lcems sepsis summary
TRANSCRIPT
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SEPSIS
Dominick C. Watts, MS, NREMT-P, FP-C
Lee County EMS
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What is Sepsis?
• Sepsis is a systemic response to an infection
• word means- the state of decay
• Sepsis is SIRS with an infection
• It does not discriminate by age, sex or race
• A patient does not have to be immunocompromised to become septic
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What is Sepsis?
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Overview
SIRSSIRSSIRSSIRS + InfectionInfectionInfectionInfection = SepsisSepsisSepsisSepsis
SepsisSepsisSepsisSepsis Severe SepsisSevere SepsisSevere SepsisSevere Sepsis Septic ShockSeptic ShockSeptic ShockSeptic Shock
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SIRS• Systemic Inflammatory Response Syndrome
• Term that was developed in an attempt to describe the clinical manifestations that result from the systemic response to infection.
• Criteria (At least two)
• Temp ≥ 100.4 or ≤ 96 F
• Heart Rate ≥ 90
• Respiratory Rate ≥ 20
• WBC ≥ 12 or ≤ 4
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Sepsis
• Meets SIRS +
• Infection (documented or suspected)
• Be suspicious of recent hospital discharge or ED admission
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Severe Sepsis• Meets SIRS + Infection +
• Organ dysfunction
• AMS
• Oliguria
• Mottling
• Delayed cap refill
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Septic Shock
• Meets SIRS + Infection + Organ dysfunction +
• Hypotension
• SBP ≤ 90 mmHg and/ or MAP ≤ 65 mmHg
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Why is this important?
• Early Goal Directed Therapy (EGDT)
• Studies show significantly reduces mortality
• EMS influences ED triage
• Sepsis identification and prompt treatment is a health care wide problem
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Little Pathophysiology
• Sepsis effects mitrochonidal oxygen utilization
• clinical research shows these patients have adequate cellular oxygen
• Coagulopathy
• microthrombosis
• Vasodilation and capillary leaking
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Challenges• Diagnosis requires strong assessment skills
• Some patients may not have two signs of SIRS (even when they are septic)
• beta blockers, pacemakers
• elderly patients
• immunosupressed patients
• Some septic patients have a good general appearance and are not hypotensive
• referred to occult or cryptic shock
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History
• Recent infection
• Recent hospital admission
• Including EDs and Urgent Cares
• Worsening viral-like symptoms
• General malaise
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History
• Body aches
• Decreased appetite
• Taking antibiotics
• Immunocompromised
• Elderly
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Signs• Temp ≤ 96 or ≥ 100.4 F
• SBP ≤ 90 mmHg or hypoperfused
• MAP ≤ 65 mmHg
• HR ≥ 90 bpm
• RR ≥ 20 bpm
• EtCO2 ≤ 37 mmHg
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Alternative EtCO2 Uses
• Kartal, Eray, Rinnert, Goksu, Beka, & Eken (2011)
• demonstrated a statistical significant correlation with EtCO2 values ≥ 37 mmHg as not having acidosis (100% sensitivity)
• also reported correlation with values ≤ 25 mmHg as being a STRONG indicator of acidosis (84% sensitivity)
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Differentials
• CHF
• Simple bacteria infection
• Viral infection
• Allergic reaction
• Toxi shock syndrome
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Prehospital Treatment
• Early recognition
• Aggressive fluid resuscitation
• Low-flow oxygen (unless hypoxic)
• Hemodynamic support
• Effective communication
• Do NOT use Lactated Ringers! (remember the patho sides?)
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• If septic shock start fluids and Dopamine together• Dopamine doses need to start at 20
mcg/kg/min for alpha affects
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Reminders• Use low tidal volumes (6 ml/ kg of ideal
body weight)
• Do NOT suppress a compensatory respiratory rate!
• Do NOT treat a compensatory heart rate unless affecting preload!
• Increase PEEP to improve oxygenation unless the patient is hypotensive
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References• Guranni, P. K., Patel, G. P., Crank, C. W., Vais, D., Lateef, O., Akimov, S., et al. (2010).
Impact of the Implementation of a Sepsis Protocol for the Management of Fluid-Refractory Septic Shock: A Single-Center, Before-and-After Study. Clinical Therapeutics , 32 (7), 1285-1293.
• Kartal, M., Eray, O., Rinnert, S., Goksu, E., Bekas, F., & Eken, C. (2011). ETCO2: a predictive tool for excluding metabolic disturbances in nonintubated patients. American Journal of Emergency Medicine , 29, 65-69.
• Marino, P. L. (2007). The ICU Book (3rd ed). Lippincott Williams & Wilkins. Philadelphia, PA.
• Nguyen, H. B., Rivers, E. P., Abrahamian, F. M., Moran, G. J., Abraham, E., Trzeciak, S., et al. (2006). Severe Sepsis and Septic Shock: Review of the Literature and Emergency Department Management Guidelines. Annals of Emergency Medicine , 48 (1), 28-54.
• Seymour, C. W., Band, R. A., Cooke, C. R., Mikkelsen, M. E., Hylton, J., Rea, T. D., et al. (2010). Out-of-hospital characteristics and care of patients with severe sepsis: A cohort study. Journal of Critical Care , 25, 553-562.
• Seymour, C. W., Cooke, C. R., Mikkelsen, M. E., Hylton, J., Rea, T. D., Goss, C. H., et al. (2010). Out-of-hospital fluid in severe sepsis: effect on early resuscitation in the emergency department. Prehosp Emerg Care , 14 (2), 145-152.
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References
• Surviving Sepsis Campaign
• Studnek, J. R., Artho, M. R., Garner, C. L., & Jones, A. E. (2010). The impact of emergency medical services on the ED care of severe sepsis. American Journal of Emergency Medicine , 1-6.
• Townsed, S., McMullan, C., & Jacobsen, D. (2011). Sepsis Detection & Initial Management. IHI Expedition- Session 1.
• Tromp, M., Hulscher, M., Bleeker-Rovers, C. P., Peters, L., van den Berg, D. T., Borm, G. F., et al. (2010). The role of nurses in the recognition and treatment of patients with sepsis in the emergency department: A prospective before-and-after intervention study. International Journal of Nursing Studies , 47, 1464-1473.
• Wang, H. E., Weaver, M. D., Shapiro, N. I., & Yealy, D. M. (2010). Opportunities for Emergency Medical Services care of sepsis. Resuscitation , 81, 193-197.