Patient Care

Muhammed Ali’s Death Underscores Importance of Prehospital Sepsis Detection

Muhammad Ali, one of the greatest athletes of all times and a world-class treasure, passed away on Friday, June 3, 2016, as result of sepsis. Imagine if an EMS crew could have detected that he was becoming septic and was able to treat him in the field, helping the hospital attack this deadly condition before it attacked his vital organs? Soon, crews all over the world will be capable of doing so.

Severe sepsis is caused by overwhelming infection, and is responsible for significant morbidity and mortality among hospitalized patients. Clinical identification of sepsis includes two or more of the systemic inflammatory response syndrome (SIRS) criteria in the presence of a suspected infection. A hallmark of severe sepsis is hypoperfusion leading to end-organ damage and cardiovascular collapse (septic shock).

In a 2011 study, the Healthcare Cost and Utilization Project (H-CUP) identified 836,000 hospital discharges in 2009 where septicemia was a principal diagnosis, and 829,500 discharges where septicemia was a secondary diagnosis. The in-hospital mortality rates for each were 16.3% and 14.7%, respectively, totaling 258,204 deaths per year directly attributable to sepsis.

With more than 258,000 lives lost per year, sepsis ranks as the third leading cause of death in the U.S. (after heart disease and cancer).1 Using data by the Centers for Disease Control and Prevention (CDC), sepsis ranks higher than chronic lower respiratory diseases, stroke, Alzheimer’s disease, diabetes and accidental deaths.

The H-CUP report also identified more than 1.6 million cases of sepsis annually and noted that survivors often face long-term debilitating effects after having sepsis such as amputations, anxiety, memory loss, chronic pain and fatigue. Shockingly, almost 60% of sepsis survivors experience worsened cognitive and/or physical function.

Many sepsis survivors also require re-hospitalization. More than 62% of people who had a primary diagnosis of sepsis who had to be readmitted were re-hospitalized within 30 days of discharge. Among children, almost half who have severe sepsis end up being hospitalized again. Sepsis is also the most expensive in-hospital condition in the U.S., costing more than $20 billion each year counting just acute care in-hospital costs.1

Ali’s tragic death reminds us that sepsis is a fatal condition, responsible for more deaths than heart attacks in this country.1 Sepsis is, however, a problem that we can control, particularly with early assessment and prehospital recognition. Early identification and aggressive treatment, particularly in regards to fluid resuscitation and antibiotics, has been shown to improve survival.

The September issue of JEMS will feature a special section dedicated to sepsis—including the assessment, detection and treatment of this fatal condition. This coverage represents the latest research, EMS agency protocols and innovative, reliable ways to easily marry SIRS criteria with end-tidal CO2 (EtCO2) reading to reliably predict that your patient has a systemic infection and is prone to sepsis. The combination of prehospital findings and the patient’s presenting condition will enable a sepsis alert program in concert with receiving facilities.

Traditionally, elevated serum lactate levels (> 4 mM/L) have been used as a sign of tissue hypoperfusion and an outcome predictor for septic patients. This has led to the development of screening tools and alert systems that may improve adherence to treatment guidelines. Prehospital screening tools rely on the suspicion of infection, ≥ 2 SIRS criteria, and point-of-care serum lactate levels.2 EtCO2 is determined by basal metabolic rate, cardiac output and ventilation. Abnormal levels signal potentially harmful imbalances in perfusion, metabolism or gas exchange.3

The JEMS special editorial section on sepsis will cite multiple studies that have shown a relationship between EtCO2 and disease severity or mortality in patients with shock, diabetic ketoacidosis and metabolic disturbances. Additionally, our authors will demonstrate how low EtCO2 levels are associated with elevated lactate levels, odds of operative intervention and mortality in patients. In these studies, decreased EtCO2 levels reflected acidotic, low-perfusion states.

The actions of EMS in alerting receiving hospitals from the field will enable earlier detection of sepsis and treatment of sepsis. You will save lives never before thought savable, and hospitals will save time and money by countering sepsis before it advances to an irreversible state of septic shock. Therefore, we believe this JEMS special editorial section on sepsis will be a game changer that will allow us all to pick up on, and, most importantly, treat septic patients much earlier than ever before. It is epic work that will change your clinical practice. Watch for it in the September issue of JEMS.

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Muhammed Ali's death underscore importance of prehospital sepsis detection

This is a Oct. 30, 1974, file photo showing George Foreman taking a right to the head from challenger Muhammad Ali in the seventh round in the match dubbed Rumble in the Jungle in Kinshasa, Zaire. Ali, the magnificent heavyweight champion whose fast fists and irrepressible personality transcended sports and captivated the world, has died according to a statement released by his family Friday, June 3, 2016. He was 74. (AP Photo/Ed Kolenovsky, File)

References

1. Sepsis Alliance. (n.d.) How large a problem is sepsis? Retrieved June 6, 2016, from http://www.sepsis.org/faq/problem/.

2. Seymour CW, Rea TD, Khan JM, et al. Severe sepsis in prehospital emergency care: Analysis of incidence, care, and outcome. Am J Respir Crit Care Med. 2012;186(12):1264–1271.

3. Allen K. Recognition of Sepsis in the Paediatric Patient: a reflective study. Links to Health and Social Care. 2016;1(1):4–18.