EMS Handoff: I’m Infected: A Prehospital Look at Sepsis

On this week’s episode of the EMS Handoff Podcast, hosts Bradley Dean and David Blevins are joined by Dr. Tyler McCardell who is currently an EMS Fellow at the University of Pennsylvania and serving as chief resident and assistant medical director for AHN Lifeflight.

During this EMS Handoff, Dr. McCardell discuss the current state of sepsis in the prehospital environment to include SIRS Criteria, continuum of sepsis, early recognition and its effects on morbidity and mortality.

And just when you thought you have enough fluid, think again. About 3% of the calls that EMS agencies run in the United States are related to Sepsis. Putting that into a little more context, that is about 136 calls for service every hour of the day, all year long. Are you ready for that handoff?

Listen to the podcast in the below audio player.

Sepsis in Prehospital Management

Overview

Sepsis is a life-threatening condition that arises when the body’s response to infection causes widespread inflammation, leading to tissue damage, organ failure and potentially death. Early recognition and management of sepsis in the prehospital setting are critical, as timely intervention can significantly reduce morbidity and mortality.

Systemic Inflammatory Response Syndrome (SIRS) Criteria

The SIRS criteria are a set of clinical signs used to identify patients who may be experiencing systemic inflammation, which can be an early indicator of sepsis. A patient is considered to have SIRS if they meet two or more of the following criteria:

1. Body Temperature Abnormalities:
   o Fever: Temperature > 38°C (100.4°F)
   o Hypothermia: Temperature < 36°C (96.8°F)
2. Heart Rate:
   o Tachycardia: Heart rate > 90 beats per minute
3. Respiratory Rate:
   o Tachypnea: Respiratory rate > 20 breaths per minute or PaCO₂ < 32 mm Hg
4. White Blood Cell Count:
   o Leukocytosis: WBC count > 12,000/µL
   o Leukopenia: WBC count < 4,000/µL
   o 10% immature (band) forms

The presence of SIRS criteria, especially when associated with a known or suspected infection, should prompt further evaluation for sepsis.

Continuum of Sepsis

Sepsis progresses through a continuum of severity, each stage carrying increasing risks of morbidity and mortality:

1. Sepsis:
   • Defined as the presence of SIRS criteria with a confirmed or suspected infection. This stage involves an inflammatory response triggered by the infection, which can lead to organ dysfunction.
2. Severe Sepsis:
   • Characterized by sepsis with associated organ dysfunction, hypoperfusion, or hypotension. Symptoms may include altered mental status, decreased urine output, hypoxia, and metabolic acidosis.
3. Septic Shock:
   • A subset of severe sepsis where profound circulatory, cellular, and metabolic abnormalities occur. This condition is characterized by persistent hypotension despite adequate fluid resuscitation and often requires vasopressor support. It carries a higher risk of mortality.

Early Recognition and Prehospital Management

Early Recognition:

• Importance: Early recognition of sepsis is crucial for improving patient outcomes. The progression from sepsis to septic shock can occur rapidly, and delays in treatment can significantly increase the risk of organ failure and death.
• Signs and Symptoms: Look for altered mental status, fever, chills, rapid heart rate, rapid breathing, decreased urine output, and hypotension. Consider the possibility of sepsis in patients with infections, particularly those who are immunocompromised, elderly, or have multiple comorbidities.

Prehospital Management Strategies:

1. Initial Assessment:
   • Scene Safety and Primary Survey: Ensure the scene is safe and perform a primary survey focusing on airway, breathing, circulation, and disability (neurological status).
   • Vital Signs Monitoring: Regularly assess temperature, heart rate, respiratory rate, blood pressure, and oxygen saturation.
2. Fluid Resuscitation:
   • IV Access: Establish intravenous access and begin fluid resuscitation. Normal saline or lactated Ringer’s solution is commonly used.
   • Fluid Bolus: Administer an initial bolus of 30 mL/kg of crystalloid fluid for hypotension or lactate > 4 mmol/L.
3. Oxygen Therapy:
   • Administer supplemental oxygen to maintain an oxygen saturation of > 94%. Use non-rebreather masks or consider advanced airway management if necessary.
4. Antibiotic Therapy:
   • While antibiotic administration is generally initiated in-hospital, prehospital providers should communicate suspected sepsis to receiving facilities to expedite antibiotic administration upon arrival.
5. Monitoring and Reassessment:
   • Continuously monitor vital signs, level of consciousness, and response to treatment. Be vigilant for signs of worsening shock or organ dysfunction.
6. Rapid Transport:
   • Prioritize rapid transport to an appropriate medical facility, ideally one with critical care capabilities. Notify the receiving facility of a suspected sepsis case en route.

Morbidity and Mortality Rates

• Impact of Early Intervention: Early recognition and treatment of sepsis in the prehospital setting can dramatically improve patient outcomes. Studies have shown that each hour of delay in appropriate antibiotic treatment increases mortality rates in septic shock patients.
• Mortality Rates: Sepsis has a high mortality rate, particularly in cases of septic shock. In-hospital mortality for septic shock can exceed 40%, making it a leading cause of death in hospitalized patients.
• Morbidity: Survivors of sepsis are at risk of long-term physical and psychological complications, including chronic pain, cognitive impairments, and post-traumatic stress disorder (PTSD).

Conclusion

Prehospital recognition and management of sepsis are critical in the fight against this life-threatening condition. EMS providers play a vital role in the early identification and stabilization of sepsis patients, significantly impacting outcomes through timely intervention and rapid transport. By adhering to protocols and maintaining a high index of suspicion for sepsis, EMS professionals can help reduce the morbidity and mortality associated with this condition.

Bradley Dean: Bradley.dean@handoffmedia.com

David Blevins: David.blevins@handoffmedia.com

Previous: Bradley Dean and David Blevins sit down with Rob Hoadley to discuss his life-changing encounter with sudden cardiac arrest.

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