October 25, 2016 1

Code Sepsis: Do You Have To Do More Than Just Give A Diesel Bolus?

Matthew J. Levy, DO, MSc, FACEP, NRP Associate Professor of Emergency Medicine, Johns Hopkins University

Medical Director, Howard County Fire and Rescue

Prehospital Sepsis

Objectives

• Review the definition of sepsis. • Understand the importance of

prehospital recognition. • Be familiar with prehospital

ways to screen for sepsis. • Be familiar with the prehospital

treatment of sepsis.

Introduction: The Sepsis Crisis in America

• Sepsis is a whole-body inflammatory, overwhelming and life-threatening response to infection. – Can lead to tissue damage, organ failure and

death. – Sepsis kills approximately 258,000 Americans

annually. – 10th leading cause of death in the US. – Survival decreases 7.6% per hour untreated. – CDC has declared it as a medical

emergency.

www.jems.com

Epidemiology

• Severe sepsis affects more the 1.6 million Americans annually and rising

• 28–50% of severe sepsis patients die.

• Many who survive suffer "post-sepsis syndrome" – Ongoing medical and quality of life issues

• The most expensive in-hospital

condition in the U.S., costing (>$20 billion/year) 4

Pathophysiology of Sepsis

• In response to a blood stream infection, an imbalance occurs of the body’s pro- and anti-inflammatory responses.

• Maladaptive reaction causes coagulation dysfunction, an impaired immune response, metabolic abnormalities, and endothelial compromise which leads to tissue damage, organ failure, and death

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Stages of Sepsis

SIRS Sepsis Severe Sepsis Septic Shock Death

• SIRS – Fever >38C (100.4F); – Heart rate >90 bpm; – RR >20 or PaCO2 <32mmHg; – Abnormal WBC (>12,000/μL

or < 4,000/μL or >10% immature [band] forms)

• Sepsis – Suspected / confirmed

infection and at least 2 of the SIRS symptoms

• Severe sepsis – Sepsis in addition to: – Hypotension, – Organ dysfunction, and – Hypoperfusion to at least one

organ.

• Septic shock

– Severe sepsis and – Persistent arterial hypotension

despite adequate fluid administration.

Surviving Sepsis Campaign

• Guidelines for sepsis therapy and improve patient outcomes. – “The timely identification of patients with sepsis,

along with the implementation of early, goal-directed therapy, is crucial to improve morbidity and mortality.”

• EMS can have a major role in the early

detection of sepsis and initiation of treatment.

www.jems.com

Early Goal-Directed Therapy (EGDT)

• Primary treatment for severe sepsis and septic shock in the ED / ICU.

• Adjustments to hemodynamics to balance O2 demand and delivery: – Initial treatment involves IV fluids (30cc/kg). – Hypotension (MAP < 65 mmHg) refractory to fluids is treated

with vasopressors. (Dopamine or Norepinepherine)

• Targets urine output >0.5 mL/kg/hr, MAP > 65 mmHg, normalizing lactate levels.

• Obtaining blood cultures and starting IV antibiotics within the first hour.

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Lactate

• Produced as a result of anaerobic conditions. – Indicates an acidotic condition in the body – Not known if this is maladaptive or protective

• Traditionally viewed as a product of global tissue hypoxia or hypoperfusion.

• Might also be due to inflammation. • Treatment of elevated lactate levels shown to be

significant for severe sepsis / septic shock. – Elevated lactate levels > 4 mmol/L significantly

associated with in-hospital mortality. – “Lactate Clearance” back to normal levels is

considered an endpoint for EGDT.

Prehospital Emergency Care: Recognition

• Given its mortality and importance of early intervention EMS can make a big impact. – Goal: Promptly recognize sepsis, initiate treatment and alert the

hospital so to can ready resuscitation resources and improve survival

– These are HIGH PRIORITY PATIENTS (Just like a stroke or STEMI)

Prehospital Emergency Care: Detection

• Most EMS sepsis protocols use at least 2 or more SIRS criteria to screen for sepsis. – Not very specific – Many conditions can cause elevation in SIRS

criteria • Can’t check easily or affordably check a WBC count in the

field

• Ideally, lactate would be measured to help better identify sepsis . – Expensive & requires additional equipment – Other surrogates for lactate elevation have been

suggested www.emsworld.com

www.traumayellow.com

The Role of ETCO2

• Lactate levels are valuable but not always available • Recent interest in the use of ETCO2 for prehospital sepsis

detection. • Significant inverse correlation between EtCO2 and lactate

levels in adult patients with severe sepsis or septic shock. • ETCO2 <26 correlates with acidotic state. • Great potential as a triage tool to help more rapidly identify

those who might be septic.

www.ems1.com

The Shock Index Another Way To Screen for Sepsis

• Shock Index (SI) = Heart Rate(HR) / Systolic BP (SBP) – Patients with SI > 0.7 have been shown to elevated lactate levels – Has been suggested that SI and SIRS might better identify sepsis

• Modified Shock Index (MSI) = HR / Mean Art Pressure (MAP) – Found to be a better predictor of mortality than HR and BP alone – Strong predictors of death:

• MSI >1.3 (hypovolemic/cardiogenic/obstructive shock) • MSI <0.7 (distributive shock)

Prehospital Emergency Care: Resuscitation

• Once sepsis is recognized initial therapy starts with IV fluid bolus: – 30ml/kg bolus (EGDT dose) – Most agencies 500ml or 1000ml bolus, reassess,

repeat to a max of 2 liters

• If MAP <65 despite fluids, start vasopressors – Dopamine 5-20 mcg/kg/min – Epinephrine 2-8mcg – Norepinepherine 1-10mcg/min

• Sepsis Alert / Code Sepsis – Immediate hospital notification / alert

www.jems.com

www.jems.com

Another Role For Prehospial Ultrasound…

• ”Empty Tank” • “Tank Not Empty”

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IVC >2 cm in diameter and inspiratory collapse less than 50% approximates CVP >10 cmH20

Summary

• Sepsis is a life threatening condition that carries a significant mortality and morbidity.

• EMS is well positioned to identify, initiate treatment and alert the hospital to get additional resources ready.

• Driving fast isn’t enough, we need to start care immediately and alert the hospital – (Hint: fluids are a great place to start but if they

don’t work, start thinking about those vasopressors!)

Questions?