections

Current Health Status: Other than frequent ear infections is growing well and is normal size for his age.

Allergies: none Medications: Amoxicillen

250mg/5ml BID, Tylenol every 6 hours

Focused Physical

Vital Signs: BP 70/50, pulse 150 and weak, resp. 32 shallow and gasping. O2 sat 88% on 15 liters blow by. Temp. 102.6 F. (rectal)

Diminished breath sounds with rales and rhonchi.

He does not like to be touched and will not bend his head without screaming.

Other Findings : 22 ga. IV catheter left anticubital. Normal saline running at 20 ml/kg boluses (one so far)

Jason weighs 24 pounds.

Lab Values

Hematocrit 50 Hemoglobin 20 WBC 18,000 (high) Sodium 140 Potassium

5.2 Chloride 100 CO2 33 Glucose 50 (low) BUN 17 Creatinine 1.3 Lactate 6 (high)

Lab Values

pH 7.3 pO2 63 pCO2 54 HCO3 24

X-ray Findings

Chest film shows fluffy patches of white in the lower lobes of both lungs

What is wrong with Jason?

What is the pathology behind his vital signs?

Why are Jason’s lab values abnormal?

Why does Jason have petechiae? What is this caused by?

Do you need to do any additional interventions to manage Jason’s ventilations?

What can be done to improve Jason’s vital signs?

Does Jason need IV fluids? How much of what kind?

Is Jason stable enough to be transported? If not what needs to be done prior to transport?

What medications might Jason need enroute?

Do you need to make any infection control arrangements prior to transporting Jason?

What are you doing to do with Jason’s Mommy?

What is Jason’s prognosis? What is he at risk for?