You’re dispatched to a 46-year-old male patient with altered mental status. On arrival, you’re greeted by a neighbor who was doing a wellness check. The neighbor informs you the patient is a paraplegic but is normally able to care for himself and his household. When you enter the house, you find the 300-pound patient lying on the couch surrounded by a large quantity of beer cans and other trash. He’s mumbling incoherently and you notice vomit on the floor.
When discussing sepsis and septic shock, several things should be going through the EMS provider’s mind. As with other types of shock, it’s important for EMS providers to understand what sepsis is, the various phases of sepsis and the signs and symptoms of each stage, and its pathophysiology.
Lastly, it’s crucial for the EMS provider to understand the big picture. These patients aren’t healed once they’re dropped off at the ED. The septic patient will go through weeks of inpatient medical care, of which EMS is the first critical link. The treatment and assessment made by EMS can be crucial in setting the pace for the care of this patient.
In 1992, the American College of Chest Physicians/Society for Critical Care Medicine issued a consensus statement to establish uniform criteria defining the sepsis syndromes.
According to these definitions, bacteremia was described as the presence of viable bacteria in the bloodstream. Fungemia is the term used when the infection is of fungal origin. Systemic inflammatory response syndrome (SIRS) exists when at least two of the following symptoms are present: temperature of less than 96.9 degrees F or greater than 100.4 degrees F; respiratory rate of at least 20 breaths per minute or partial pressure of arterial carbon dioxide (PaCO2) greater than 32 mmHg; heart rate greater than 100 beats per minute (bpm); and leukocyte count greater than 12,000 per dL or less than 4,000 per dL or less than 10% bands. When SIRS is present with bacteremia or fungemia, the diagnosis is then sepsis.
Severe sepsis is sepsis with one or more signs of organ dysfunction, hypoperfusion or hypotension. Examples of signs that indicate one of these three criteria include metabolic acidosis, acute alterations in mental status, oliguria, or adult respiratory distress syndrome. Septic shock is defined as sepsis accompanied by both organ dysfunction and hypotension that’s not responsive to fluid resuscitation.
When bacteria enter the patient’s bloodstream, an inflammatory response is initiated. Neutrophils swarm the toxins produced by the bacteria, and the patient’s condition degenerates to one of shock.
Pathophysiology of Sepsis
Of all bacteria responsible for septic infections, gram negative bacteria are the most common causes. Escherichia coli (E. coli) and Klebsiella enterobacter are the most common of these gram negative bacteria to cause sepsis. These two bacteria account for somewhere between 60–70% of all cases.
The urinary tract is the most common portal of entry for these bacteria, and the most common infections leading to sepsis are urinary tract infections (UTIs) that are caused by indwelling catheters or untreated infections that occur in non-catheterized patients. Because of the frequency of urinary catheterization and the risk of infection associated with this procedure, it could be argued that this is one of the most dangerous procedures performed repeatedly throughout the day in hospitals worldwide. Regardless of whether catheterization is involved, UTIs are the leading cause of hospital-borne infections that lead to mortality.
Respiratory infections are the second leading cause of sepsis. The most common bacteria responsible for sepsis from respiratory infection include Pseudomonas, Klebisella enterobacter, Serratia and E. coli. Medical devices such as endotracheal tubes and tracheostomies are often the portal of entry for bacteria into the respiratory system. Aspiration from feeding tubes is also a common cause of respiratory infection, although patients without feeding tubes can aspirate as well—especially those with impaired swallowing control.
The third most common source of sepsis is the gastrointestinal (GI) tract. E. coli, Klebsiella enterobacter and Serratia are all common bacterial culprits in the GI tract, along with Salmonella. Bacteria enter the bloodstream from the GI tract through bowel obstructions, perforations and abscesses, such as those that occur with diverticulitis. Billiary causes of sepsis, which are closely related to GI causes, are caused by cholangitis, an infection of the gall bladder, and billiary obstructions from gall stones or tumors.
