SEPSIS- THE BIG NASTY -SEPSIS
SEPSIS is a beast with massive jaw and many teeth. Its like a predator hiding in wait. Unlike a snake, raptor, lion, or spider, it can choose its method when ever and however it wants. It also can be vicious and unrelenting. Or it can be a slow poison eating away slowly and painfully. As ALS providers we have many methods of combating SEPSIS, but understanding the pathology can help us with our defense and may even allow us to gain some offense.
As Paramedics we could be first step in a life saved by recognition of Sepsis. Low BP, Tachycardia, and Elevated temp are the most common. However sepsis doesn’t follow a path of tradional signs and symptoms. Many organization and agencies will put into place numbers to follow for sepsis regonition. We firmly believe that regonition of sepsis comes with expirence and intuition. Let’s look at a case.
34 yr old male. Hx of substance abuse has been clean for 3 years. Hep A pos, and chronic abdominal pain. He calls 911 for a fever he hasn’t been able to break for 3 days. On arrival he is pale, sweaty and shaking. Vitals are: HR: 128, RR: 24, BP: 74/38, O2: 91%, ETCO2: 18, Temp: 102.5°. He is slightly lethargic. He states his friend was diagnosed with strep yesterday and has been sick for days.
Physical exam reveals pitting edema in face, neck and legs. Crackles throughout lungs. Wheezing on inspiration. Pt is leaking from soars on hands.
What concerns you the most? How are you going to treat? What are some assumptions you can make.
What are your protocols?
Here are some hard fast truths about sepsis resuscitation.
NS is more acidic than LR. LR is much more “balanced”.
30ml/kg/hr is more appropriate 20ml/kg/hr. There is a lot of science and debate on titration to urine output. However in the 911 scenario we typically don't spend enough time with the patient to measure and titrate urine output.
Levophed is now the most common pressor for hypotension with suspected sepsis.
Review you policies and dosing, please be careful when doing mcg/kg dosing. Many agencies use a 0.01-3 mcg/kg/min dosing. Be aware of dosing per hour and the sympathetic response and alpha constriction.
I have found a lot of positive success in using Levophed along with using a second line pressor like an epic drip or vasopressin drip.
Consider sympathetic response is blunted with renal imparement. Use Ketamine.
Etomidate contraindicated.
Propofol and Versed blunt sympathetic response.
If hemoglobin is low and patient is acidic or alkalitic, they have reduced O2 carrying capacity. Do not over sedate.
Agencies that allow for antibiotics should be aggressive with treatment. Remember not all Antibiotics are LR compatible.
Albuterol, Xopenex, and Ipatropirum Bromide (Atrovent) are all helpful with fluid shift. Albuterol will compound tachycardia.
Pt’s cells are leaking. Check BGL even if no history of diabetes.
Keep patient warm... if fluid resuscitation is started patients can drop temps very quickly.
Atypical findings that should be of concern:
non diabetic hx with elevated BGL and tachycardia!
Edema noted globally w no hx of CHF...
lethargic with fruity smell smell or strong urine smell.
any patient w immune issues or blood diseases w/fever or strangely low temp.
Transferring a patient? Remember lactic acid, ABGs WBCs and UAs. If time permits, see if the trends are improving, stagnant, or getting worse.
34 yr old male. Hx of substance abuse has been clean for 3 years. Hep A pos, and chronic abdominal pain. He calls 911 for a fever he hasn’t been able to break for 3 days. On arrival he is pale, sweaty and shaking. Vitals are: HR: 128, RR: 24, BP: 74/38, O2: 91%, ETCO2: 18, Temp: 102.5°. He is slightly lethargic. He states his friend was diagnosed with strep yesterday and has been sick for days.
Physical exam reveals pitting edema in face, neck and legs. Crackles throughout lungs. Wheezing on inspiration. Pt is leaking from soars on hands.
What concerns you the most? How are you going to treat? What are some assumptions you can make.
What are your protocols?
Here are some hard fast truths about sepsis resuscitation.
NS is more acidic than LR. LR is much more “balanced”.
30ml/kg/hr is more appropriate 20ml/kg/hr. There is a lot of science and debate on titration to urine output. However in the 911 scenario we typically don't spend enough time with the patient to measure and titrate urine output.
Levophed is now the most common pressor for hypotension with suspected sepsis.
Review you policies and dosing, please be careful when doing mcg/kg dosing. Many agencies use a 0.01-3 mcg/kg/min dosing. Be aware of dosing per hour and the sympathetic response and alpha constriction.
I have found a lot of positive success in using Levophed along with using a second line pressor like an epic drip or vasopressin drip.
Consider sympathetic response is blunted with renal imparement. Use Ketamine.
Etomidate contraindicated.
Propofol and Versed blunt sympathetic response.
If hemoglobin is low and patient is acidic or alkalitic, they have reduced O2 carrying capacity. Do not over sedate.
Agencies that allow for antibiotics should be aggressive with treatment. Remember not all Antibiotics are LR compatible.
Albuterol, Xopenex, and Ipatropirum Bromide (Atrovent) are all helpful with fluid shift. Albuterol will compound tachycardia.
Pt’s cells are leaking. Check BGL even if no history of diabetes.
Keep patient warm... if fluid resuscitation is started patients can drop temps very quickly.
Atypical findings that should be of concern:
non diabetic hx with elevated BGL and tachycardia!
Edema noted globally w no hx of CHF...
lethargic with fruity smell smell or strong urine smell.
any patient w immune issues or blood diseases w/fever or strangely low temp.
Transferring a patient? Remember lactic acid, ABGs WBCs and UAs. If time permits, see if the trends are improving, stagnant, or getting worse.