1. It’s Not Always
Sepsis

2. Sepsis

3. Sepsis is an infection

4. Sepsis is rare

5. Sepsis only affects the
very sick / old

6. They’ll find it
at the hospital

7. Sepsis

8. Sepsis

9. The body’s overwhelming and life-
threatening response
to infection which can lead to tissue
damage, organ failure, and death.
Center for Disease Control and Prevention. (2016, August). Making Health Care Safer: Think Sepsis. Time Matters.

10. Acquired infection
Blood vessel problems
Circulatory collapse
Duckworth, R. L. (2016, January 25). The ABCs of Pediatric Sepsis | EMSWorld.com. EMS World.

11. 250,000
prostate cancer, breast cancer and AIDS
combined
Rhee, Chanu, Raymund Dantes, Lauren Epstein, David J. Murphy, Christopher W. Seymour, Theodore J. Iwashyna, Sameer S. Kadri, et al. “Incidence and Trends of Sepsis in US Hospitals Using Clinical vs Claims Data, 2009-2014.” JAMA 318, no. 13 (October 3, 2017): 1241–49.
https://doi.org/10.1001/jama.2017.13836.

12. Leading cause death
Leading cause readmission
Liu, Vincent, Gabriel J. Escobar, John D. Greene, Jay Soule, Alan Whippy, Derek C. Angus, and Theodore J. Iwashyna. “Hospital Deaths in Patients With Sepsis From 2 Independent Cohorts.” JAMA 312, no. 1 (July 2, 2014): 90–92. https://doi.org/10.1001/jama.2014.5804.

13. $27 Billion
Increasing6.25%

14. 25-30%
40-70%
Hajj, J., Blaine, N., Salavaci, J., & Jacoby, D. (2018). The “Centrality of Sepsis”: A Review on Incidence, Mortality, and Cost of Care. Healthcare, 6(3). https://doi.org/10/gfvzk5

15. 4heart attack
10
Severe Sepsis
Seymour, Christopher W., Thomas D. Rea, Jeremy M. Kahn, Allan J. Walkey, Donald M. Yealy, and Derek C. Angus. “Severe Sepsis in Pre-Hospital Emergency Care: Analysis of Incidence, Care, and Outcome.” American Journal of Respiratory and Critical Care Medicine 186 (December
15, 2012): 1264–71. https://doi.org/10.1164/rccm.201204-0713OC.

16. EMS Transports 50%
of patients with severe sepsis
arriving at the ED
Those patients tend to be older and
sicker
Femling J, et al., South Med J 2014;107(12):751-756. https://www.ncbi.nlm.nih.gov/pubmed/25502152
Wang HE, et al., Resuscitation 2010;81(2):193-197. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4028958/

17. EMS tends to be first medical contact since .
87%
of sepsis cases begin in the community
prior to hospitalization
Femling J, et al., South Med J 2014;107(12):751-756. https://www.ncbi.nlm.nih.gov/pubmed/25502152
Wang HE, et al., Resuscitation 2010;81(2):193-197. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4028958/

19. Patients arriving via EMS tend
to be more sick
but receive care
more quickly
Depinet, H. E., Eckerle, M., Semenova, O., Meinzen-Derr, J., & Babcock, L. (2018). Characterization of Children with Septic Shock Cared for by Emergency Medical Services. Prehospital Emergency Care

20. Every hour of delay
can
increase
Han, Y. Y., Carcillo, J. A., Dragotta, M. A., Bills, D. M., Watson, R. S., Westerman, M. E., & Orr, R. A. (2003). Early Reversal of Pediatric-Neonatal Septic Shock by Community Physicians Is Associated With Improved Outcome. Pediatrics, 112(4)

21. EMS use of guidelines
improvesmortality
Evans, I. V. R., Phillips, G. S., Alpern, E. R., Angus, D. C., Friedrich, M. E., Kissoon, N., … Seymour, C. W. (2018). Association Between the New York Sepsis Care Mandate and In-Hospital Mortality for Pediatric Sepsis. JAMA, 320(4), 358–367.

22. EMS-specific education
improvesoutcomes
Evans, I. V. R., Phillips, G. S., Alpern, E. R., Angus, D. C., Friedrich, M. E., Kissoon, N., … Seymour, C. W. (2018). Association Between the New York Sepsis Care Mandate and In-Hospital Mortality for Pediatric Sepsis. JAMA, 320(4), 358–367.

23. Understand
Improve
Coordinate

24. Learn ABCs
Use
Be

25. Prehospital Sepsis Alert
decreased time to treatment
30-60minutes
13.6% vs 26.7%
Halimi, K., Freeman-Garrick, J., Agcaoili, C., Choy, K., Claridge, F., Jacobs, M., & Taigman, M. (2011). Prehospital identification of sepsis patients and alerting of receiving hospitals: impact on early goal-directed therapy. Crit Care, 15, P26. https://doi.org/10.1186/cc10395

26. Cell damage from infection
Chemical signal release
• Vasodilation
• Increase blood flow
• Increased permeability
• Increased metabolism
Inflammatory Response
National Association of Emergency Medical Technicians (NAEMT). (2019). AMLS Advanced Medical Life Support (3rd ed.).

