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Sepsis

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 10 th leading cause of death 50 deaths per 100,000 Americans

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Sepsis

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  1. Sepsis Presence Regional EMS System

  2. In the movie Independence Day • Will Smith and Jeff Goldblum destroy the alien invaders by inserting a “virus” into their system.

  3. Sepsis Overwhelming infection in the blood 10th leading cause of death 50 deaths per 100,000 Americans 1/3 arrive in ED by EMS

  4. 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

  5. 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

  6. Immune System • “If you ain’t for us, you’re against us”

  7. It’s a jungle out there. . . • Immune system • Leukocytes – white blood cells • Natural barriers • Inflammation

  8. What makes you sick? • Bacteria • Viruses • Prions • Fungi • Parasites

  9. Natural Immunity • Anatomical Barriers • Inflammation

  10. Anatomical Barriers/ Castle Walls • Epithelium • Sebaceous glands • Sweat, tears, saliva • Mechanical responses—respiratory, urinary, gastrointestinal

  11. Functions of Inflammation • Destroy and remove unwanted substances. • Wall off infected and inflamed area. • Stimulate the immune response. • Promote healing.

  12. Biochemical Agents of Inflammation • Vasoactive amines. • Histamine • Chemotactic factors • Attraction of WBC

  13. So what happens • Vascular response. • Increased permeability. • Exudation of white cells. • Fever. • Leukocytosis. • Increased circulating plasma proteins

  14. Leukocytes • Phagocytes

  15. Inflammation

  16. Hallmarks of Acute Inflammation • Redness • Pain • Heat • Swelling

  17. Sepsis • Bacterial infection in blood • Inflammation system wide • Too much of a good thing • Heat = fever • Capillary leaking = distributive shock • Systemic edema

  18. Who Gets Sepsis? Elderly Infants Immunosuppression Hospitalized patients Preexisting conditions Severe trauma

  19. Sources of Infection Urinary Tract Infection Pneumonia Wounds – decubiti

  20. Sepsis • Overwhelming systemic infection • Hemodynamic instability • Systemic inflammation • Leaking capillaries • Hypotension • Tachycardia

  21. Poor Perfusion on Cell Level • Normal Aerobic Metabolism • Breaking down glucose with oxygen • End products = CO2 and H2O • Hypoxic Anaerobic Metabolism • Breaking down glucose without oxygen • End product = lactic acid

  22. Lactate Production Makes cells acidic Damages cells Damages vital organs Multi-organ failure

  23. Septic Shock -- Distribuatory • Systemic vasodilation • Container too big • Capillary Leaking • Loss of fluid into interstitial spaces • Can’t get fluid back

  24. Signs and Symptoms of Sepsis • Change in temperature (high or low) • Hypo-perfusion – shock • MAP < 60 mm/Hg • MAP = (2X DP) + SP • 3 • BP 88/40 (2 x 40) + 88 = 168 = 56 • 3 3

  25. Tachycardia • Tachypnea – • Acute Respiratory Distress Syndrome • Altered mental state • Elevated WBC • Elevated lactate levels • Skin: rashes, color changes, lymph nodes

  26. 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

  27. First Rule of EMS • If it is wet, and it’s not yours, don’t touch it.

  28. Second Rule of Sepsis BSI If the patient is coughing, wear a mask.

  29. Sepsis • Management • 100% Oxygen • Ventilation support • Fluid replacement • BP/perfusion maintenance -- vasopresssors • “Kill off the Bug” • Outcome is frequently fatal

  30. Review • Consider the following questions as a group. • If doing this CE individually, please e-mail your answers to: • Shelley.Peelman@presencehealth.org • Use “December 2013 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.

  31. 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.

  32. 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

  33. 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

  34. 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

  35. What is wrong with Lou? • 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?

  36. Case Study 2 • Dispatched at 1000 for elderly person sick for 2 days with a urinary tract infection.

  37. 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.

  38. 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

  39. 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

  40. 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.

  41. 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.

  42. 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

  43. 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

  44. 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?

  45. How do you want to manage Mrs. Schmidt? What do you do if she doesn’t tolerate fluid boluses?

  46. Case Study 3 • Dispatch: You are dispatched to transfer an 18 month old boy to Children’s Hospital in Chicago.

  47. 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

  48. 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

  49. 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.

  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

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