Transcript Sepsis February 2016

Sepsis
Presence Regional EMS System
February 2016
In the movie Independence Day

Will Smith and Jeff Goldblum destroy the
alien invaders by inserting a “virus” into
their system.
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In humans, invasion of the body by foreign
pathogens (disease producing proteins) can
be fatal to human bodies.
Sepsis
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Overwhelming infection in the blood
10th leading cause of death
50 deaths per 100,000 Americans
1/3 arrive in ED by EMS
Objectives
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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
Objectives
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List the appropriate PPE for EMS providers
caring for patients with sepsis
Outline the assessment and management of
the septic patient on an EMT level
Discuss the rationale for Advanced
treatment measures for the septic patient
Immune System
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Considering that we are faced by a hostile army
of microorganisms swarming on our skin,
invasions of airborne bacteria and viruses and a
whole host of foreign proteins in food and
chemicals, we stay amazingly healthy most of the
time.
All invaders are either harmful or disease
causing microorganisms called pathogens or
foreign proteins called antigens
Immune System
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The body has a single minded approach to all
invaders:
 “If
you ain’t for us,
you’re against us”
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The ability to recognize who is “with us”
and fight those who are “against us” is the
responsibility of the Immune system.
It’s a jungle out there. . .
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Because this branch of the Immune System is responsible
for the defense of the body, military references are used to
describe what is going on in the body.
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Immune system: Everybody is born with
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Leukocytes – white blood cells
Natural barriers
Inflammation
What makes you sick?
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Bacteria ** most likely to cause sepsis
Viruses
Prions
Fungi
Parasites
Natural Immunity: Everyone is
born with. First line of defense
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Anatomical Barriers
Inflammation
Anatomical Barriers
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Just as a castle has strong, tall walls to
protect the individuals inside, the body has
barriers to entrance into the body to protect
itself from harm. The first lines of defense
are the anatomical surface barriers.
These are the physical, chemical and
mechanical barriers found at any portal or
potential entry into the body.
Anatomical Barriers/ Castle Walls
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Intact skin
Epithelium – cells that slough off
Mucus membranes
Sebaceous glands
Sweat, tears, saliva
Mechanical responses—respiratory, urinary,
gastrointestinal
If Barriers Fail
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All of the available soldiers of the immune
system need to be called into action.
The call to action is through the
inflammatory process, the second stage of
the immune system. While it is annoying to
us on a personal level, inflammation is an
important part of the immune process.
Functions of Inflammation
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Destroy and remove unwanted substances.
Wall off infected and inflamed area to
prevent the spread of damaging agents to
nearby tissues
Stimulates other branches of the immune
system
Disposes of destroyed microorganisms
Sets the stage for repair.
Biochemical Agents of Inflammation
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Materials released when tissue is injured
Vasoactive amines.
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Histamine
Chemotactic factors
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Attraction of WBC
So what happens
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Vascular response: vasodilation with increased
blood flow to area.
Increased permeability: capillary leaking =
swelling of the injured area
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Swelling of injured area:
Pressure on pain receptors
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Exudation of white cells:
WBC leave blood stream and move
into spaces between cells
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Moves oxygen and nutrients closer to
injured cells
Increased blood flow increases temperature
of the area = fever
Increased circulating plasma proteins =
increased clotting factors
Leukocytes: WBC attracted by
histamine
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Phagocytes – destroy unwanted materials and
“gobble up” foreign entities.
Inflammation
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In the following picture, a splinter has passed
through the protective barrier of the skin bringing
foreign materials (microorganisms--germs) with
it. The inflammatory response is called into
action with histamine release, pain, redness, heat
and swelling. The army of phagocytes called to
the area pass easily through the leaking
capillaries. The phagocyte WBCs begin to
destroy pathogens and clean up any destroyed
tissue.
Inflammation
Hallmarks of Acute Inflammation
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Caused by histamine release
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Redness
Pain
Heat
Swelling
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Inflammation is the lowly foot soldier of the Immune
System. As a non-specific response it is rapidly deployed
in huge numbers.
Inflammation is always prepared and can respond within
minutes. However, the response is generic and essentially
the same regardless of the type of invader be it bacteria,
virus, a blister, a sprained ankle or a mosquito bite.
Regardless of the cause of the trigger, the response of
Inflammation will always be the four Cardinal Hallmarks:
redness, pain, heat and swelling.
