As you arrive at the house, an anxious female meets you at the door telling you she’s concerned about her father. She explains that her father hasn’t been feeling well during the past couple of days. When she was unable to contact him by phone that morning, she came to his home, where she found him in bed unconscious. She tells you her father is 69 years old and is normally healthy and active. He was recently diagnosed with Type II diabetes but has been able to control his disease with diet. Her grandfather died of a stroke, and she’s concerned her father has had a stroke as well. Her father’s name is Cole.
Presentation
Approaching Cole, who’s lying in bed, you note his skin to be pink, and you see the rise and fall of his chest. He doesn’t respond to you when you call his name. When you gently pinch his shoulder, he only moans and withdraws. He has a rapid pulse rate and feels hot to the touch. Your partner removes the pillow, repositions Cole’s head and applies oxygen.
The physical exam reveals hot skin and rapid respiratory rate. Auscultation of the chest reveals crackles in the base of the right lung. Pulse is 110; blood pressure is 86/34, and blood glucose level is 198 mg/dL. Readdressing the earlier comment made by the daughter about her father not feeling well, she tells you her father has had a respiratory infection and was treated with over-the-counter medications. He hadn’t gone to the doctor. Concerned about his blood pressure, you prepare Cole for transport. Two IV lines are established, and you begin to administer fluid. Concerned that the infection in Cole’s lungs may have spread, you notify the receiving emergency department (ED) the patient is in septic shock.
Discussion
Sepsis is a potentially life-threatening condition caused by the body’s reaction to an infection. Sometimes referred to as “infection in the blood,” sepsis is a widespread infection that triggers a series of reactions in the body, resulting in the signs and symptoms we associate with sepsis. The most common cause of sepsis is Gram-negative bacteria, but sepsis can also be caused by other bacteria, viruses and fungi. Common points of entry into blood stream include the lungs as with pneumonia, kidney infections stemming from bladder infections, IV sites, surgical wounds and bed sores (decubitus ulcers). Sepsis can affect all ages and patients with a depressed immune response, such as people with HIV or diabetes, and the elderly are at increased risk for sepsis.
When faced with a foreign pathogen, the body launches an immune response to attack the infection. Macrophages and neutrophils are white blood cells responsible for phagocytosis, which is the engulfing of foreign pathogens in the body. They also participate in the inflammatory process by releasing molecules known as cytokines, which trigger a series of other inflammatory mediators, all in an attempt to combat the foreign pathogen. Interluken 1 (IL-1) and tumor necrosis factors (TNF) are two of the cytokines thought to have greatest role it the development of sepsis.
If there’s a continued toxin release, the above mentioned process goes on unregulated, and sepsis will develop. This process is known as the systemic inflammatory response syndrome (SIRS), and SIRS in the presence of an infection is sepsis. This process results in systemic vasodilation and alteration of cardiac output due to a decrease in preload. The patient progresses into distributive shock. Signs of sepsis include altered mental status, tachycardia, warm or cool skin, areas of mottled skin, tachypnea and hypotension. By nature of septic shock being a distributive shock, mean arterial pressure (1/3 systole + 2/3 diastole) can drop rapidly, resulting in decreased end-organ perfusion.
Treatment
Patients in septic shock require aggressive treatment in the field and in the hospital. EMS workers should recognize the septic shock by obtaining complete histories and performing through physical exams. Providers should manage patient airways with oxygen and ventilatory support as necessary. Aggressive fluid resuscitation may increase blood pressure by increasing preload. If there’s no response to fluid, such pressers as Dopamine should be considered. Be sure to consider other causes of symptoms, such as altered blood glucose levels and toxins.
Some EMS agencies are acquiring field lactate levels as another determinate of perfusion status. In-hospital treatment continues to focus on restoring perfusion and then administrating the appropriate antibiotic therapy aimed at the cause of infection. Outcome of patients with septic shock is determined by overall patient health and early recognition and aggressive treatment. EMS working in conjunction with EDs can make a difference in patient outcome.
