Lots has been written about about sepsis lately, and I figured, why not one more? The scope of this article, as opposed to giving you the physiology of sepsis down to the molecular level, I’m going to give you something quick and dirty about sepsis that you can use today (hopefully, I mean, why not?). Sorry about the rustiness of my pen, I have been taking care of other issues (like personal, financial, and occupational issues… you know, life) so I haven’t had much time to write because my mind is getting pulled in so many other directions.
So what you need to know about sepsis today is that often it hides itself as other things. Altered levels of consciousness, cardiac issues, and hyperglycemia, as well as a multitude of other problems can hide a systemic infection. The good news is, aside from the cardiac problems that require special medications, the treatment modalities are all the same.
The protocols set out for the Memphis Fire Department are 2 pronged, with an additional questionnaire to determine if the patient is in a severe sepsis state.
The criteria for SIRS (Systemic Inflammatory Response Syndrome) are:
- Respirations >20
- Heart Rate >90
- Glucose >150
- Temperature >100.5 or <96.5
- wbc >12000 or <4000
Also, we have to have a source of infection, like an open sore, cough, painful urination, flu symptoms, or even recent chemotherapy (immunocompromise), or even recent contacts with sick people.
Going a step further, we also screen for organ dysfunction, which would indicate a severe septic state. Symptoms include:
- Altered mental status
- Systolic BP <90 mmHg
- Oxygen saturation <92% on room air
- Skin signs of poor perfusion
- Lactate level >2
Any one of the first two indicates a septic state. All three, and you’ve got a life threatening situation. You should be able to quickly screen for the severe sepsis part fairly easily, and quickly. A patient with a low oxygen saturation for no reason and signs of poor perfusion should be easy enough to pick off, and if you have AMS and you’re not investigating further you’re in the wrong place.
The only issue that I’ve seen is that frequently, paramedics (including myself in my younger days) have been fooled into thinking that in the presence of a rapid heart rate, poor signs of perfusion, and altered mental status is related to a cardiac issue as opposed to sepsis. This is where a REALLY good rapid assessment is needed. It needs to include things we can do quickly that will distinguish between cardiac and immune issues.
The best indicator that tells me to look elsewhere is a serum blood glucose. Not to say that you can’t have a diabetic that is hyperglycemic, in a symptomatic SVT, AND has the flu or a febrile illness (in which case I tell you to pick one and try it), but the odds are slim that all three exist at the same time.
The good news is, that the treatment is pretty uncomplicated. Too often we shoot for a complex explanation for a problem only to say that that there isn’t anything we can do. We need get venous access my any means necessary (peripheral IV, EJ, or interosseous) and use very aggressive IV therapy. I’m talking multiple lines. Why you ask?
Well, we need to set the hospital up to provide some additional treatments, like antibiotics. and if we’re using pressors to try and support the circulatory system and keep it from collapsing, they can’t give antibiotics through that IV line, they need another to start that.
Also, we need to pay more attention to reversing tissue hypoxia and keep oxygen flowing. Oxygen therapy and IV therapy go hand in hand here, the more of an increase in blood pressure we can provide, the more likely we can get oxygen to vital organs. Remember, the cause of circulatory collapse in sepsis is a container problem and less of a pump problem (although, it could be all three) so waste to effort in your level of aggressiveness.
It felt good to be writing again, and hopefully I can keep it up.