The death of NASCAR champion Kyle Busch on May 21 was attributed to severe pneumonia that rapidly progressed into sepsis — highlighting a potential gap in community and professional education: how quickly sepsis kills.
I spoke with State of Maryland EMS Medical Director Dr. Timothy Chizmar, who noted, “There is increasing public awareness of the word ‘sepsis.’ However, data from recent surveys indicate that most people still have misconceptions about sepsis, and do not fully understand its time-sensitive nature. Public awareness of sepsis has generally lagged behind stroke and heart system awareness.”
| MORE: 8 ways to foster a public safety-community relationship with PR
Prior to Busch’s death, he was reportedly experiencing symptoms of a respiratory condition, including coughing up blood and shortness of breath for several days, before he was found unresponsive in a training simulator in Concord, North Carolina, according to national media outlets.
“Sepsis is the body’s extreme response to a serious infection; where the immune system begins a complex physiologic response that can damage organs and may lead to death if not treated quickly,” Dr. William Teeter told me.
Teeter, University of Maryland School of Medicine associate professor of emergency medicine and critical care, and a former paramedic, said that early recognition by any clinician is vital.
“Any clinician should have a high suspicion for sepsis in a sick patient, especially with known infection and/or signs the body is struggling,” Teeter said. “Abnormal vitals, such as a rapid heart rate, fast breathing, low or falling blood pressure, altered mental status, mottled or cool skin and low SpO2 … don’t discount in a patient without fever.”
Signs and symptoms of sepsis
As part of a campaign to educate the public, MedStar Health, with campuses across Washington, D.C., Northern Virginia and Maryland, developed the acronym SEPSIS for people to identify the condition as early as possible.
- S – Shivering, fever or very cold
- E – Extreme pain or discomfort
- P – Pale, discolored, clammy or sweaty skin
- S – Sleepiness, confusion or disorientation
- I – “I feel like I might die”
- S – Shortness of breath
An infection can progress to sepsis within hours, depending on the type of infection and the patient’s level of vulnerability.
“Older adults and immunocompromised patient may not present with fever,” Chizmar said. “In contrast, these patients may present with low body temperature or hypothermia.”
Chizmar said that early signs of sepsis that often go under-appreciated are tachycardia and tachypnea.
Dr. Matthew Levy, professor of emergency medicine at Johns Hopkins and University of Maryland, and a nationally recognized EMS medical director, agreed that these patients often do not follow typical patterns.
“They may not have a fever. They may present with weakness, a fall or confusion,” Levy said. “Sometimes, the only clue is a change in baseline. Remember that many older adults have hypertension, so a normotensive blood pressure for them may represent relative hypotension.” Even with normal vitals early on, do not rule sepsis out, he noted. “Maintain a high index of suspicion.”
“If caregivers report a baseline change, then sepsis should be in your differential,” Teeter emphasized.
The Sepsis Alliance, the leading sepsis organization in the U.S. working to save lives and reduce suffering from sepsis proposes the acronym TIME:
- T – Temperature (higher or lower than normal)
- I – Infection (signs or symptoms of a previous or current infection)
- M – Mental decline (confused, sleepy, difficult to rouse)
- E – Extremely ill (“I feel like I might die”)
‘A true medical emergency within hours’
For many EMS clinicians, sepsis has historically received less attention than other time-sensitive conditions, like heart attack and stroke, despite the important role prehospital providers play in early recognition and treatment. However, Busch’s death and former New York City Mayor Rudy Giuliani’s hospitalization with pneumonia in early May beg the question, do we — and the general public — know enough?
“In most cases, no,” Teeter said. “Heart attack and stroke have decades of excellent public messaging behind them. Sepsis is far less recognized by the public, partly because its presentation is often more subtle and slow developing compared to stroke and heart attack.”
Many patients present as having a vague illness in early stages and often don’t have a single iconic symptom, like chest pain or neurologic deficit. Most lay people don’t know that an infection can become a true medical emergency in just hours.
Levy noted, “sepsis can be trickier, particularly early on, because its symptoms may be vaguer. Some patients do not have a clear reason to call [EMS] early. They may present with general complaints or symptoms of sepsis and often, it’s a late presentation.”
Levy agrees public awareness campaigns have gained some traction but not to the level of stroke or STEMI.
“Sepsis is harder to define and harder to message,” Levy said. “For EMS, that means early recognition still depends heavily on clinicians in the field and local implementation.”
Chizmar added, “there is clearly more work to be done. Further public education on the signs and symptoms and the time-sensitive nature of sepsis would be helpful.”
Sepsis treatment in the field
After a prehospital clinician identifies sepsis, clinicians should follow their local protocols for treatment.
Levy said the key goes back to early recognition.
“Establish IV or IO access, give fluids if there are signs of hypoperfusion, support oxygenation and reassess frequently,” Levy said. “If hypoperfusion persists despite fluids, have a low threshold to start vasopressors as protocols allow.”
Levy added that some EMS systems are also exploring prehospital antibiotics for septic shock.
“The evidence is limited and evolving, but this is most appropriate in patients with clear shock when transport times are prolonged (particularly beyond an hour) and are best coordinated with a large system of care,” Levy said. “Early notification to the receiving hospital is key so they are ready on arrival.”