Other causes beyond these four leading causes include medical appliances, bacterial endocarditis, infected grafts and thrombophlebitis.
Sepsis may also be the product of trauma. Because the skin is the body’s largest protective barrier, when its integrity is impaired, the body is at a much greater risk for infection that can result in sepsis. Penetrating injuries that impact the vasculature place the patient at a particularly high risk of developing sepsis. Burns over large percentages of the body frequently lead to fatal cases of sepsis as well.
Regardless of the point of entry, immunocompromised patients are at greatest risk for sepsis. These include those on immunosepressants for organ transplant, AIDS patients and persons with diabetes. The elderly are by definition considered immunocompromised due to their lowered immune response to infection that’s simply a result of aging.
Stages of Septic Shock
As previously described, septic shock is defined as sepsis accompanied by hypotension that’s not responsive to fluid resuscitation, along with organ dysfunction.
Septic shock can be further divided into two states: the hyperdynamic state and the hypodynamic state. Patients in the hyperdynamic state display a fever; warm, dry skin; tachycardia and tachypnea; mental status changes; and decreased urine output. Patients in the hypodynamic state, on the other hand, display either increased or decreased core temperature; cool skin; tachycardia and tachypnea; obtundation; and oliguria.
Septic shock can also be described in terms of four stages. In Class I shock, vital signs are within normal limits and few symptoms are present. In Class II shock, vital signs begin to change. The patient’s heart rate will be greater than 100, their respiratory rate will be over 20, and the pulse pressure may begin to narrow. Capillary refill is generally less than 2 seconds in this stage, and the patient may begin to show signs of lethargy.
Class III shock is the first stage in which the patient becomes hypotensive. The patient’s heart rate in this stage is usually greater than 120 bpm, and their respiratory rate may be as high as 30–40 breaths per minute. Capillary refill remains less than two seconds in this stage, and the patient generally displays an altered mental status.
Class IV shock is the most serious, and in this stage, the patient’s heart rate remains over 120 bpm, the respiratory rate remains between 30–40, and the blood pressure is very low. Capillary refill is often as slow as four seconds, which indicates very poor end-organ perfusion. The patient’s mental status is altered, and the patient may be obtunded or unresponsive. Patients in this stage require longer stays in ICUs and have a much higher mortality rate.
The number of organs that fail are a strong indicator of mortality in septic shock. Only 14.9% of patients who suffer failure of one organ die, while 76.7% of patients who have dysfunction of five organs will die. Early and aggressive care to preserve organ function and reverse septic shock are essential to improving mortality rates.
Case Study Continued
Family has arrived as you’re performing your initial assessment. The airway is patent with a fecal odor present, breathing is rapid and shallow, the pulse is tachycardic, and the skin is pale, cool and diaphoretic. Your physical assessment reveals a distended abdomen. Vital signs are heart rate 118, palpated blood pressure of 70, respirations at 30, SpO2 of 84%, and an EtCO2 of 29. A 12-lead ECG was obtained without any ST abnormalities present in a sinus tachycardia with occasional premature ventricular contractions. His blood glucose is 54 mg/dL. The patient has a penicillin allergy bracelet on his right wrist.
The family is able to help provide a history for the patient. The family shows you where he keeps his medications. He’s on Soma (carisoprodol), Lortab (acetaminophen and hydrocodone), Lasix (Furosemide), Nitro Stat (Nitroglycerin) and aspirin. The family informs you he was in a car accident six years ago, causing the paralysis, and has had two heart catheterizations last year. Nobody knows what he’s had to eat prior to the event. He was found around 10:00 a.m. by his neighbor with an unknown duration of the incident.
