sepsis 2016

4. SIRS (SYSTEMIC INFLAMMATORY RESPONSE SYNDROME)
Systemic Inflammatory Response Syndrome (SIRS) is defined as an “abnormal,
generalized inflammatory reaction remote from the initial insult.”
In severe sepsis, the body's balance between inflammatory and anti-inflammatory
chemical responses gets out of whack. A massive release of pro-inflammatory
mediators creates an uncontrolled inflammatory response. This systemic
inflammatory response is known as SIRS (systemic inflammatory response
syndrome).
Once SIRS is underway, impaired fibrinolysis interrupts the body's normal clotting
cascade, and the blood begins to clot abnormally. Critical microvasculature,
essential to supplying oxygen to the body's organs, begins to clog and fail.
Systemic inflammation, vasodilatation and capillary leakage contribute to
hypotension and the rapid slide into end-organ hypoxia and failure.

6. PURPOSE
This protocol is to be used on patients suspected of being severely septic.
Sepsis is a clinical syndrome that results from the human body’s response to
infection.
While bacteria probably account for most cases, sepsis can also be the result of
infection by fungi, viruses and parasites.

7. CLINICALLY, IT IS THE PRESENCE OF TWO OR
MORE OF THE FOLLOWING:
 Temperature less than 96.8°F or greater than 100.4°F.
 Heart rate greater than 90 bpm.
 Respiratory rate greater 20 or a ETCO2 ≤ 25 mmHg.
 White blood cell count less than 4,500 or greater than 10,000 l/mm.

8. SEPSIS IS MORE LIKELY TO OCCUR IN SEVERAL
HIGH-RISK POPULATIONS.
Always have a higher index of suspicion when evaluating the elderly or the very
young, patients who are bed confined or immobile, and patients who have had
recent surgeries or invasive medical procedures.
Also, be highly suspicious of patients receiving immunosuppressive treatments like
chemotherapy or post-organ transplant medications.
Recognize that some disease processes leave the patient naturally immuno-
compromised. This is the case with diabetes, liver cirrhosis, autoimmune disease
and HIV/AIDS populations.

9. SEVERE SEPSIS
Severe sepsis is characterized by poor perfusion, leading to a buildup of serum
lactate and resulting metabolic acidosis. EtCO2 levels decline in the setting
of both poor perfusion and metabolic acidosis. To compensate for metabolic
acidosis, patients increase their minute ventilation. This increased
respiratory rate “blows off” carbon dioxide and lowers EtCO2. At the same
time, poor tissue perfusion decreases the amount of blood flow to the alveoli
of the lungs, reducing the amount of carbon dioxide that can be exhaled—the
most dramatic demonstration of this process is during cardiac arrest.
Therefore, EtCO2 is inversely proportional to lactate: As lactate levels rise in
septic patients, EtCO2 levels drop.
Previous studies have shown that low EtCO2 levels correlate with elevated
lactate levels and predict mortality in patients with suspected sepsis, severe
sepsis and septic shock. In fact, low pre-hospital EtCO2 levels predict
metabolic acidosis and mortality across a wide spectrum of patient
complaints.

10. SEPTIC SHOCK
Septic shock is low blood pressure due to sepsis that does not
improve after reasonable amounts of intravenous fluids are given.
In severe sepsis and septic shock, broad-spectrum antibiotics (usually two
or a β-lactam antibiotic with broad coverage) are recommended. Some
recommend they be given within 1 hour of making the diagnosis stating
that for every hour delay in the administration of antibiotics, there is an
associated 7.6% rise in mortality.
Approximately 20–35% of people with severe sepsis and 30–70% of people
with septic shock die.

11. IS THIS SEPTIC SHOCK WITH PNEUMONIA?

12. BASIC LEVEL: EMT AND PARAMEDIC
 Initial Patient Assessment Protocol 2.1.1
 Airway Assessment/Management Protocol 2.1.2.
 Oxygen via nasal cannula @ 2 - 4 LPM to maintain pulse ox ≥ 94% (non-rebreather @15
LPM if SpO2 < 90%). If sepsis is suspected, use nasal cannula capable of measuring end tidal
CO2.
 Attach cardiac monitor and pulse oximeter.
 Measure and/or record patient’s temperature.
 Assess for possible source of infection:
Ask about recent illnesses, surgeries, invasive procedures or trauma. Has the patient had a
respiratory infection or been feeling ill?
Ask about symptoms of gastrointestinal or bladder infections, abdominal discomfort and
unusual body or joint pain.
Also ask about current or past prescriptions for antibiotics, steroids or immuno-suppressants.

