Septic shock: A quiet evolution in EMS management
Lactate evaluation may the next EMS vital sign
By Art Hsieh
There were several trends presenting at this year's EMS Today in DC. One of these is a quiet evolution in the assessment, identification and management of the septic patient.
There are about a million cases of sepsis in the United States each year, according to T. Ryan Mayfield, MS, EMT-P, Manager of the Center for EMS Quality, Integration and Research, Centura South Denver EMS. Of these, 215,000 die.
When compared to the approximate 133,000 deaths that occur from acute myocardial infarction, it becomes apparent that EMS must become involved in the acute management of sepsis.
During the session, Mayfield described recent research that he conducted in the Denver metro region. Specifically trained EMS providers, working with specific assessment and management protocols, began early treatment with large amounts of saline.
The crews also alerted the receiving hospital early. As a result, when compared to the patients who were not managed early, the death rate from sepsis fell from 33 percent, down to 14 percent. Hospital stays dropped by one day, and intubation rates were reduced by 25 percent.
One of the tests that the medics used was a lactate monitor. Similar in shape and use to a glucometer, it measures the level of lactate in a drop of capillary bed. Lactate is a by product of metabolism; if hypoperfusion exists, anaerobic conditions results and lactate levels rise.
Patients with potential sepsis were evaluated using SIRS criteria, which included:
Temp >38C (100.4 F) or <36C
RR > 20 bpm or mechanically ventilated
Lactate level > 4 mmol/L
Note that the blood pressure may not necessarily low. A patient can be significantly hypoperfusing and still have a "normal" blood pressure, causing a condition known as "cryptic shock".
Patients experiencing this condition have a significantly higher chance of dying if not identified and treated early.
This and other similar research is pointing to another exciting area of development that prehospital providers can provide definitive treatment prior to hospital admission. Look for more information on this in the future.