Sepsis

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Sepsis

• Presence Regional EMS System

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In the movie Independence Day

• Will Smith and Jeff Goldblum destroy the alien
  invaders by inserting a virus into their system.

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Sepsis

• Overwhelming infection in the blood
• 10th leading cause of death
• 50 deaths per 100,000 Americans
• 1/3 arrive in ED by EMS

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Objectives

• Outline the physiology of the immune system
• Describe the pathophysiology of sepsis on the
  cell level and how it presents on the systemic
  level.
• Discuss the signs and symptoms of sepsis
• List the appropriate PPE for EMS providers caring
  for patients with sepsis
•  

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• Outline the assessment and management of the
  septic patient
• Discuss the rationale for Advanced treatment
  measures for the septic patient
• Review the Presence Health Code Sepsis protocol

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Immune System

• If you aint for us, youre against us

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Its a jungle out there. . .

• Immune system
• Leukocytes white blood cells
• Natural barriers
• Inflammation

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What makes you sick?

• Bacteria
• Viruses
• Prions
• Fungi
• Parasites

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Natural Immunity

• Anatomical Barriers
• Inflammation

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Anatomical Barriers/ Castle Walls

• Epithelium
• Sebaceous glands
• Sweat, tears, saliva
• Mechanical responsesrespiratory, urinary,
• gastrointestinal

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Functions of Inflammation

• Destroy and remove unwanted substances.
• Wall off infected and inflamed area.
• Stimulate the immune response.
• Promote healing.

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Biochemical Agents of Inflammation

• Vasoactive amines.
• Histamine
• Chemotactic factors
• Attraction of WBC

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So what happens

• Vascular response.
• Increased permeability.
• Exudation of white cells.
• Fever.
• Leukocytosis.
• Increased circulating plasma proteins

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Leukocytes

• Phagocytes

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Inflammation
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Hallmarks of Acute Inflammation

• Redness
• Pain
• Heat
• Swelling

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Sepsis

• Bacterial infection in blood
• Inflammation system wide
• Too much of a good thing
• Heat fever
• Capillary leaking distributive shock
• Systemic edema

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Who Gets Sepsis?

• Elderly
• Infants
• Immunosuppression
• Hospitalized patients
• Preexisting conditions
• Severe trauma

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Sources of Infection

• Urinary Tract Infection
• Pneumonia
• Wounds decubiti

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Sepsis

• Overwhelming systemic infection
• Hemodynamic instability
• Systemic inflammation
• Leaking capillaries
• Hypotension
• Tachycardia

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Poor Perfusion on Cell Level

• Normal Aerobic Metabolism
• Breaking down glucose with oxygen
• End products CO2 and H2O
• Hypoxic Anaerobic Metabolism
• Breaking down glucose without oxygen
• End product lactic acid

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Lactate Production

• Makes cells acidic
• Damages cells
• Damages vital organs
• Multi-organ failure

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Septic Shock -- Distribuatory

• Systemic vasodilation
• Container too big
• Capillary Leaking
• Loss of fluid into interstitial spaces
• Cant get fluid back

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Signs and Symptoms of Sepsis

• Change in temperature (high or low)
• Hypo-perfusion shock
• MAP lt 60 mm/Hg
• MAP (2X DP) SP
• 3
• BP 88/40 (2 x 40) 88 168 56
• 3 3

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• Tachycardia
• Tachypnea
• Acute Respiratory Distress Syndrome
• Altered mental state
• Elevated WBC
• Elevated lactate levels
• Skin rashes, color changes, lymph nodes

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Complications with Elderly

• Poor temperature regulation
• Relative hypotension (MAP lt80)
• What is normal BP at this age
• Relative bradycardia
• Damaged baroreceptors in carotid arteries
• Rx Beta Blockers

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First Rule of EMS

• If it is wet, and its not yours,
  dont touch it.

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Second Rule of Sepsis BSI

• If the patient is coughing, wear a mask.

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Sepsis

• Management
• 100 Oxygen
• Ventilation support
• Fluid replacement
• BP/perfusion maintenance -- vasopresssors
• Kill off the Bug
• Outcome is frequently fatal

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• Code Sepsis

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Definitions

• Systemic Inflammatory Response Syndrome SIRS is
  a widespread inflammatory response to a variety
  of severe clinical injuries. This syndrome is
  clinically indicated by the presence of two or
  more of the following
• Hypotension systolic less than 90
• Tachycardia greater than 90
• Temp - 101 or less than 96.8
• Altered level of consciousness
• Respiratory rate greater than 20

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• Sepsis Clinical signs of SIRS are present
  together with evidence of infection.
• Severe Sepsis Sepsis associated with organ
  dysfuction, hypoperfusion, or hypotension.

