What time of shock would sepsis be? Hypovolemic Cardiogenic Distributive Obstructive
-Defined as sepsis complicated by end-organ dysfunction -Altered mental status, hypotension, elevated creatinine concentration, or evidence of DIC.
-as a state of acute circulatory failure characterized by persistent -arterial hypotension despite adequate fluid resuscitation or by tissue hypoperfusion (manifested by a lactate concentration greater than 4 mg/dL) unexplained by other causes.
end and exo-toxins
-High end Dopamine....start these patients at 20 mcg/kg/min - Pressor of choice is Noreph -If patient is septic shock start fluid and pressors -Titrate with patient - Many patient require 3-5 L of fluids
Lcems sepsis summary
Lee County EMS SEPSISDominick C. Watts, MS, NREMT-P, FP-C
What is Sepsis?• Sepsis is a systemic response to an infection • word means- the state of decay • Sepsis is SIRS with an infection• It does not discriminate by age, sex or race• A patient does not have to be immunocompromised to become septic
SIRS• Systemic Inflammatory Response Syndrome • Term that was developed in an attempt to describe the clinical manifestations that result from the systemic response to infection. • Criteria (At least two) • Temp ≥ 100.4 or ≤ 96 F • Heart Rate ≥ 90 • Respiratory Rate ≥ 20 • WBC ≥ 12 or ≤ 4
Sepsis• Meets SIRS + • Infection (documented or suspected) • Be suspicious of recent hospital discharge or ED admission
Severe Sepsis• Meets SIRS + Infection + • Organ dysfunction • AMS • Oliguria • Mottling • Delayed cap refill
Why is this important?• Early Goal Directed Therapy (EGDT) • Studies show significantly reduces mortality• EMS influences ED triage• Sepsis identification and prompt treatment is a health care wide problem
Little Pathophysiology• Sepsis effects mitrochonidal oxygen utilization • clinical research shows these patients have adequate cellular oxygen• Coagulopathy • microthrombosis• Vasodilation and capillary leaking
Challenges• Diagnosis requires strong assessment skills• Some patients may not have two signs of SIRS (even when they are septic) • beta blockers, pacemakers • elderly patients • immunosupressed patients• Some septic patients have a good general appearance and are not hypotensive • referred to occult or cryptic shock
History• Recent infection• Recent hospital admission • Including EDs and Urgent Cares• Worsening viral-like symptoms• General malaise
History• Body aches• Decreased appetite• Taking antibiotics• Immunocompromised• Elderly
Alternative EtCO2 Uses• Kartal, Eray, Rinnert, Goksu, Beka, & Eken (2011) • demonstrated a statistical significant correlation with EtCO2 values ≥ 37 mmHg as not having acidosis (100% sensitivity) • also reported correlation with values ≤ 25 mmHg as being a STRONG indicator of acidosis (84% sensitivity)
Prehospital Treatment• Early recognition• Aggressive fluid resuscitation• Low-flow oxygen (unless hypoxic)• Hemodynamic support• Effective communication• Do NOT use Lactated Ringers! (remember the patho sides?)
• If septic shock start fluids and Dopamine together • Dopamine doses need to start at 20 mcg/kg/min for alpha affects
Reminders• Use low tidal volumes (6 ml/ kg of ideal body weight)• Do NOT suppress a compensatory respiratory rate!• Do NOT treat a compensatory heart rate unless affecting preload!• Increase PEEP to improve oxygenation unless the patient is hypotensive
References• Guranni, P. K., Patel, G. P., Crank, C. W., Vais, D., Lateef, O., Akimov, S., et al. (2010). Impact of the Implementation of a Sepsis Protocol for the Management of Fluid-Refractory Septic Shock: A Single-Center, Before-and-After Study. Clinical Therapeutics , 32 (7), 1285-1293.• Kartal, M., Eray, O., Rinnert, S., Goksu, E., Bekas, F., & Eken, C. (2011). ETCO2: a predictive tool for excluding metabolic disturbances in nonintubated patients. American Journal of Emergency Medicine , 29, 65-69.• Marino, P. L. (2007). The ICU Book (3rd ed). Lippincott Williams & Wilkins. Philadelphia, PA.• Nguyen, H. B., Rivers, E. P., Abrahamian, F. M., Moran, G. J., Abraham, E., Trzeciak, S., et al. (2006). Severe Sepsis and Septic Shock: Review of the Literature and Emergency Department Management Guidelines. Annals of Emergency Medicine , 48 (1), 28-54.• Seymour, C. W., Band, R. A., Cooke, C. R., Mikkelsen, M. E., Hylton, J., Rea, T. D., et al. (2010). Out-of-hospital characteristics and care of patients with severe sepsis: A cohort study. Journal of Critical Care , 25, 553-562.• Seymour, C. W., Cooke, C. R., Mikkelsen, M. E., Hylton, J., Rea, T. D., Goss, C. H., et al. (2010). Out-of-hospital fluid in severe sepsis: effect on early resuscitation in the emergency department. Prehosp Emerg Care , 14 (2), 145-152.
References• Surviving Sepsis Campaign• Studnek, J. R., Artho, M. R., Garner, C. L., & Jones, A. E. (2010). The impact of emergency medical services on the ED care of severe sepsis. American Journal of Emergency Medicine , 1-6.• Townsed, S., McMullan, C., & Jacobsen, D. (2011). Sepsis Detection & Initial Management. IHI Expedition- Session 1.• Tromp, M., Hulscher, M., Bleeker-Rovers, C. P., Peters, L., van den Berg, D. T., Borm, G. F., et al. (2010). The role of nurses in the recognition and treatment of patients with sepsis in the emergency department: A prospective before-and-after intervention study. International Journal of Nursing Studies , 47, 1464-1473.• Wang, H. E., Weaver, M. D., Shapiro, N. I., & Yealy, D. M. (2010). Opportunities for Emergency Medical Services care of sepsis. Resuscitation , 81, 193-197.