RAPID FIELD INTERVENTION
Field units responding to possible septic emergencies
must be aware of qSOFA and utilize it when they find out the patient is
suspected of having any type of infection.
o
“Old-School”
medics and Emergency Medical Personnel have some false misconceptions concerning
sepsis that need to debunked:
o
“My patient
doesn’t have a fever” – Depending on where the patient is in the range of
sepsis the fever could possibly be high or your patient could be cold. Any
body temperature under 97.9 could indicate a much worse level of sepsis than a
higher temperature.
o
“My patient
doesn’t have diabetes so I will not check sugar levels” – Septic patients may
very well develop hyperglycemia due to factors such as, “insulin clearance is
increased leading to a reduction in insulin-mediated glucose uptake” (Mathonnet & Cariou, 2007, p. 16).
Levels above 140 should be taken very serious, especially
if the patient does not have a diabetic history.
CONSIDER
TREATMENTS
Depending on your level of certification, field
personnel should consider the following where local protocols allow:
Lactated Ringers over Normal Saline:
Normal Saline is basically
NACL in water (although for purposes of serum sodium, it neither adds nor
subtracts sodium, however Lactated Ringers is different:
Lactated Ringers normally is
made up of the following:
130 meq of sodium ion = 130 mmol/l
109 meq of chloride ion = 109 mmol/l
28 meq of lactate = 28 mmol/l
4 meq of potassium ion = 4 mmol/l
3 meq of calcium ion = 1.5 mmol/l
The important thing about Lactated Ringers is that its
lactate ions are involved with acid/base metabolism. Lactate being metabolized
in the (normal) will buffer acidosis. There
are different types of crystalloid fluids. Crystalloids such as lactated
ringers (LR) or PlasmaLyte are considered "balanced fluids," while
chloride-rich fluids such as normal saline (NS) are not.
Dr. Evan Schwarz, MD conducted
research on the use of LR vs NS and discovered the following:
A recent review cited several
studies associating NS infusions with the development of a hyperchloremic
metabolic acidosis, in addition to other findings of questionable clinical
importance. Recently, other studies demonstrated that NS leads to more adverse
events and worse patient outcomes compared with resuscitation with a balanced
fluid. A large retrospective cohort study compared patients undergoing either
elective or emergent open general surgical operations that received either NS
or a balanced fluid the day of the procedure. Unadjusted in-hospital mortality
(5.6% CI 5.3-5.8 versus 2.9% CI 2.0-4.2; P<0.001) and the number of patients
developing major complications (33.7 versus 23%) were significantly greater in
the group that received NS compared with the group that received balanced
crystalloids.
After using propensity scoring to
correct for multiple variables, the difference in mortality was no longer
significantly different; however, patients that received NS were 4.8 times more
likely to require dialysis (P<0.001). In addition, an analysis of patients
requiring emergent general surgery showed an adjusted odds of death nearly 50%
less in the cohort that received a balanced resuscitation compared with NS (OR
0.51 CI 0.28-0.95).(Schwarz, 2015)
While some articles and studies have suggested that the
use of LR makes no difference, with just one article that indicates it does
make a difference (even though there are tons that indicates LR is best) why
not err on the side of caution and use LR for the aggressive treatment of
Sepsis?
Rapid restoration of deficient fluid levels not only will
modulate inflammation if it exists but will in fact, reduce the need for drug
therapy (Levinson, Casserly, &
Levy, 2011).
In one study
performed on 263 patients there was a 16% mortality reduction in patients that
received rapid fluid resuscitation compared to those that did not.
Early-Goal-Directed Therapy
While this article is meant to focus on field
interventions of sepsis it should be mentioned about the importance of ‘Early
Goal-Directed Therapy.’ EGDT includes the
study mentioned previously where the patients received rapid fluid
resuscitation along with the monitoring of central venous pressure (CVP) and
central venous oxygen saturation (Scvo2).
Of the 263 patients in the group, those that received EGDT had an
overall 46.5% mortality reduction. Despite
clear and documented evidence of the effectiveness of EGDT it is still
underutilized and controversial (Levinson
et al., 2011).
Vasopressin
In some states, the use of Vasopressin is approved for
the use by Advanced EMTs, whereas other frontline medications for sepsis are
not, such as dopamine. Vasopressin is a
drug then when used correctly increases MAP (Mean Arterial Pressure) while at
the same time decrease catecholamine requirements.
The goal of using vasopressin is to improve tissue
perfusion and also to improve cellular derangements caused by any form of
sepsis and septic shock. While several
studies may lead to a possible belief that vasopressin, when used alone, has a
little effect on mortality rates, there are no studies that indicate it has a
negative effect when used. A logical
theory would be to use vasopressin in extreme cases due to the fact it is a treatment,
howbeit small, it is a treatment that could reduce mortality.
The use of vasopressin in combination with
corticosteroids showed a 44.7% less mortality rate than by not using
vasopressin. The use of just
norepinephrine and corticosteroids showed only a 35.9% lower mortality rate. (Gordon, 2014, p. 8)
Dopamine
Norepinephrine as a first
line vasopressor has been a long time recommendation, but also dopamine has
been recommended as well as a first line vasopressor. Whereas dopamine was used as the first line
medication, a slight increase in cardiac arrhythmias was reported (Levinson et al., 2011, p. 5). On most ambulances, dopamine is carried
routinely while other drugs used in the treatment for septic shock are not, so
dopamine may be the drug to utilize to extreme sepsis patients.
High Flow Oxygen
While considerations must be given to patients with severe
respiratory compromise, the use of high flow oxygen must be used when treating
patients with suspected sepsis. A target
of SpO2 of 95% must be utilized at all times.
The EMS worker must also understand that SpO2 devices are not always
presenting a true reading and what may appear normal, may indeed be false. High Flow O2 with a minimum of 10LPM must be
maintained in the patient that meets positive qSOFA criteria.
References
Schwarz, E. (2015). In sepsis,
fluid choice matters. Retrieved from
http://www.medpagetoday.com/Blogs/EPMonthly/51742