Sepsis
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Bacterial infection in blood
Inflammation system wide
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Too much of a good thing
Heat = fever
Capillary leaking = massive fluid loss
=distributive shock
Systemic edema
Poor delivery of oxygen and sugar to cells =
poor perfusion
Who Gets Sepsis?
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Elderly aging immune system
Infants immature immune system
Immunosuppression
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From disease or steroids
Over stressed immune system
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Hospitalized patients
Preexisting conditions
Severe trauma
How often does EMS encounter
Sepsis
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More than you might think!
Seattle Washington
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3.3/100 patient contacts = Sepsis
2.3/100 patient contacts = AMI/STEMI
2.2/100 patient contacts = Stroke
Common Sources of Infection
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Urinary Tract Infection
Pneumonia
Wounds – decubiti
Sepsis
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Overwhelming systemic infection
Hemodynamic (cardiovascular) instability
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Systemic inflammation
Leaking capillaries
Hypotension
Tachycardia --- fast heart rate
Fast breathing
Poor Perfusion on Cell Level
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Normal Aerobic Metabolism
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Normal delivery of oxygen and glucose
Breaking down glucose with oxygen
End products = CO2 and H2O
Hypoxic Anaerobic Metabolism
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Abnormal delivery of oxygen and glucose
Breaking down glucose without oxygen
End product = lactic acid
Lactate Production
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Makes cells acidic
Damages cells
Damages vital organs
Multi-organ failure
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No way to measure Lactate in the prehospital setting but some agencies have
End Tidal CO2 devices
Metabolic Acidosis
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Compensatory Respiratory Alkalosis
Not creating CO2 so
ET CO2 < 35 mmHg
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Septic Patients studied had 33-30 mmHg
Surviving patients 34-31 mmHg
Non surviving patients 30-21 mmHg
Rule out Diabetic ketoacidosis with blood
glucose
For EMS
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ETCO2 as accurate as Lactate levels
Obtained without blood letting
Obtained in < 1 minute
Septic Shock -- Distributive
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Systemic vasodilation
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Container too big
Capillary Leaking
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Loss of fluid into interstitial spaces
Can’t get fluid back
Signs and Symptoms of Sepsis
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Reflect systemic inflammation
Reflect cellular damage
Signs and Symptoms of Sepsis
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Change in temperature (high or low)
Hypo-perfusion – shock
Mean Arterial Pressure (MAP) < 65 mm/Hg
MAP = (2X Diastolic BP) + Systolic BP
3
BP 90/50 (2 x 50) + 90 = 190 = 63
3
3
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Signs and Symptoms of Sepsis
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Tachycardia = fast heart rate
Tachypnea = fast breathing
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Acute Respiratory Distress Syndrome
Altered mental state
Elevated WBC
Elevated lactate levels/ low EtCO2
Skin: rashes, color changes, lymph nodes
Complications with Elderly
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Poor temperature regulation (may be cold)
Relative hypotension (MAP <80)
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What is normal BP at this age?
If normal BP high, move MAP value up
Relative bradycardia (may have slow heart
rate)
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Damaged baroreceptors in carotid arteries
Rx: Beta Blockers
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How to approach someone with sepsis
First Rule of EMS
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If it is wet, and it’s not yours,
don’t touch it.
Second Rule of Sepsis BSI
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If the patient is coughing, wear a mask.
Management of Sepsis
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Oxygen to 94-99%
Ventilation support
Fluid replacement – ALS/ILS
BP/perfusion maintenance – vasopressors
“Kill off the Bug”
Outcome is frequently fatal
Fluid or Vasopressor??
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Passive Leg Raising
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Form of orthostatic Vital Signs
Elevate legs 45 degrees
30 sec to 1 min
Look for
Change in BP down = hypovolemia
 Change in EtCO2 1-2 mm/Hg
 If EtCO2 goes up, needs more fluid
 If EtCO2 goes down, needs vasopressors
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Sepsis Protocol – Region 6
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CRITERIA: (Must meet the following)
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Age > 18 years
NOT Pregnant
History suggestive of infection or currently being treated for
infection:
 Pneumonia (cough, shortness of breath)
 UTI (indwelling foley catheter, suprapubic catheter, etc)
 Abdominal Pain, Diarrhea
 Wound/Skin Infection
 Infected indwelling device (central line, port, etc)
 Recent Hospitalization and/or Surgery
 Immunocompromised
CRITERIA (cont.)
