Sepsis PRESENCE REGIONAL EMS SYSTEM. In the movie Independence Day Will Smith and Jeff Goldblum...
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Transcript of Sepsis PRESENCE REGIONAL EMS SYSTEM. In the movie Independence Day Will Smith and Jeff Goldblum...
SepsisPRESENCE REGIONAL EMS SYSTEM
In the movie Independence Day
Will Smith and Jeff Goldblum destroy the alien invaders by inserting a “virus” into their system.
Sepsis
Overwhelming infection in the blood
10th leading cause of death 50 deaths per 100,000 Americans 1/3 arrive in ED by EMS
Objectives Outline the physiology of the immune
system Describe the pathophysiology of sepsis
on the cell level and how it presents on the systemic level.
Discuss the signs and symptoms of sepsis
List the appropriate PPE for EMS providers caring for patients with sepsis
Outline the assessment and management of the septic patient
Discuss the rationale for Advanced treatment measures for the septic patient
Review the Presence Health Code Sepsis protocol
Immune System
“If you ain’t for us, you’re against us”
It’s a jungle out there. . .
Immune system Leukocytes – white blood cells Natural barriers Inflammation
What makes you sick?
Bacteria Viruses Prions Fungi Parasites
Natural Immunity
Anatomical Barriers Inflammation
Anatomical Barriers/ Castle Walls
Epithelium Sebaceous glands Sweat, tears, saliva Mechanical responses—
respiratory, urinary,
gastrointestinal
Functions of Inflammation
Destroy and remove unwanted substances.
Wall off infected and inflamed area.
Stimulate the immune response. Promote healing.
Biochemical Agents of Inflammation
Vasoactive amines.Histamine
Chemotactic factorsAttraction of WBC
So what happens
Vascular response.
Increased permeability.
Exudation of white cells.
Fever.
Leukocytosis.
Increased circulating plasma proteins
Leukocytes
Phagocytes
Inflammation
Hallmarks of Acute Inflammation
Redness Pain Heat Swelling
Sepsis Bacterial infection in blood Inflammation system wide
Too much of a good thingHeat = feverCapillary leaking = distributive
shockSystemic edema
Who Gets Sepsis?
Elderly Infants Immunosuppression Hospitalized patients Preexisting conditions Severe trauma
Sources of Infection
Urinary Tract Infection Pneumonia Wounds – decubiti
Sepsis
Overwhelming systemic infection Hemodynamic instability
Systemic inflammationLeaking capillariesHypotensionTachycardia
Poor Perfusion on Cell Level
Normal Aerobic MetabolismBreaking down glucose with oxygenEnd products = CO2 and H2O
Hypoxic Anaerobic MetabolismBreaking down glucose without
oxygenEnd product = lactic acid
Lactate Production
Makes cells acidic Damages cells Damages vital organs Multi-organ failure
Septic Shock -- Distribuatory
Systemic vasodilation Container too big
Capillary LeakingLoss of fluid into interstitial
spacesCan’t get fluid back
Signs and Symptoms of Sepsis
Change in temperature (high or low) Hypo-perfusion – shock
MAP < 60 mm/HgMAP = (2X DP) + SP 3BP 88/40 (2 x 40) + 88 = 168 =
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3 3
Tachycardia Tachypnea –
Acute Respiratory Distress Syndrome
Altered mental state Elevated WBC Elevated lactate levels Skin: rashes, color changes,
lymph nodes
Complications with Elderly Poor temperature regulation
Relative hypotension (MAP <80)What is normal BP at this age
Relative bradycardiaDamaged baroreceptors in
carotid arteriesRx Beta Blockers
First Rule of EMSIf it is wet, and it’s not
yours, don’t touch it.
Second Rule of Sepsis BSI
If the patient is coughing, wear a mask.
Sepsis
Management100% OxygenVentilation supportFluid replacementBP/perfusion maintenance --
vasopresssors“Kill off the Bug”Outcome is frequently fatal
Code Sepsis
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Systemic Inflammatory Response Syndrome – SIRS is a widespread inflammatory response to a variety of severe clinical injuries. This syndrome is clinically indicated by the presence of two or more of the following:
Hypotension – systolic less than 90
Tachycardia – greater than 90
Temp - 101 or less than 96.8
Altered level of consciousness
Respiratory rate greater than 20
Definitions
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Sepsis – Clinical signs of SIRS are present together with evidence of infection.
