There has been an increasing amount of attention placed on the rapid identification and treatment of patients experiencing sepsis. Recall that sepsis is a highly exaggerated response by the body’s immune system to an infection. As the reaction worsens, hypoperfusion can cause one or more of the patient’s organ systems to fail.
Severe sepsis affects more than one million people in the United States annually [1]. Between 26 and 50 percent of those patients with sepsis die. Moreover, the rate of sepsis is rising.
It has been shown that early recognition and treatment of sepsis by EMS providers can reduce the mortality rate [2]. Early fluid therapy and early notification for antibiotic treatment may be the reasons for why sepsis patients do better when transported by EMS. Here are five key points to keep in mind when assessing a suspected sepsis patient.
1. Sepsis is not always septic shock
EMS providers may mistakenly believe that a patient has to be hypotensive or in shock before being labeled septic. Much like other forms of hypoperfusion, the body will be in shock long before a drop in blood pressure. Suspect compensated shock if the patient is tachypneic (respiratory rate greater than 20 breaths per minute) and tachycardic (heart rate greater than 90 beats per minute).
2. Measure temperature accurately
Historically, a patient’s body temperature is not measured in the field as part of the patient assessment vital sign process. However, detecting either a fever (temperature greater than 38 C or 100.4 F) or a lower than normal temperature (less than 36 C or 96.8 F) can help drive a suspicion of sepsis. Technology such as temporal scan thermometers are accurate and noninvasive, making them well suited to field use.
3. Develop a strong history of the chief complaint
While many patients will describe a classic development of an infection — fever, chills, body aches —others may not. Use SAMPLE and OPQRST to assess the patient’s chief complaint. Geriatric patients are well known for not having a fever when having an infection, due to the aging process. Ask patients about recent procedures such as surgery or diagnostic testing that may have exposed the patient to the risk of infection. Changes in urinary frequency, color and consistency may point to a urinary tract infection. Diabetic patients and immunocompromised patients, such as those with cancer or HIV, are at greater risk for sepsis.
4. Assess lactate levels if possible
Lactate is a byproduct of anaerobic metabolism occurring in tissues where oxygen levels are low. A lactate level greater than 4 mmols, in conjunction with other vital sign findings, may be a strong indicator of sepsis. Several EMS systems have successfully used point of care meters to measure lactate levels in the field. However, these devices have been restricted for such use. Other systems are using more complex diagnostic equipment such as iSTATs to measure lactate in the field.
5. Measure exhaled carbon dioxide to strengthen a suspicion of sepsis
Carbon dioxide is a byproduct of metabolism and is excreted through the lungs during exhalation. A normal capnography reading ranges between 35 to 45 mm Hg. Patients in sepsis will have lower than normal end tidal carbon dioxide readings secondary to hypoperfusion and the formation of microclots along the capillary beds. An ETCO2 reading of less than 25 mm Hg, coupled with a suspicious history and the vital signs described earlier, may point to a patient who needs immediate intervention.
6. Treat sepsis early and aggressively
Finally, don’t be timid about initiating sepsis treatment. A patient who is showing significant signs of sepsis will require a large amount of fluid quickly. Up to two liters may be needed in the early phases of resuscitation. A vasopressor such as norepinephrine or dopamine may also be needed to maintain vascular tone while antibiotic therapy is initiated.
Reference
1. National Center for Health Statistics Data Brief No. 62 June 2011. Inpatient care for septicemia or sepsis: a challenge for patients and hospitals
2. Guerra, W. F., Mayfield, T. R., Meyers, M. S., Clouatre, A. E., & Riccio, J. C. (2013). Early detection and treatment of patients with severe sepsis by prehospital personnel. Journal of Emergency Medicine, 44(6), 1116–1125. doi:10.1016/j.jemermed.2012.11.003
