We’ve gotten that call. It’s 0200, and the skilled nursing facility in your district wants to send a patient out to the ER on “doctor’s orders.” And dispatch wants you to run it as a nonemergency response. Routine, routine, routine.
The orders, as it seems, have to do with a derangement in the patient’s white blood cell count, possibly indicating an infection somewhere. And their electrolytes are way off. Everything is skewed. So you make your way to your patient to perform an assessment, and your patient looks like death: pale skin, fever, chills, rigors, confusion, and anxiety. Difficulty breathing, fatigue, malaise. Your patient is also vomiting.
The stench from both her urinary catheter and her medication port access make you cringe as you start your head to toe hands-on assessment. Baseline vitals signs are terrible; she’s hypotensive at 80 mmHg/palp, tachypneic, her oxygen saturation is in the toilet, and her heart rate is over 140.
We’ve arrived too late in the game. Sepsis in the adult patient is more common than a myocardial infarction, and it takes more lives than cancer. And while it kills more than 4,000 pediatric patients per year, for the purpose of this piece we will focus on the adult patient.
So what is sepsis? Putting it in simple terms, sepsis is the body’s overwhelming reaction to an infection that progresses to shock. And shock, as we are all aware, is a momentary pause in the act of death. The immune response triggered by infection is usually worse than the infection itself, leading to organ failure and destruction of tissue. And since tissue hypoxemia and organ failure can occur before hypotension ever presents itself, this patient just went from routine to critical. Systemic hypovolemia has occurred.
And EMS can make a difference here. Sepsis progresses; sometimes right in front of you. If you suspect sepsis, identification starts with a great, detailed assessment. You’re looking for a few markers, here, to determine if your patient is experiencing systemic inflammatory response system (SIRS, if you’d like an acronym). Any two is indication of SIRS.
Here’s what we are looking for in our assessment:
- Heart rate greater than 90 bpm
- Respirations over 20 per minute
- Fever 100.4 and up
- If labs are available, an elevated white blood cell count
EMS normally doesn’t take temperatures in the field. We lay our hand on the patient’s skin and usually say “hot” or “not hot.” But in recognition of the dangers of sepsis, many agencies are including automatic thermometers as part of the first-in bags. If you don’t have one, grab one from staff or a family member. Get that baseline temperature to report to the ER.
Equally as important is an end-tidal Co2 reading. ETCO2 monitors are commonplace on EMS rigs across the nation. Normal ETCO2 readings are between 35 mmHg and 45 mmHg. Septic patients will read below 25 mmHg. And since sepsis has many causes – urinary tract infections, pneumonia, meningitis, recent surgical complications, skin abscesses and infected decubitus ulcers, have a high index of suspicion when gathering that patient’s PHI, even before the assessment.
In recent months, lactate monitors have been showing up in some agencies in a beta-test mode. Sepsis dumps lactic acid into the bloodstream as tissues start to self-destruct. A point-of-contact lactate reading with a portable meter can clinch the differential diagnosis of sepsis in the field.
Many hospitals have sepsis response teams, just like STEMI and brain attack alert teams. If you strongly suspect sepsis, you can alert the receiving facility to have a team waiting. Sepsis requires aggressive and long-term treatment, so if you in the field can make that all-important differential diagnosis early, we just might be able to save some lives here.
Interventions en route to the hospital are frustratingly simple. Follow your local medical direction’s protocols, obviously, but two large-bore IVs and a 20 mL/kg bolus has become standard of care in the face of systemic hypovolemia. High-flow oxygen. A 12-lead EKG. Manage the airway if your patient deteriorates. Alert the ER. And get them there as rapidly as possible; true treatment can only occur in the hospital setting.
So remain sharp; EMS providers that work for agencies without a sepsis alert system, maybe you can consider suggesting one.
Disclaimer: The content in this article is the opinion of the writer and does not necessarily reflect the policies or opinions of US Patriot Tactical.
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