Severe Sepsis – Sepsis associated with organ dysfuction, hypoperfusion, or hypotension.
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Why Do We Care? Every year, severe sepsis strikes more
than 1 million Americans (globally 20-30 million patients)
Estimated cost is more than $20 billion for sepsis care
Patients surviving sepsis have twice the risk of death in the following 5 years
The incidence of sepsis following surgery tripled between 1997 and 2006
Hospitalizations for sepsis have doubled in the last 10 years
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Where Did We Start?Baseline data: PCMC Sepsis Mortality
25.6%Baseline data: PUSMC Sepsis Mortality
17.8%Baseline data: PCMC Cost Per Patient
$22,191Baseline data: PUSMC Cost Per Patient
$17,073
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Why Do We Care?Patients receiving the sepsis bundle within the first hour have a mortality rate reduction of 14% and a reduction of 5.1 days in length of stay.
Early sepsis strategies are associated with 1 life being saved for every 7 treated.
The Genesis Project
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Why Do We Care?
We have the ability to save lives by using the appropriate tools to catch and treat sepsis.
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Definition of Code Sepsis Patient must be hypotensive with one
other SIRS criteria and a possible source of infection.
Hypotension – systolic less than 90
Tachycardia – greater than 90
Temp - 101 or less than 96.8
Altered level of consciousness
Respiratory rate greater than 20
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Code Sepsis Creates a Team Response
Code Sepsis will be paged overhead.Responders to include:
PhysicianHouse SupervisorPhlebotomyPrimary RNRadiology
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Procedure – EMS to Emergency Dept.
Paramedic unit follows established Region VI protocols and care guidelines for Sepsis Patients.
Paramedic unit calls report to the hospital prior to leaving the scene to initiate the Code Sepsis.
If the patient meets criteria then a Code Sepsis will be called.
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The RN receiving the radio report will notify the charge nurse and the emergency department physician. The designee will activate the Code Sepsis by dialing communication and giving the Location.Upon patient arrival, RN initiates sepsis protocol.Immediate evaluation per emergency room physician.
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Code Sepsis Protocol
1.Labs: CBC, CMP, PT/PTT, Procalcitonin, Blood cultures, UA/UC
2.RT: ABG (Lactic Acid), Oxygen to keep sat greater than 90%
3.Portable CXR, if not done previously4.IV: 2 Large bore PIVs
1 Liter 0.9% NS bolus via pressure bag. Notify physician for vasopressors if pt.
remains hypotensive despite fluid resuscitation.
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5. Cardiac monitor, Vital signs every 15 min. Undress pt. and place in gown, Insert Foley catheter – Strict I & O
6. Discuss with physician possible need for central line if patient remains hypotensive despite fluid resuscitation and vasopressors are needed.
7. Discuss with physician stat antibiotic orders.
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Surviving Sepsis Starts With YouBe aware of sepsis signs / symptomsComplete MEWS screens every 8 hoursComplete screening on all ED patients
age 18+ED physicians, assess all admissionsCall Code Sepsis when patient meets
criteriaFollow protocols
Case Study 1
You are called to an apartment for a 19 year old “man down”
You find Lou lying prone in bed. He is pale and looks to be sleeping. His chest is barely moving
His roommate says he came home from work and found Lou like this.
Lou moans when you stimulate him, He does not wake up and does not follow commands. He will not open his eyes
His airway is open and clear He is breathing 28 per minute
with rales and rhonchi in his lungs His skin is pale, hot and dry,
pulse is fast and weak
Lou’s roommate said he was complaining of a sore throat and a massive headache this morning and decided not to go to class at the community college. He has been studying and working 2 jobs.
He has no known allergies, no medical history. He has been taking Tylenol cold pills for 2 days for his symptoms
His roommate just found him and called 911
BP 88/60, P. 140, R. 28, Temp hot Pulse Oximetry 89% on room air Blood sugar 100 When you examine Lou you find a
fine petechial rash on his chest, back and arms. Lou cries out whenever you move him, particularly his neck and back
What is wrong with Lou? Does he meet Code Sepsis criteria? What body system is infected in this
case? What BSI should you have on? What can you guess his lactate
level is? High or low? How do you want to manage Lou?
Case Study 2
Dispatched at 1000 for elderly person sick for 2 days with a urinary tract infection.
You respond to a large assisted living center.
