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It's Not Always Sepsis

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Sepsis is an emergent medical condition that kills more people annually than prostate cancer, breast cancer, and AIDS combined. For every two heart attack patients cared for by EMS, five patients are hospitalized by sepsis. EMS transports 60% of patients with severe sepsis arriving at the ED and yet EMS providers are often unaware of its presence or what they should do if they find it. This presentation discusses new sepsis criteria along with expert commentary as to how they can be applied in the field. This program includes real-world, practical methods for EMS identification, assessment and field treatment of life-threatening sepsis and looks at the current state of sepsis critical care as well as what we can anticipate in the coming months and years.

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It's Not Always Sepsis

  1. 1. It’s Not Always Sepsis
  2. 2. Sepsis
  3. 3. Sepsis is an infection
  4. 4. Sepsis is rare
  5. 5. Sepsis only affects the very sick / old
  6. 6. They’ll find it at the hospital
  7. 7. Sepsis
  8. 8. Sepsis
  9. 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. 10. Acquired infection Blood vessel problems Circulatory collapse Duckworth, R. L. (2016, January 25). The ABCs of Pediatric Sepsis | EMSWorld.com. EMS World.
  11. 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. 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. 13. $27 Billion Increasing6.25%
  14. 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. 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. 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. 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/
  18. 18. 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
  19. 19. 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)
  20. 20. 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.
  21. 21. 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.
  22. 22. Understand Improve Coordinate
  23. 23. Learn ABCs Use Be
  24. 24. 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
  25. 25. 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.).
  26. 26. 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.).
  27. 27. 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.).
  28. 28. 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.).
  29. 29. ONE SIZE DOES NOT
  30. 30. 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
  31. 31. 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
  32. 32. Acquired infection Blood vessel problems Circulatory collapse
  33. 33. Follow the Patient’sC H A R T
  34. 34. C H A R TDuckworth, R. L. (2016, September 1). Recognizing Pediatric Sepsis with CHART Mnemonic. JEMS : A Journal of Emergency Medical Services.
  35. 35. C H A R T
  36. 36. Acquired infection Blood vessel problems Circulatory collapse
  37. 37. Acquired infection B C
  38. 38. Complaints
  39. 39. Common Sites of Primary Infection National Association of Emergency Medical Technicians (NAEMT). (2019). AMLS Advanced Medical Life Support (3rd ed.).
  40. 40. C H A R T
  41. 41. History
  42. 42. Risk Factors National Association of Emergency Medical Technicians (NAEMT). (2019). AMLS Advanced Medical Life Support (3rd ed.).
  43. 43. Risk Factors National Association of Emergency Medical Technicians (NAEMT). (2019). AMLS Advanced Medical Life Support (3rd ed.).
  44. 44. Risk Factors National Association of Emergency Medical Technicians (NAEMT). (2019). AMLS Advanced Medical Life Support (3rd ed.).
  45. 45. C H A R T
  46. 46. A Blood vessel problems C
  47. 47. Assessment National Association of Emergency Medical Technicians (NAEMT). (2019). AMLS Advanced Medical Life Support (3rd ed.).
  48. 48. Assessment National Association of Emergency Medical Technicians (NAEMT). (2019). AMLS Advanced Medical Life Support (3rd ed.).
  49. 49. Assessment National Association of Emergency Medical Technicians (NAEMT). (2019). AMLS Advanced Medical Life Support (3rd ed.).
  50. 50. 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
  51. 51. 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.).
  52. 52. 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
  53. 53. 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
  54. 54. 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
  55. 55. C H A R T
  56. 56. A B Circulatory collapse
  57. 57. Code Sepsis Sepsis Alert
  58. 58. ONE SIZE DOES NOT
  59. 59. Sensitivity
  60. 60. My SA Criteria Bad Vitals = Bad Vitals = Bad Vitals = Bad Vitals =
  61. 61. 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
  62. 62. C H A R T
  63. 63. ABCs
  64. 64. 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
  65. 65. Increase O2 Decrease WOB Acidosis +Increased metabolic rate +Increased respiratory rate = Increased oxygen demand CPAP BVM 123
  66. 66. 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
  67. 67. Fluids Overload risks Lung injury Heart failure Abdominal compartment syndrome Cerebral edema Higher risk of mortality 123
  68. 68. 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
  69. 69. Correct hypoglycemia Dextrose 10% 25g IV/IO 123
  70. 70. Correct hypocalcemia Calcium Chloride 1g 123
  71. 71. Broad spectrum antibiotics Blood cultures 123
  72. 72. Don’t Need To Correct Temperature 98.6 f 123
  73. 73. 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
  74. 74. 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
  75. 75. 123
  76. 76. Understand Improve Coordinate
  77. 77. Acquired infection Blood vessel problems Circulatory collapse
  78. 78. C H A R T
  79. 79. SEPSIS ALERT Code Sepsis Sepsis Alert
  80. 80. Be Heard

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