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At least TWO of the following criteria (new to
patient):
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Temperature > 38°C (100.4°F) or < 36°C (96°F)sd
Heart Rate > 90
Respiratory Rate > 20
Altered Mental Status
Hypoperfusion as manifested by ONE of the
following:
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Manual SBP < 90; MAP < 65
SpO2 < 90
Sepsis Protocol – Region 6
FR/BLS TREATMENT:
 INITIAL MEDICAL CARE
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Check blood glucose level. If blood glucose < 60
mg/dl refer to DIABETIC EMERGENCIES Protocol
for treatment.
Administer OXYGEN at 15 lpm by nonrebreather mask
Call for intercept per INTERCEPT CRITERIA.
Reassess patient and vital signs every 5 minutes.
Sepsis Protocol – Region 6
ILS/ALS TREATMENT
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Continue FR/BLS TREATMENT
Notify receiving hospital of “SEPSIS ALERT”
Consider 12-Lead EKG
Establish at least one large bore IV
 Administer 20ml/kg NS fluid bolus (Document
TOTAL amount of IVF given)
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Reassess after each 250ml increment and STOP fluids if
signs of pulmonary edema (increasing shortness of breath or
rales/crackles on lung exam)
May repeat to maintain SBP > 90 or MAP > 65 as long as
pulmonary edema is not suspected.
Total amount of IVF should not exceed 2000 mL
Sepsis Protocol – Region 6
Continue to reassess patient including vital
signs (manual BP), breath sounds,
capnography (< 25 mmHg indicative of
severe sepsis), cardiac monitor.
Below the line:
 Medical Control may consider
DOPAMINE infusion if SBP < 90 or MAP
< 65 despite adequate fluid resuscitation.
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Review
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Consider the following questions as a group.
If doing this CE individually, please e-mail your
answers to:
[email protected]
Use “February 2016 CE” in subject box.
You will receive an e-mail confirmation. Print
this confirmation for your records, and document
the CE in your PREMSS CE record book.
IDPH sitecode: 06-7100-E-1216
Case Study 1
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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.
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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 times per minute with
rales and rhonchi in his lungs
His skin is pale, hot and dry and his pulse
is fast and weak
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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 two
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
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BP 88/60, P. 140, R. 28, Temp hot
Pulse Oximetry 89% on RA; EtCO2 30
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
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What is wrong with Lou?
What body system is infected in this case?
What BSI should you have on?
How do you want to manage Lou?
Case Study 2
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Dispatched at 1000 for elderly person sick
for 2 days with a urinary tract infection.
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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
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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
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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
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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.
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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
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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
EtCO2 27
Monitor shows atrial fibrillation with unifocal
PVC
Head to Toe
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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
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What is wrong with Mrs. Schmidt? What
is the source of the infection?
What BSI should you have on?
What can you guess her lactate level is?
High or low?
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How do you want to manage Mrs.
Schmidt?
What do you do if she doesn’t tolerate fluid
boluses?
Case Study 3
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Dispatch: You are dispatched to transfer
an 18 month old boy to Children’s Hospital
in Chicago.
Initial Transfer History
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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.
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Chief Complaint: Fever
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Initial Assessment
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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
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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
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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: Amoxicillin 250mg/5ml BID,
Tylenol every 6 hours
Focused Physical
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Vital Signs: BP 70/50, pulse 150 and
weak, resp. 32 shallow and gasping.
O2 sat 88% on 15 liters blow by.
EtCO2 29
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.
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Other Findings : 22 ga. IV catheter left
antecubital. Normal saline running at 20
ml/kg boluses (one so far)
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Jason weighs 24 pounds.
Lab Values
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Hematocrit 50
Hemoglobin 20
WBC 18,000 (high)
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Sodium 140
Chloride 100
Glucose 50 (low)
Creatinine 1.3
Potassium 5.2
CO2
33
BUN
17
Lactate
6 (high)
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pH
pO2
pCO2
HCO3
7.3
63
54
24
X-ray Findings
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Chest film shows fluffy patches of white in
the lower lobes of both lungs
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What is wrong with Jason?
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What is the pathology behind his vital
signs?
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Why are Jason’s lab values abnormal?
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Why does Jason have petechiae? What is this
caused by?
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Do you need to do any additional interventions to
manage Jason’s ventilations?
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What can be done to improve Jason’s vital signs?
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Does Jason need IV fluids? How much of what
kind?
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Is Jason stable enough to be transported? If not
what needs to be done prior to transport?
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What medications might Jason need enroute?
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Do you need to make any infection control
arrangements prior to transporting Jason?
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What are you doing to do with Jason’s
Mommy?
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What is Jason’s prognosis? What is he at
risk for?