code sepsis: do you have to do more than just give a...
TRANSCRIPT
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?