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• Why Do We Care?

• Every year, severe sepsis strikes more than 1
  million Americans (globally 20-30 million
  patients)
• Estimated cost is more than 20 billion for
  sepsis care
• Patients surviving sepsis have twice the risk of
  death in the following 5 years
• The incidence of sepsis following surgery tripled
  between 1997 and 2006
• Hospitalizations for sepsis have doubled in the
  last 10 years

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• Where Did We Start?

• Baseline data PCMC Sepsis Mortality 25.6
• Baseline data PUSMC Sepsis Mortality 17.8
• Baseline data PCMC Cost Per Patient
  22,191
• Baseline data PUSMC Cost Per Patient
  17,073

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• Why Do We Care?

• Patients receiving the sepsis bundle within the
  first hour have a mortality rate reduction of 14
  and a reduction of 5.1 days in length of stay.
• Early sepsis strategies are associated with 1
  life being saved for every 7 treated.
• The Genesis Project

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• Why Do We Care?

• We have the ability to save lives by using the
  appropriate tools to catch and treat sepsis.

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• Definition of Code Sepsis

• Patient must be hypotensive with one other SIRS
  criteria and a possible source of infection.
• Hypotension systolic less than 90
• Tachycardia greater than 90
• Temp - 101 or less than 96.8
• Altered level of consciousness
• Respiratory rate greater than 20

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• Code Sepsis Creates a Team Response

• Code Sepsis will be paged overhead.
• Responders to include
• Physician
• House Supervisor
• Phlebotomy
• Primary RN
• Radiology

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• Procedure EMS to Emergency Dept.

• Paramedic unit follows established Region VI
  protocols and care guidelines for Sepsis
  Patients.
• Paramedic unit calls report to the hospital prior
  to leaving the scene to initiate the Code Sepsis.
• If the patient meets criteria then a Code Sepsis
  will be called.

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• The RN receiving the radio report will notify the
  charge nurse and the emergency department
  physician.
• The designee will activate the Code Sepsis by
  dialing communication and giving the Location.
• Upon patient arrival, RN initiates sepsis
  protocol.
• Immediate evaluation per emergency room
  physician.

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• Code Sepsis Protocol

• Labs CBC, CMP, PT/PTT, Procalcitonin, Blood
  cultures, UA/UC
• RT ABG (Lactic Acid), Oxygen to keep sat greater
  than 90
• Portable CXR, if not done previously
• IV 2 Large bore PIVs
• 1 Liter 0.9 NS bolus via pressure bag.
• Notify physician for vasopressors if pt. remains
  hypotensive despite fluid resuscitation.

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• Cardiac monitor, Vital signs every 15 min.
  Undress pt. and place in gown, Insert Foley
  catheter Strict I O
• Discuss with physician possible need for central
  line if patient remains hypotensive despite fluid
  resuscitation and vasopressors are needed.
• Discuss with physician stat antibiotic orders.
•  

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• Surviving Sepsis Starts
• With You

• Be aware of sepsis signs / symptoms
• Complete MEWS screens every 8 hours
• Complete screening on all ED patients age 18
• ED physicians, assess all admissions
• Call Code Sepsis when patient meets criteria
• Follow protocols

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Case Study 1

• You are called to an apartment for a 19 year old
  man down
• You find Lou lying prone in bed. He is pale and
  looks to be sleeping. His chest is barely moving
• His roommate says he came home from work and
  found Lou like this.

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• Lou moans when you stimulate him, He does not
  wake up and does not follow commands. He will not
  open his eyes
• His airway is open and clear
• He is breathing 28 per minute with rales and
  rhonchi in his lungs
• His skin is pale, hot and dry, pulse is fast and
  weak

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• Lous roommate said he was complaining of a sore
  throat and a massive headache this morning and
  decided not to go to class at the community
  college. He has been studying and working 2
  jobs.
• He has no known allergies, no medical history.
  He has been taking Tylenol cold pills for 2 days
  for his symptoms
• His roommate just found him and called 911

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• BP 88/60, P. 140, R. 28, Temp hot
• Pulse Oximetry 89 on room air
• Blood sugar 100
• When you examine Lou you find a fine petechial
  rash on his chest, back and arms. Lou cries out
  whenever you move him, particularly his neck and
  back

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• What is wrong with Lou?
• Does he meet Code Sepsis criteria?
• What body system is infected in this case?
• What BSI should you have on?
• What can you guess his lactate level is? High or
  low?
• How do you want to manage Lou?

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Case Study 2

• Dispatched at 1000 for elderly person sick for 2
  days with a urinary tract infection.

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• You respond to a large assisted living center.
• Your patient is 82 year old Mrs. Schmidt, who is
  sitting in a recliner in her apartment.