Your patient is 82 year old Mrs. Schmidt, who is sitting in a recliner in her apartment.
Initial Assessment
Mental Status: lethargic, moans when disturbed
Airway has large amounts of mucus in mouth and rattling in her throat
Breathing is labored and shallow. Skin is very pale and warm, moist
to touch, poor radial pulses, very weak and irregular
History
Allergies: None Medications: Capoten 25 mg TID,
Diabinese 100 mg daily, pyridium 200 mg TID, Gantrisin 1 gm. TID
Previous Illnesses: Breast cancer 7 years ago, completed radiation and chemotherapy, hypertension and type II diabetes
Current Health Status: Mrs. Schmidt has been in good health. She has been at this facility for 2 years. She is up and dressed every day and eats her meals in the dining room. She is very active in social activities.
Events: Mrs. Schmidt went to see her doctor 2 days ago for a urinary tract infection. He put her on pyridium and gantrisin, which she has been taking. Mrs. Schmidt told the staff that she did not feel well yesterday and that she ached all over. She wanted only tea for supper last night. They found her this morning in her recliner in this condition.
Focused Physical
BP 80/60 Pulse 88 irregular Respirations 20, she breathes fast,
then slows down to a period of apnea and then speeds up again
Blood sugar 190 Pulse oximetry: 86% on room air Montior shows atrial fibrillation
with unifocal PVC
Head to Toe
Responds only by moaning when spoken to
Jugular veins distended Breath sounds have soft crackles
in bases Abdomen soft and not tender Gross edema of legs, arms and
face
What is wrong with Mrs. Schmidt? Does she meet Code Sepsis
criteria? What is the source of the
infection? What BSI should you have on? What can you guess her lactate
level is? High or low?
How do you want to manage Mrs. Schmidt?
What do you do if she doesn’t tolerate fluid boluses?
Case Study 3
Dispatch: You are dispatched to transfer an 18 month old boy to Children’s Hospital in Chicago.
Initial Transfer History
Jason has been sick for 3 days. It started out as an ear infection, but he is much worse today.
Jason has been in the ED for 90 minutes.
Chief Complaint: Fever
Initial Assessment
Mental Status: Lethargic. Responds to pain only by whimpering and trying to draw away.
Airway: Open, but must be suctioned periodically for mucus
Breathing: Shallow and gasping 32 times/minute
Circulation: Skin is cool, pale and clammy. His arms and legs are mottled. He has purple blotches and petechiae on his trunk. He has peri-oral and peripheral cyanosis. His pulse is 150 and weak. His blood pressure is 70/50.
Focused History Events: Jason’s mother took him
to the doctor for an ear infection 3 days ago. He was much worse this morning.
Physical Illnesses: Frequent ear infections
Current Health Status: Other than frequent ear infections is growing well and is normal size for his age.
Allergies: none Medications: Amoxicillen
250mg/5ml BID, Tylenol every 6 hours
Focused Physical
Vital Signs: BP 70/50, pulse 150 and weak, resp. 32 shallow and gasping. O2 sat 88% on 15 liters blow by. Temp. 102.6 F. (rectal)
Diminished breath sounds with rales and rhonchi.
He does not like to be touched and will not bend his head without screaming.
Other Findings : 22 ga. IV catheter left anticubital. Normal saline running at 20 ml/kg boluses (one so far)
Jason weighs 24 pounds.
Lab Values
Hematocrit 50 Hemoglobin 20 WBC 18,000 (high) Sodium 140 Potassium
5.2 Chloride 100 CO2 33 Glucose 50 (low) BUN 17 Creatinine 1.3 Lactate 6 (high)
Lab Values
pH 7.3 pO2 63 pCO2 54 HCO3 24
X-ray Findings
Chest film shows fluffy patches of white in the lower lobes of both lungs
What is wrong with Jason?
What is the pathology behind his vital signs?
Why are Jason’s lab values abnormal?
Why does Jason have petechiae? What is this caused by?
Do you need to do any additional interventions to manage Jason’s ventilations?
What can be done to improve Jason’s vital signs?
Does Jason need IV fluids? How much of what kind?
Is Jason stable enough to be transported? If not what needs to be done prior to transport?
What medications might Jason need enroute?
Do you need to make any infection control arrangements prior to transporting Jason?
What are you doing to do with Jason’s Mommy?
What is Jason’s prognosis? What is he at risk for?