George Adolf

1. George Adolf

2. Myths • The elderly, for the most part are the only people who contract sepsis. • Sepsis only affects people with pre-existing conditions. • Sepsis is the same thing as blood poisoning (septicemia). • Sepsis and septic shock are always fatal.

3. Incidence • Over 750,000 patients are diagnosed with sepsis annually, with an increase of 90% in the number of diagnoses over the last 10 years. • The cause for this is believed to be the rise of drug-resistant bacteria

4. Mortality • In otherwise healthy individuals, the mortality rate for sepsis is 5% • If severe sepsis develops, mortality rises sharply • If hypotension (the hallmark of septic shock) is present, mortality rises to 50%

5. At-Risk Populations • Elderly, infants, surgical patients, chronically ill and immuno-supressed patients are all at increased risk of contracting sepsis because of compromised or diminished immune function. • The mortality rates for these catagories are also raised.

6. Definitions • a. Sepsis – a SIRS response triggered by infection • b. Septicemia – sepsis originating from an infection in the bloodstream • c. Systemic Inflammatory Response Syndrome – systemic (bodywide) immune response meeting two or more of the following criteria • i. Temperature above 100.4 ˚F , below 96.8 ˚F • ii. HR > 90 bpm • iii. RR > 20 or PaCO2 < 32 mmHg • iv. Extreme high/low WBC count

7. a. Chills, low grade fever, shaking, body aches, N&V, vertigo, other flu-like symptoms b. Occasional AMS including confusion, lethargy and increased fatigue S/S of Sepsis

8. Purpura/rash in children with sepsis caused by meningococcal infection

9. Influenza vs. Sepsis Sepsis can be misdiagnosed as the flu because symptoms are nearly identical often. Try to rule out sepsis when considering a diagnosis of influenza.

10. Sources of Infection • Dirty wounds (debris) • Complex wounds (open fractures) • Burns • Puncture wounds • Impaled Objects • Crush Injuries

11. Infected Wounds

12. Progression of Sepsis • a. Local infection occurs triggering non-specific inflammatory cell response • i. Vasodilation occurs allowing more blood to reach infected area enhancing immune response by allowing increased movement of antibodies and immune cells (Phagocytes) into affected area in order to combat infection • ii. Increased Local Vessel Permeability Increases, permits antibodies & phagocytes to move out of bloodstream into surrounding infected cells

13. Sepsis Chain

14. Image: various causes & signs of infection/sepsis

15. Progression of Sepsis cont. • b. Local Inflammatory Response Ineffective > infection spreads beyond original location • c. Body initiates systemic inflammatory response to infection > infection becomes sepsis at this point

16. Progression of Sepsis cont. • d. Severe sepsis • i. Organ dysfuntion, poor perfusion or hypotension • ii. Characterized by: hypotension (<90 mmHg systolic), altered mental state, hyperglycemia w/o Hx of diabetes, hypoxemia, & decreased urine output • iii. Body’s response to severe sepsis > release of histamines, prostaglandins, cytokines causing systemic vasodilation and increased capillary permeability> fluid shift from intravascular space to the extravascular space > increased systemic inflammation & relative hypovolemia causing hypotension

17. Progression of Sepsis cont. • e. Septic Shock • i. When aggressive fluid replacement and vasopressors fail to maintain a SBP of at least 90 w/ continued signs of severe sepsis > pt now in septic shock (tx increasingly difficult, mortality now over 50%)

18. Progression of Sepsis cont. • f. Multiple organ dysfunction Syndrome • i. Two or more organs fail to function properly, homeostasis not maintained without aggressive interventions • ii. MODS will develop within 3-5 days of uncorrected septic shock • iii. Final stage of an infection that has overtaken the body > death shortly

19. Assessment • a. ABCs, manage critical problems • b. Complete SAMPLE hx • i. How long has pt been ill? • ii. Is there any hx of infections? • iii. Prior medical complications/conditions? • iv. Any surgeries? • v. Pain or fever? • c. Complete physical exam • i. Sick/Not Sick • ii. Signs of infection?

20. A sign of infection A bad IV site

21. Management of Sepsis • a. Oxygen – patients with sepsis have an increased oxygen demand, oxygen supply to tissue is often inadequate even with supplemental O2 in patients with severe sepsis • b. Ventilatory Support – patients with severe sepsis often require mechanical ventilatory support, consider intubation and the use of a respirator if available • c. Capnography and Pulse Oximetry to maintain SpO2 above 90, and monitor PaCO2 – respiratory alkalosis (PaCO2 < 32 mmHg) is common

22. Management of Sepsis cont. • d. Monitor hypotension and use fluid replacement, Trendelenburg position to maintain adequate BP • e. Initiate IV access – consider large bore IVs for aggressive Tx with crystalloid solutions, bolus in 500 mL increments to maintain SBP of at least 90 mmHg • f. Consider vasopressors (dopamine) for pts not responsive to fluid boluses • g. Once infection successfully located or suspected consider IV antibiotics if available – some EMS agencies are beginning to carry drugs such as Rocephin

23. Keep in mind: Septic patients are prone to rapid deterioration, ALS providers should be utilized if available • rapid transport if airway compromise or inadequate respiration; registers V,P, or U on AVPU scale; unstable vitals or oral temperature > 100˚F