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 38 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?