Sepsis: Six Things You Need to Know to Save Lives

By Frances Hall

It’s 2 am and you’ve just shut your eyes when the tones go off again: a 22-year-old female with foot pain. “My feet hurt, too,” your partner mutters. The patient’s right ankle has a deep cut that’s swollen and oozing. She has a blood pressure of 110/70, a heart rate of 108, and is mildly febrile at 99.8. Your partner tells you that she’s breathing 16 times a minute but you’re not sure that he actually counted. She seems kind of wilted and tired, but it is the middle of the night. She refuses the ambulance transport. You offer to help her walk to her boyfriend’s car and she declines again. “I’ll go to the urgent care when it opens in the morning.” Fine. You collect a refusal signature. Your general impression and chief complaint are the same: foot pain.

Sepsis is a rare complaint where every minute counts. It’s common, accounting for between 1% and 8% of all 9-1-1 calls. It affects a huge and variable population annually, including previously healthy people.^{1, 2} It’s deadlier than strokes and heart attacks, with mortality for patients with severe sepsis at about 20% to 50%.³ Sepsis occurs when a once local infection has spread throughout the body and the immune response is now doing more harm than good.⁴

Here’s how to help these patients, in six steps:

1. Appreciate the Importance of Prehospital Sepsis Recognition

It’s normal to feel your attention wander over as someone teaching sepsis continues to use words like “cytokines” and “suppressed fibronolysis.” While a casual understanding of the underlying process is fine, there’s a crucial reason to have a

thorough grasp of the signs and symptoms of this disorder: Many patients with serious sepsis will often have their first contact with the medical system via EMS. Studies suggest that as many as half of patients ultimately diagnosed with severe sepsis weren’t assessed or treated until they called 9-1-1 for their symptoms.³ Another study found that 25% of children with severe sepsis first presented via ambulance.⁵

If we know sepsis backwards and forwards, we have the chance to aid the survival of hundreds of patients over the course of a career.

2. Accept That Sepsis Scales Can’t Save You

Sepsis definitions, like sepsis presentations, vary greatly. Individuals have an infection they may not know about or be able to report. Patients with serious sepsis are in shock, so they tend to have a fast heart rate, fast breathing, low blood pressure and low end tidal capnography. These patients can also have an abnormally high blood sugar. However, these signs can be obscured or entirely absent due to medications, medical history, or just random chance.

Sepsis patients tend to have temperatures above 100.5, unless they are among a minority suffering from what is informally known as “cold sepsis” and have a temperature below 97 instead. They can be altered and weak or alert and strong.⁶

Some of the brightest minds in medicine have tried to make a scale that will help healthcare providers ferret out the patient suffering from severe sepsis from all of the other patients who are weak or short of breath or dizzy for less urgent reasons. Unfortunately, studies suggest that none of these scales work as intended.⁷ These scales are certainly worth reading and can be used as a means of learning about sets of symptoms that should prompt consideration of this diagnosis but should never be relied upon as a rule-out.⁸

3. Use End-Tidal Capnography on Patients With Vague Complaints

End-tidal capnography is a noninvasive real-time measurement of how well your patient is perfusing. The body takes in oxygen, sugar and water through ingestion and inhaling and produces, among other things, carbon dioxide, which it gets rid of by exhaling. A normal EtCO₂ reading is between 35 and 45. So if your patient has a much lower EtCO2, you need to ask yourself what part of this process isn’t working.²

Furthermore, an EtCO₂ of under 25 is both associated with a sepsis diagnosis and with patient mortality.⁹ Measure end tidal on patients who are complaining of general weakness, altered mental status, shortness of breath, abnormal vitals, dizziness, or any other situation where you’re on the fence about sick or not sick. An abnormally low end-tidal can greatly inform your clinical decision-making and, if it helps you identify sepsis in the field, save a life.

4. Consider and Ask About Common Sources of Infection

Successfully identifying sepsis often hinges on one crucial piece of information: the original source of the infection. Patients calling 9-1-1 for shortness of breath may not know to mention the wisdom tooth surgery they had three days ago. Providers need to ask about any wounds, pain, or other irritation from common sources. Here are two acronyms to consider using to help you remember common infection sources:

FEBRILE

• F foreign bodies
• E epidermis
• B brain
• R renal
• I intestinal
• L lungs
• E empty spaces

LUCAS

• L lungs
• U urine
• C CNS
• A abdominal
• S skin¹⁰

It’s important to remember that an infection can make a home just about anywhere. A patient can have a septic tooth, heart lining, spinal cord, bone, or any other organ. I find it helpful to just ask patients with suspected sepsis if they are experiencing pain anywhere at all.⁵

Finally, the absence of a known or suspected source of infection can’t rule out sepsis as a consideration. Up to 11% of sepsis patients in ICUs have “occult sepsis,” or sepsis where the source of infection is never discovered.⁴

5. Insist on Transport Via Ambulance to the Closest Facility

You’ve successfully identified sepsis in the prehospital setting. Like our major trauma patients, these patients need rapid transport. These patients need immediate IV antibiotics that they can only get in hospital. Numbers vary slightly, but once a septic patient is hypotensive their odds of surviving this illness decrease by 7% for every additional hour it takes for them to get those antibiotics.³

These patients should arrive in an ambulance. For reasons that are not entirely clear, patients with sepsis who are brought to the hospital in an ambulance received antibiotics 35 minutes earlier and are given more appropriate triage designations than their equally sick counterparts who travel in a personal vehicle.^{1, 11, 12}

6. Use Your Words

Once you’ve identified a septic patient, you can do a simple magic trick to save their life: patients get the treatment they need to survive sooner if you use the word “sepsis” in a hand-off report. Say, “we think this patient has sepsis.” If you’re correct, your patient will receive antibiotics a whopping 52 minutes earlier than patients who do not get this introduction into the ER. In an illness where every minute counts, accelerating treatment by almost an hour is huge.¹³

Case Study Conclusion

You’re called to the local urgent care the next morning. Female, 22, hypotension at 76. It’s the same woman as last night but this time it’s bad: heart rate of 156, respiratory rate in the 30s, temperature of 103, blood sugar of 320, skin that looks grey. She’s listless and doesn’t seem to recognize you. She gets two lines, fluid boluses, norepinephrine when those fail, oxygen, and a lights and sirens trip to the hospital. But none of that prevented her demise seven days later in the ICU.

But there’s an alternate version of this story: Last night, through a haze of exhaustion, you personally counted a respiratory rate and found it to be 24 times per minute. You took a blood glucose, 188, and an end tidal, 24. You argued with her for the 14 minutes it took for her to agree to take an ambulance ride to the ER, right now.

You made weary eye contact with the receiving nurse. “Sepsis. She has sepsis,” you say.

The nurse looked back at you, clearly concerned. “Honey, I know that. And I heard you the first six times.”

You returned to quarters, sleeping soundly with the knowledge that no matter what happens now the care you provided was perfect.

Take Home Points:

• Sepsis identification is a crucial EMS skill.
• Sepsis can present with a huge variety of symptoms
• Use LUCAS and FEBRILE to remember to ask about possible sources of infection
• Utilize capnography with any patient with a vague complaint or unclear triage status
• Once sepsis is suspected, transport via ambulance to the closest facility providing early notification whenever possible
• Use the word “sepsis” in your hand off report to the receiving facility

References