The Septic Patient
Although a standard scene size-up will occur during an evaluation of a septic patient, the provider must remember to utilize all senses. For example, what was the temperature of the room? Was the thermostat set extremely high, and if so, was the patient still complaining of feeling cold? Since fever is a good indicator of infection, this information is valuable. Are there any noticeable odors in the house that seem to be developing from the patient? What do the odors smell like? Infections have a distinct, foul odor that’s difficult to describe. Urine from patients with urinary tract infections smells extremely concentrated. A patient’s breath may indicate a bowel obstruction when a fecal odor is present.
During the initial patient assessment, it’s important to pay close attention to any medical devices that may be present. When examining tracheostomies, the provider should evaluate if there’s any sputum or mucus present in the trachea or around the site. When evaluating peripherally inserted central catheter lines, other vascular access devices or sites for tube feeding, the site around where the device is inserted into the skin should be evaluated for redness, inflammation and pus.
Lastly, when present, the Foley catheter device should be thoroughly assessed by the provider, since it’s one of the most valuable sources of information about sepsis in the field. When evaluating a Foley, it’s not necessary to evaluate the device at its insertion site in the field. EMS providers should be paying attention to the tubing and the collection system. Is the tubing clear? Is there any buildup? What color is the urine in the collection bag? Is there any blood or sediment present? Is the urine clear, translucent or opaque? How has the output been? All of these questions can help lead the provider toward an appropriate field diagnosis.
Another key component of evaluating a septic patient is utilizing the SAMPLE mnemonic when obtaining a patient history. This includes signs, symptoms, allergies, medications, last oral intake, events leading, and risk factors. An EMS provider can obtain a great deal of information with a thorough patient history.
When obtaining signs and symptoms of a septic patient, you must be perceptive and willing to listen to the patient. Observable signs that a provider may notice while assessing a septic patient include poor skin turgor, foul odors, vomiting, inflammation and neurological deficits.
The skin is a common portal of entry for various microbes. The provider should evaluate the skin, paying close attention to accidental or intentional breaks. Identify edematous areas, redness or fluid leakage around wounds or medical equipment. When evaluating patients who are predominantly sedentary, evaluate their posterior for decubitus ulcers or other signs of skin breakdown.
Measurable signs include fever, altered vital signs described before, Glasgow Coma Scale ratings, and changes to skin color, temperature or condition. Patients will need to be asked the appropriate questions in order to evaluate the symptoms, which include pain at infected sites, nausea, dizziness, weakness, altered urinary frequency, and altered bowel consistency and frequency.
Allergies should be obtained for every patient. This becomes even more important, however, when transporting potentially septic patients. Considering the fact that antibiotics are generally the definitive treatment for septic patients, it’s very valuable for the EMS provider to alert the hospital staff of potential antibiotic allergies. This information should be obtained as soon as is reasonable in case the patient suffers any altered mentation en route and is unable to relay this information themselves.
Patients’ medications can be a valuable resource during a methodical patient assessment. A knowledgeable provider is able to tell if the patient is taking any steroids (such as prednisone), antipyretics (such as Tylenol) or antibiotics (such as Cipro). Steroids act as immunosuppressants, which can increase the potential for infection due to reduced immune system responses. Antipyretics can indicate the patient has been experiencing a fever. The absence of a fever may be either the effect of the medication or the presence of worsening sepsis.
When evaluating antibiotics, remember to gather several important pieces of information. The provider should ask the patient why they were prescribed and evaluate if the chief complaint is comparable to the reason for the prescription. Has the reason for the prescription been resolved? When did the initial infection begin? When were the antibiotics initiated? When did the patient stop taking the antibiotics or did they complete the course?
The past medical history of a patient can reveal a great deal of information. Many chronic conditions may be brought to light with acute exacerbations. For this reason, the EMS provider should be familiar with various presentations of a wide variety of chronic complaints. It’s also important for the EMS provider to pay close attention to any long-term medical devices such as Foley catheters and feeding tubes that the patient may have because of the possibility of introducing infection to the body. Providers should be observant for any signs of a sedentary lifestyle or impaired mobility, which can lead to possible decubitus ulcers or other pressure wounds.