29. SIRS
Systemic Inflammatory
Response Syndrome
Burns, Trauma, Pancreatitis, Ischemia
Infection
National Association of Emergency Medical Technicians (NAEMT). (2019). AMLS Advanced Medical Life Support (3rd ed.).

30. SIRSCell damage from infection
Chemical signal release
Triggered inflammatory response
• Vasodilation
• Increased permeability
• Increased metabolism
• Cellular damage
• Hemorrhage
• Clotting & DIC
National Association of Emergency Medical Technicians (NAEMT). (2019). AMLS Advanced Medical Life Support (3rd ed.).

31. SIRS
Two or more of the following in adults:
• Temperature > 38 C (100.4 F) or < 36 C (96.8 F)
• Heart rate > 90 beats per minute
• Respiratory rate > 20 breaths per minute or PaCO2 <32 mmHg
• WBC > 12,000 cell/mm3, <4,000 cell/mm3, or >10% immature forms
National Association of Emergency Medical Technicians (NAEMT). (2019). AMLS Advanced Medical Life Support (3rd ed.).

32. ONE SIZE
DOES NOT

33. CMS
Sepsis
• Suspected infection +2 SIRS criteria
Septic Shock
• Sepsis +organ dysfunction +hypoperfusion despite fluid or lac >4
Sep 1
Barbash, I. J., Davis, B., & Kahn, J. M. (2019). National Performance on the Medicare SEP-1 Sepsis Quality Measure. Critical Care Medicine, 47(8), 1026–1032. https://doi.org/10.1097/CCM.0000000000003613

34. Sepsis 3
Sepsis
• Life threatening organ dysfunction
Septic Shock
• Sepsis +hypotension requiring pressors + lactate >2mmol/L
Surviving
Sepsis
Campaign
Levy, M. M., Evans, L. E., & Rhodes, A. (2018). The Surviving Sepsis Campaign Bundle: 2018 update. Intensive Care Medicine, 44(6), 925–928. https://doi.org/10/gd6dsr

36. Acquired infection
Blood vessel problems
Circulatory collapse

37. Follow the Patient’sC
H
A
R
T

38. C
H
A
R
TDuckworth, R. L. (2016, September 1). Recognizing Pediatric Sepsis with CHART Mnemonic. JEMS : A Journal of Emergency Medical Services.

39. C
H
A
R
T

40. Acquired infection
Blood vessel problems
Circulatory collapse

41. Acquired infection
B
C

42. Complaints

43. Common Sites of
Primary Infection
National Association of Emergency Medical Technicians (NAEMT). (2019). AMLS Advanced Medical Life Support (3rd ed.).

44. C
H
A
R
T

45. History

46. Risk Factors
National Association of Emergency Medical Technicians (NAEMT). (2019). AMLS Advanced Medical Life Support (3rd ed.).

47. Risk Factors
National Association of Emergency Medical Technicians (NAEMT). (2019). AMLS Advanced Medical Life Support (3rd ed.).

48. Risk Factors
National Association of Emergency Medical Technicians (NAEMT). (2019). AMLS Advanced Medical Life Support (3rd ed.).

49. C
H
A
R
T

50. A
Blood vessel problems
C

51. Assessment
National Association of Emergency Medical Technicians (NAEMT). (2019). AMLS Advanced Medical Life Support (3rd ed.).

52. Assessment
National Association of Emergency Medical Technicians (NAEMT). (2019). AMLS Advanced Medical Life Support (3rd ed.).

53. Assessment
National Association of Emergency Medical Technicians (NAEMT). (2019). AMLS Advanced Medical Life Support (3rd ed.).

54. Assessment
Rhodes, A., Evans, L. E., Alhazzani, W., Levy, M. M., Antonelli, M., Ferrer, R., Kumar, A., Sevransky, J. E., Sprung, C. L., Nunnally, M. E., Rochwerg, B., Rubenfeld, G. D., Angus, D. C., Annane, D., Beale, R. J., Bellinghan, G. J., Bernard, G. R., Chiche, J.-D., Coopersmith, C., … Dellinger, R. P. (2017).
Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Critical Care Medicine, 45(3), 486. https://doi.org/10/f9s5h5

55. Mean Arterial Pressure
MAP of 70 - 110 : mmHg Normal
Target MAP >65 mmHg
National Association of Emergency Medical Technicians (NAEMT). (2019). AMLS Advanced Medical Life Support (3rd ed.).