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Initial Assessment

• Mental Status lethargic, moans when disturbed
• Airway has large amounts of mucus in mouth and
  rattling in her throat
• Breathing is labored and shallow.
• Skin is very pale and warm, moist to touch, poor
  radial pulses, very weak and irregular

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History

• Allergies None
• Medications Capoten 25 mg TID, Diabinese 100 mg
  daily, pyridium 200 mg TID, Gantrisin 1 gm. TID
• Previous Illnesses Breast cancer 7 years ago,
  completed radiation and chemotherapy,
  hypertension and type II diabetes

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• Current Health Status Mrs. Schmidt has been in
  good health. She has been at this facility for 2
  years. She is up and dressed every day and eats
  her meals in the dining room. She is very active
  in social activities.

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• Events Mrs. Schmidt went to see her doctor 2
  days ago for a urinary tract infection. He put
  her on pyridium and gantrisin, which she has been
  taking. Mrs. Schmidt told the staff that she did
  not feel well yesterday and that she ached all
  over. She wanted only tea for supper last night.
  They found her this morning in her recliner in
  this condition.

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Focused Physical

• BP 80/60
• Pulse 88 irregular
• Respirations 20, she breathes fast, then slows
  down to a period of apnea and then speeds up
  again
• Blood sugar 190
• Pulse oximetry 86 on room air
• Montior shows atrial fibrillation with unifocal
  PVC

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Head to Toe

• Responds only by moaning when spoken to
• Jugular veins distended
• Breath sounds have soft crackles in bases
• Abdomen soft and not tender
• Gross edema of legs, arms and face

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• What is wrong with Mrs. Schmidt?
• Does she meet Code Sepsis criteria?
• What is the source of the infection?
• What BSI should you have on?
• What can you guess her lactate level is? High or
  low?

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• How do you want to manage Mrs. Schmidt?
• What do you do if she doesnt tolerate fluid
  boluses?

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Case Study 3

• Dispatch You are dispatched to transfer an 18
  month old boy to Childrens Hospital in Chicago.

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Initial Transfer History

• Jason has been sick for 3 days. It started out
  as an ear infection, but he is much worse today.
  
• Jason has been in the ED for 90 minutes.
• Chief Complaint Fever

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Initial Assessment

• Mental Status Lethargic. Responds to pain only
  by whimpering and trying to draw away.
• Airway Open, but must be suctioned periodically
  for mucus
• Breathing Shallow and gasping 32 times/minute

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• Circulation Skin is cool, pale and clammy. His
  arms and legs are mottled. He has purple
  blotches and petechiae on his trunk. He has
  peri-oral and peripheral cyanosis. His pulse is
  150 and weak. His blood pressure is 70/50.

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Focused History

• Events Jasons mother took him to the doctor
  for an ear infection 3 days ago. He was much
  worse this morning.
• Physical Illnesses Frequent ear infections
• Current Health Status Other than frequent ear
  infections is growing well and is normal size for
  his age.
• Allergies none
• Medications Amoxicillen 250mg/5ml BID, Tylenol
  every 6 hours

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Focused Physical

• Vital Signs BP 70/50, pulse 150 and weak, resp.
  32 shallow and gasping. O2 sat 88 on 15 liters
  blow by. Temp. 102.6 F. (rectal)
• Diminished breath sounds with rales and rhonchi.
• He does not like to be touched and will not bend
  his head without screaming.

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• Other Findings 22 ga. IV catheter left
  anticubital. Normal saline running at 20 ml/kg
  boluses (one so far)
• Jason weighs 24 pounds.

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Lab Values

• Hematocrit 50 Hemoglobin 20
• WBC 18,000 (high)
• Sodium 140 Potassium 5.2
• Chloride 100 CO2 33
• Glucose 50 (low)
• BUN 17
• Creatinine 1.3
• Lactate 6 (high)

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Lab Values

• pH 7.3
• pO2 63
• pCO2 54
• HCO3 24

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X-ray Findings

• Chest film shows fluffy patches of white in the
  lower lobes of both lungs

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• What is wrong with Jason?
• What is the pathology behind his vital signs?
• Why are Jasons lab values abnormal?

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• Why does Jason have petechiae? What is this
  caused by?
• Do you need to do any additional interventions to
  manage Jasons ventilations?
• What can be done to improve Jasons vital signs?

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• Does Jason need IV fluids? How much of what
  kind?
• Is Jason stable enough to be transported? If not
  what needs to be done prior to transport?
• What medications might Jason need enroute?

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• Do you need to make any infection control
  arrangements prior to transporting Jason?
• What are you doing to do with Jasons Mommy?
• What is Jasons prognosis? What is he at risk
  for?

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