Monday Morning Medical Director’s Message
Perhaps no topic in medical literature has received as much attention in the past few years as sepsis and septic shock, which are the topics for this month’s continuing education presentation. Over the past 10 years, Critical Care and Infectious Disease experts have offered several revisions and modifications with regard to: - The definition of sepsis: “Life-threatening organ dysfunction due to dysregulated host response to infection.”
- Removing “severe sepsis” as an actual category of the sepsis continuum.
- The nature, origin, and production of lactate in sepsis: Lactate is now believed to be generated as a byproduct of pyruvate overproduction due to endogenous epinephrine stimulation. This refutes the theory that lactate is produced during “anaerobic metabolism.” However, most texts still adhere to the production of lactate as a result of anaerobic metabolism.
- The cause of acidosis in sepsis (current theories suggest that acidosis in sepsis is not due to “lactic acid” but rather due to chloride and hydrogen ion accumulation and loss of bicarbonate).
- Recommendations regarding whether invasive monitoring of central venous pressure (CVP) is necessary or beneficial.
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Despite all the flurry of activity and revisions in the sepsis arena, many of the fundamental aspects remain the same. Early identification, immediate resuscitation, and antibiotic administration are paramount, key to patient survival. To this end, the EMS provider must be able to suspect sepsis based on history, including the all-important septic risk factors, physical examination, and ancillary testing. Be aware of the risk factors for sepsis, which include diabetes, chronic renal failure, cancer, post-op patients, those with indwelling devices, and those patients on immunosuppressant medications. Sepsis can be diagnosed at the bedside by an astute EMS provider, nurse, nurse practitioner, PA, or physician. No complicated testing is required for sepsis identification, but early identification is essential to a good outcome. Prompt resuscitative and definitive treatment translates to decreased mortality. Remember: Systemic Inflammatory Response Syndrome (SIRS) + Suspected Infection = Sepsis
We are all familiar with SIRS criteria as an indicator for the presence of sepsis—any two of these criteria make the patient “SIRS-positive.” Although there are several potential causes of SIRS, such as pancreatitis, burns, overdose, trauma, pulmonary embolism, etc., sepsis should always remain a high-level consideration in the differential diagnosis of a SIRS-positive patient.
| SIRS Criteria |
| Temperature greater than 38°C (100.4°F) or less than 36°C (96.8°F) Heart Rate greater than 90, Respiratory rate greater than 20 or PaCO2 less than 32 mm Hg WBC greater than 12,000/mm3 or <4,000mm3 or >10% bands |
Another clinical tool is the qSOFA score (also known as quick SOFA, for quick sepsis related organ failure assessment) which is a bedside prompt that may identify patients with suspected infection who are at greater risk for a poor outcome:
The UH protocols include elements of SIRS and qSOFA, which are BOTH on page 6/3, under “SIRS Checklist Clinical Findings.”
If a patient is SIRS-positive, the clinician must “look for the infection” which may or may not be obvious. Common sources of sepsis include:
- The urinary tract, especially in patients who have undergone surgery or instrumentation of the urinary tract and those with a Foley catheter. Clues for urinary tract infection include dysuria, hematuria, fever, chills, flank pain, and cloudy urine noted in the Foley collection bag.
- The respiratory tract, where patients with pneumonia may have fever, chills, productive cough, shortness of breath, and pleuritic chest pain. Physical findings could include increased respiratory rate, low pulse oximetry, accessory muscle use, crackles, or wheezes noted on lung auscultation.
- The skin and joints, where the EMS provider should examine the skin for signs of erythema, warmth, and tenderness to palpation. Wounds can become secondarily infected, including non-traumatic wounds (infected foot wounds on diabetics, decubiti on debilitated patients), post-surgical wounds, and post-traumatic wounds, such as lacerations and punctures. Signs of septic arthritis (joint infections) include joint swelling, redness, tenderness, and decreased range of motion.
- The GI tract, where the provider should inquire about vomiting, diarrhea, and abdominal pain. Patients with appendicitis, diverticulitis, ascending cholangitis, acute pancreatitis, mesenteric ischemia and bowel obstruction and perforation are all examples of gut-related sepsis. The physical findings could include diminished bowel sounds, abdominal distention, tenderness to palpation, and guarding. Rebound tenderness indicates peritonitis, which is a serious complication often noted in the patient with abdominal sepsis.
Early recognition and treatment are key to survival. Treatment includes crystalloid fluids, vasopressors as needed, and early antibiotic administration. More to come next week.
Stay well,
Andrew Garlisi, MD EMS Medical Director
University Hospitals EMS Training & Disaster Preparedness Institute