13. ALS LEVEL 1: PARAMEDIC ONLY
Notify receiving hospital of a possible sepsis patient (call sepsis alert if
applicable) if patient meets the following three criteria:
 Suspected infection based on history and physical exam.
 Two or more of the following:
Temp > 100.4 F or < 96.8 F
Respiratory Rate > 20 breaths/min
Heart Rate > 90 beats/min
 EtCO2 ≤ 25 mmHg
Initiate IV of Normal Saline. If BP Systolic ≤ 90 mm Hg, bolus with 250 ml
IV fluid and repeat prn up to 2 liters.
Check vital signs and breath sounds in-between each bolus.

14. ALS LEVEL 2: MEDICAL CONTROL
Contact Medical Control or Medical Director for any questions or
Problems.

15. CAPNOGRAPHY
Capnography, a well-known tool in EMS, provides valuable
information not only about ventilation but perfusion as well. As
long as the body is metabolizing glucose and oxygen, waste
products will be eliminated into the bloodstream. They can only
be released into the alveolus if there’s normal perfusion of the
lung with blood.
As perfusion decreases, so does the EtCO2. This results in
elevation of the metabolic waste, which is comprised mainly of
lactic acid. Therefore, EtCO2 level is inversely proportional to
lactate levels. As we see lactate levels rise in septic patients, we
see EtCO2 levels drop. EtCO2 readings of less than 25 mmHg in
the clinical setting of shock are associated with significant
increase in mortality. Patients with EtCO2 of 25 mmHg may have
lactate levels as high as 6.1 mmol/L. Capnography can be
monitored and helpful in assessing the impact of therapies
designed to improve perfusion.
This method of sepsis detection, however, is being underused.

16. ETCO2

17. IMMUNOSUPPRESSANTS
Immunosuppressants are drugs or medicines that lower the body's ability
to reject a transplanted organ. Another term for these drugs is anti-
rejection drugs. There are 2 types of immunosuppressants:
Induction drugs: Powerful antirejection medicine used at the time of
transplant.
Maintenance drugs: Anti-rejection medications used for the long term.
There are usually 4 classes of maintenance drugs:
•Calcineurin Inhibitors: Tacrolimus and Cyclosporine.
•Anti-proliferative agents: Mycophenolate Mofetil, Mycophenolate
Sodium and Azathioprine.
•mTOR inhibitor: Sirolimus.
•Steroids: Prednisone.

18. COMMON IMMUNOSUPPRESSANT DRUGS

19. STEROIDS
A steroid is an organic compound with four rings arranged in a specific
configuration. Examples include the dietary lipid cholesterol, the sex
hormones estradiol and testosterone and the anti-inflammatory drug
dexamethasone. Steroids have two principal biological functions:
certain steroids are important components of cell membranes which
alter membrane fluidity, and many steroids are signaling molecules
which activate steroid hormone receptors.

20. SEPSIS EVEN MORE DEADLY FOR STEROIDS USERS
Doctors say that sepsis has occurred when a pathogen – usually a bacteria –
gets into the bloodstream. Extremely aggressive bacteria can cause fatal
septic shock, which means that organs close off their blood supply and die
off through lack of oxygen.
In theory, anabolic hormones raise the chance of septic shock occurring. IGF-1
activates the molecular switches extracellular-signal-regulated kinases 1 and
2 and nuclear factor kappa B in the body's cells. These molecular switches
are involved in anabolic processes, but also in inflammatory reactions,
which cells use to protect themselves against pathogens. In extreme cases
of exposure to these substances, the immune reactions that occur cause
septic shock.
So if a pathogenic bacteria ends up in the bloodstream of a steroids user, you
would expect his body to react more severely than that of a non-user.

21. ANTIBIOTICS
Antibiotics, also called anti-bacterials, are a type of antimicrobial drug used
in the treatment and prevention of bacterial infections. They may either
kill or inhibit the growth of bacteria.
Antibiotics are not effective against viruses such as the common cold or
influenza and may be harmful when taken inappropriately.

22. ANTIBIOTICS
Penicillin Metronidazole Erythromycin
Amoxicillin
Cephalosporin Tetracycline
Ciprofloxacin

23. JEMS ASSESSING $ MANAGING SEPSIS IN THE PREHOSPITALSETTING
Thu Oct 29, 2015 By Keith Widmeier, BA< NRP< FP-C, Keith Wesley, MD, FACEP
Ergo-log.com 02-28-2015
Kaohsiung J Med Sci June 27, 2011