Columns, Patient Care

Quickly Recognizing a Life-Threatening Infection

Issue 11 and Volume 42.

Careful assessment helps recognize life-threatening infection

You and an engine company arrive to a single family, two-story home. You’re met at the door by a male in his late 20s. He says he called you after coming to check on his 58-year-old father after he missed their tee time. He found his father, Matt, lying in bed and unresponsive.

He leads you upstairs to his father’s bedroom and tells you his mom died two years ago and Matt now lives by himself. He isn’t aware of his dad having any significant medical history.

As you enter the bedroom you see Matt sleeping. His breathing is rapid and deep. His skin looks flushed from across the room. You approach the bedside calling his name. You shake his shoulder but receive no response. You gently apply pressure to his fingernail and he moans as he pulls his hand away.

Matt’s skin is cool and clammy to the touch and his pulse is rapid, about 120 beats per minute. Your partner confirms a blood pressure (BP) of 96/42 mmHg. Auscultation of lung sounds reveals clear air movement on the left and crackles at the base of the right side. Pulse oximetry read 88% and a blood glucose finger stick reads 96 mg/dL. After administering oxygen via a non-rebreather mask, pulse oximetry reads 93%.

The remainder of the physical exam reveals a healthy appearing 58-year-old male in good shape with no obvious surgical scars. A quick assessment of the bedroom and adjacent bathroom reveals only a bottle of multivitamins for men. No other medications are found.

The firefighters help you and your partner carry Matt downstairs to the stretcher. You continue administering oxygen and repeat the physical assessment during transport. Matt’s pulse climbs to 130 and BP drops to 94/38 mmHg. He’s unresponsive to any stimulus.

After an 18-minute emergent transport, you transfer care to the ED. The staff establishes two IVs and begins rapid administration of fluid. An ED physician tells you, “It appears to be septic shock.”

Discussion

Sepsis is defined as life-threatening organ dysfunction caused by a host’s response to infection. More simply, sepsis is the body’s overactive and toxic response to an infection.

Our body’s immune system typically functions to protect us from pathogens such as bacteria or viruses. The inflammatory response allows the movement of white blood cells to the area of the pathogen while attempting to isolate the infection. When the pathogen moves into the blood stream, the body’s response becomes systemic, resulting in dilation and hyperpermeability of all blood vessels-they become larger and begin to leak.

The systemic inflammatory response syndrome (SIRS) criteria is commonly used to identify a patient with sepsis. SIRS criteria include a temperature > 100.4 degrees F (38 degrees C) or < 96.8 degrees F (36 degrees C), a heart rate > 90 and a respiratory rate > 20. SIRS criteria also require an elevated white blood cell count-a value typically unknown by EMS.

As sepsis progresses, it can lead to septic shock, resulting in altered mental status and multiple organ failure. Once a patient moves into septic shock, the mortality rate is greater than 40%. Aggressive treatment is required early if these patients are going to survive.

Prehospital providers play an important role in the course of treatment. First, you must recognize a patient who’s septic or in septic shock. The SIRS criteria are a good tool to help identify patients with sepsis. Note, however, that not all septic patients are hot to the touch; some have a decrease in body temperature. Elevated heart and respiratory rates in addition to a history of not feeling well are all good indicators a patient is septic.

When a patient with sepsis has their mean arterial pressure (MAP) drop below 65 mmHg, they’re progressing into shock. MAP is calculated by multiplying the diastolic value by two, adding the systolic value and then dividing by three. This is the average pressure in the vascular system and is a better indicator of perfusion than just a systolic BP.

In our scenario, Matt had an initial MAP of 60 mmHg, which then dropped to 56.6 mmHg indicating he was in septic shock. Because septic shock, a type of distributive shock, drops the BP by dilating the blood vessels, the diastolic value tends to drop faster than with other types of shock. Considering only the systolic value may lead you to miss a person who’s in septic shock. Most automatic BP machines will calculate MAP and display it next to the BP.

Once you’ve identified a patient in septic shock, time is critical. You should evaluate and maintain the patient’s airway, administering oxygen as needed. Consider other causes of altered mental status such as blood glucose level or chemical intoxication. If it’s within your scope of practice, establish two IVs and administer fluid at 30 mL/kg. If the patient’s BP doesn’t respond to fluid, a vasopressor such as norepinephrine should be started. Many hospitals have aggressive in-hospital protocols to treat sepsis, so be sure to inform the receiving facility as early as possible.

Conclusion

Septic shock can progress quickly, and sepsis can be subtle in presentation. Use assessment criteria to help identify a septic patient and quickly get the patient to definitive care.

Also remember, sepsis is caused by a pathogen you don’t want; take appropriate body substance isolation (BSI) precautions. Be safe.