By being aware of the various events that could have potentially led to the patient’s current chief complaint, the provider can gain valuable information about the potential cause of the sepsis. Ask about any recent surgeries the patient may have had. Evaluate surgical incisions for inflammation, redness or pus that may be present at the site. Closely note any recent infections or trauma that may have initiated the path toward sepsis. While the signs and symptoms of infection will generally not be present within the prehospital setting following a traumatic injury, the provider may observe them during interfacility transport.
Lastly, the patient’s ability to perform activities of daily living should be evaluated. Patients with limited ability to perform these activities may be more likely to have extensive chronic medical problems and medical devices, which increases the risk for infection. Other issues with limited activities of daily living include the increased likelihood of pressure sores resulting from decreased mobility or increased exposure to pathogens because of an impaired ability to maintain hygienic living conditions.
When treating the septic patient, it’s necessary to treat the whole patient, not just the physical manifestations. The patient’s emotional status can inhibit patient care. Patients who have experience with sepsis or other critical illnesses may desire not to be transported out of fear.
Patients may have several questions that may delay or stop transportation efforts. Questions may include: How could I afford this? Who will take care of my spouse? Who will take care of my pet? Will I have to stay at the hospital for a long period of time? Will they have to put in a breathing tube? The EMS provider will have to acknowledge the patient’s concerns about prolonged ICU stays and possible mechanical ventilator care, particularly if they’ve had this experience in the past. Most importantly, the provider must ensure they are always empathetic to the patient’s situation and needs.
Case Study Continued
Your partner places the patient on oxygen by non-rebreather at 15 LPM. You move him to the stretcher, secure it and load it in the ambulance.
Due to crew shortages, you’ve elected to transport the patient to the local critical access hospital 20 minutes away. The nearest hospital with critical care capabilities is 50 minutes away. You obtain vascular access with an 18-gauge IV and infuse 700 mL of saline prior to arrival at the ED. Vital signs on arrival at the ED include a heart rate of 112, blood pressure of 78/palp, respirations at 26, SpO2 of 94% and an EtCO2 of 32.
Patients in sepsis will have a rather long road to recovery. However, EMS care can go beyond supportive measures. The first, and possibly the most important aspect of prehospital care is early identification. Early identification of sepsis can help the provider determine an appropriate facility to transport the patient to. Appropriate facilities have critical care services and operating room capabilities as needed.
Providers will begin by treating the patient’s symptoms. Oxygen should be administered and titrated to SpO2. If febrile, the provider should consider passive cooling techniques. A full set of vital signs should be obtained along with an ECG. Depending on the underlying cause of the patient’s sepsis, capnography may be indicated.
Some EMS systems have begun obtaining finger-stick lactate acid levels on-scene to help guide out-of-hospital management. IV fluids should be administered in large quantities while monitoring the patient for fluid overload. Fluids should be titrated to a systolic blood pressure of 90. Depending on transport time, the provider may need to consider a vasopressor. Dopamine is the primary vasopressor in the prehospital setting and can be considered at five mcg/kg/min.
Sepsis is a complex set of signs, symptoms and causes, and even defining sepsis accurately can be difficult. Providers need to be aware of the definitions of sepsis and related conditions, the processes involved and the common causes of sepsis. In the field, a thorough scene size-up, history and assessment are all imperative to detecting sepsis on the “general illness” call. Sepsis is a disorder that affects individuals across all ages and general health condition, and it’s one the prehospital provider should be ever-diligent in seeking and treating.
Part two of this two-part series will be featured in our March issue.
- Bone RC, Balk RA, Cerra FB, et al. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Chest. 1992;101(6):1644–1655.
- Kahn P, Divatia JV. Severe sepsis bundles. Indian J Crit Care Med. 2010;14(1):8–13.
- Venes D. Taber’s Cyclopedic medical dictionary, 21st ed. F.A. Davis Co.: Philadelphia, 2009.