56. Shock Index
Koch, E., Lovett, S., Nghiem, T., Riggs, R. A., & Rech, M. A. (2019). Shock index in the emergency department: Utility and limitations. Open Access Emergency Medicine : OAEM, 11, 179–199. https://doi.org/10/ggbncq

57. El-Radhi, A. S., & Barry, W. (2006). Thermometry in paediatric practice. Archives of Disease in Childhood, 91(4), 351–356. https://doi.org/10.1136/adc.2005.088831

58. 0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
40.00%
< 95 F 98.6 F - 100.9 F 100.9 F - 103.1 F > 103.1 F
Patient Temp vs % Sepsis Mortality
Kushimoto, S., Gando, S., Saitoh, D., Mayumi, T., Ogura, H., Fujishima, S., … Aikawa, N. (2013). The impact of body temperature abnormalities on the disease severity and outcome in
patients with severe sepsis: an analysis from a multicenter, prospective survey of severe sepsis. Critical Care, 17(6), R271. https://doi.org/10.1186/cc13106
Yamamoto, S., Yamazaki, S., Shimizu, T., Takeshima, T., Fukuma, S., Yamamoto, Y., … Fukuhara, S. (2016). Body Temperature at the Emergency Department as a Predictor of Mortality in
Patients With Bacterial Infection. Medicine, 95(21). https://doi.org/10.1097/MD.0000000000003628

59. C
H
A
R
T

60. A
B
Circulatory collapse

61. Code Sepsis
Sepsis Alert

62. ONE SIZE
DOES NOT

63. Sensitivity

64. My SA Criteria
Bad Vitals =
Bad Vitals =
Bad Vitals =
Bad Vitals =

66. Koyama, S., Yamaguchi, Y., Gibo, K., Nakayama, I., & Ueda, S. (2019). Use of prehospital qSOFA in predicting in-hospital mortality in patients with suspected infection: A retrospective cohort study. PLOS ONE, 14(5), e0216560. https://doi.org/10/gf8wbb

69. C
H
A
R
T

70. ABCs

71. Consider Intubation
Inhibits 11-β-hydroxylase, enzyme necessary for cortisol production
Can block normal stress response for 4-24 hours
Can cause relative adrenal insufficiency
Increased severity of illness adjusted mortality in adults and children

72. Increase O2 Decrease WOB
Acidosis
+Increased metabolic rate
+Increased respiratory rate
= Increased oxygen demand
CPAP
BVM
123

73. Fluids
30 ml/kg crystalloids
up to stopping points
Signs Improve
Rales
Hepatomegaly
MAP >65 mmHg
4,000 ml (move to pressors)
Lactate < mmol/L
123

74. Fluids
Overload risks
Lung injury
Heart failure
Abdominal compartment syndrome
Cerebral edema
Higher risk of mortality
123

75. Consider Pressors
Norepinephrine (Levophed): First line
- 0.1-2 mcg/kg/min IV/IO, titrate to MAP >65 mm/Hg
- Vasopressin 0.03 u/min to boost MAP or lower NE
Epinephrine: Most available
- 0.1-1 mcg/kg/min IV/IO, titrate to MAP >65 mm/Hg
Dopamine: Not recommended
- arrhythmias in adults
- immune dysfunction in pediatric patients
123

76. Correct hypoglycemia
Dextrose 10% 25g IV/IO
123

77. Correct hypocalcemia
Calcium Chloride 1g
123

78. Broad spectrum antibiotics
Blood cultures
123

79. Don’t Need To Correct Temperature
98.6 f
123

80. Patient temperature vs mortality
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
40.00%
< 95 F 98.6 F - 100.9 F 100.9 F - 103.1 F > 103.1 F
Kushimoto, S., Gando, S., Saitoh, D., Mayumi, T., Ogura, H., Fujishima, S., … Aikawa, N. (2013). The impact of body temperature abnormalities on the disease severity and outcome in patients with severe sepsis: An analysis
from a multicenter, prospective survey of severe sepsis. Critical Care, 17(6), R271. https://doi.org/10.1186/cc13106
Hunter, B. (2019). Severe Sepsis Patients with Hypothermia Receive Less Timely Antibiotics and Have Higher Mortality. New England Journal of Medicine. Retrieved from
https://www.jwatch.org/na48592/2019/02/26/severe-sepsis-patients-with-hypothermia-receive-less

84. Eye contact
Environment
Ensure ABCs
Structured report
Supply documentation
Duckworth, R. (n.d.). Five Ways to Perfect the Patient Handoff | EMS World. Retrieved December 4, 2017, from https://www.emsworld.com/article/12257122/five-ways-to-perfect-the-patient-handoff

85. 123

86. Understand
Improve
Coordinate

87. Acquired infection
Blood vessel problems
Circulatory collapse

88. C
H
A
R
T

89. SEPSIS ALERT
Code Sepsis
Sepsis Alert

91. Be Heard