Years ago, I was at a conference and decided to go to a class that was put on by a peer of mine, Mike Grill. He gave a lecture regarding sepsis activation and early recognition. I was blown away! For years, I never thought of how terrible this disease process is. As the third-leading cause of death in U.S. hospitals, sepsis has taken the cake and eaten it, too.
What can we do as prehospital providers? Obviously, we can’t administer antibiotics, but we most definitely can take steps to help our patients.
Infection
Whether a patient develops a urinary tract infection, pneumonia, cellulitis or any other infection, the situation can grow until the infection takes the fight into the vasculature. Once it’s in the blood stream, a system response is warranted. The problem then is that the body is behind the eight ball in terms of reacting to the infection. Therefore, when we refer to sepsis, we are talking about the body’s overreaction/inappropriate response to the infection in the blood.
Downstream from the body’s response, we come across serious issues: low blood pressure, high heart rate and fever. We must consider what these signs and symptoms cause systemically throughout the body.
What do we get when we have low blood pressure and high heart rate? As it progresses, we get worsening hypoperfusion, and hypoperfusion is a shock state. In this case, it’s distributive shock as the vessels have dilated. We have a problem getting blood and oxygen to where we must get them to, not to mention that we are going to have some altered mental status because of the hypoperfusion as well as a little fever. Overall, this is a cascading disaster for the body that can happen in a matter of hours in terms of multisystem organ failure.
Recognition
What can you do for patients who are suffering from septic shock? The most important thing to do is recognize it. The sooner that the patient is healing, the less the amount of damage that’s caused.
What are you looking for though? Any possible infection is a good start. The other indicators are hypotension, tachycardia, fever, altered mental status, end tidal CO2 readings, respiratory rates and other coexisting factors, such as a Foley catheter, recent antibiotics and diabetes. For every hour that a patient goes without being recognized for sepsis, there is a 4–9 percent increase in mortality.
Resuscitation
Once you know that you’re dealing with sepsis, you must start to resuscitate. The patient is hypotensive and unable to have enough preload to the heart because of the lack of blood pressure, so you must increase that volume.
Start two large-bore IVs to start to get fluid into the patient (20ml/kg). Giving enough fluid might prove to be difficult, so consider Levophed as a vasopressor to assist in increasing blood pressure.
We are fortunate in my system to have IV Tylenol, which is 1g delivered over 10 minutes or so. Because Tylenol is an antipyretic, it reduces the fever rather effectively in IV form. I had patients who went from nonverbal to speaking clearly within 10 minutes of IV acetaminophen administration.
You have a role
If your patient has a sepsis, it’s critical for you to dig into what might be going on. Look for infection, evaluate the signs/symptoms, reference your scorecard, rapid transport to the local hospital, bilateral large IVs, fluids and antipyretics, and let the hospital know that you’re bringing a code sepsis, so they can get broad-spectrum antibiotics going as soon as possible.
In prehospital, your job is to find the problems and give the patients the best buffer that you can until they reach definitive care.
