Code Sepsis - Presence Health
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Transcript Code Sepsis - Presence Health
Sepsis
PRESENCE 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 factors
Attraction
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 thing
Heat
= fever
Capillary
leaking = distributive
Systemic
edema
shock
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
Leaking
inflammation
capillaries
Hypotension
Tachycardia
Poor Perfusion on Cell Level
Normal Aerobic Metabolism
Breaking
End
down glucose with oxygen
products = CO2 and H2O
Hypoxic Anaerobic Metabolism
Breaking
oxygen
End
down glucose without
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 Leaking
Loss
of fluid into interstitial spaces
Can’t
get fluid back
Signs and Symptoms of
Sepsis
Change in temperature (high or low)
Hypo-perfusion – shock
MAP
< 60 mm/Hg
MAP
=
BP
(2X DP) + SP
3
88/40 (2 x 40) + 88 = 168 = 56
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 bradycardia
Damaged
baroreceptors in
carotid arteries
Rx
Beta Blockers
First Rule of EMS
If
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
Management
100%
Oxygen
Ventilation
Fluid
support
replacement
BP/perfusion
maintenance -vasopresssors
“Kill
off the Bug”
Outcome
is frequently fatal
Code Sepsis
Definitions
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
31
Sepsis – Clinical signs of SIRS are
present together with evidence of
infection.
Severe Sepsis – Sepsis associated with
organ dysfuction, hypoperfusion, or
hypotension.
32
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
33
Where Did We Start?
Baseline data: PCMC
25.6%
Sepsis Mortality
Baseline data: PUSMC Sepsis Mortality
17.8%
Baseline data: PCMC Cost Per Patient
$22,191
Baseline data: PUSMC Cost Per Patient
$17,073
34
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
35
Why Do We Care?
We have the ability to save lives
by using the appropriate tools to
catch and treat sepsis.
36
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
37
Code Sepsis Creates a
Team Response
Code Sepsis will be paged overhead.
Responders to include:
Physician
House
Supervisor
Phlebotomy
Primary
RN
Radiology
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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.
39
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.
40
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 previously
4. 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.
41
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.
42
Surviving Sepsis Starts
With You
Be aware of sepsis signs / symptoms
Complete MEWS screens every 8 hours
Complete screening on all ED patients age
18+
ED physicians, assess all admissions
Call Code Sepsis when patient meets
criteria
Follow protocols
43
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?