Tuesday, March 14, 2017
Friday, March 10, 2017
Just One of Many Sad Stories
Your patient has called 911 because they feel
so badly they can’t even imagine going to the hospital on their own. Diagnosed with a urinary tract infection five
days ago and prescribed Ciprofloxacin, the patient returned home and began
taking their medications. Each time the
patient would take the medication she would experience vomiting. Now, four days later, the patient is
exhausted, and tired of just getting increasingly sick as each hour
passes. She calls 911.
 |
| English: A paramedic preparing a intra-venous infusion for a patient (Photo credit: Wikipedia) |
The
911 system screens the call and once the patient indicates she is just sick and
wants someone to take her to the hospital, the EMD system generates the call as
an Alpha, non-emergency response because the patient is conscious and
alert. EMS is activated and checks
en route.
The
patient’s house is in a very rural, country setting and EMS arrives 19 minutes
later. The patient presents as conscious, alert
and oriented. She is cool to the
touch. She says she doesn’t know why she
is cool because she was burning up all night.
Her heart rate is about 133 beats per minute, and her BP is 90/60. The patient is able to walk down the front
steps of the residence to the ambulance after a 20 minute on-scene time. The patient did receive a fluid bolus on the
way to the hospital of normal saline due to the decrease in blood
pressure. After a non-emergency
transport, she arrives at the emergency department 25 minutes later and patient
care is transferred over and EMS personnel leaves. The patient is dead seven hours later from
decompensated septic shock. \
Most
EMS providers would have suspected flu, or possibly an intolerance to the
antibiotics, or some type of virus on this patient and the call would have been
handled in a routine manner just as the emergency department handled it, at the
cost of the patient who has now passed away.
Benchmarks
could have easily been used to determine the patient’s level of sickness within
the first ten minutes of being on scene.
Why are so many patients with sepsis overlooked? Why do so many people die aimlessly from
sepsis each year?
Field Interventions
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
The goal of any vasopressor therapy is to improve the
perfusion of tissue and cellular derangements that is normally caused by septic
shock (Levinson, Casserly, &
Levy, 2011, p. 5).
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
Capnography
For years functional assessment of athletes’ fitness levels has included the assessment of serum levels and lactate levels for many different types of athletics. These levels are an indication of the degree of metabolic levels which are an indication of possible physiological wear on the cell. Normally these levels can be and are checked using capnography.
When we understand that serum lactate levels are a prime indicator of possible sepsis in the patient with suspected infections then we can understand that the use of capnography is a perfect way of identifying the possible severity of sepsis.
Capnography has been used for a long period of time in the EMS field. The measurement of exhaled end-tidal carbon dioxide (EtCO2) is a mandatory measurement tool for every cardiac arrest call the EMS personnel will run.
Abnormal levels of EtCO2 may indicate a derangement in perfusion, metabolism and/or gas exchange. Capnography, the waveform measurement of exhaled end-tidal carbon dioxide (EtCO2), is a well-known tool in EMS. EtCO2 is a continuous variable determined by basal metabolic rate, cardiac output, and ventilation. Thus, abnormal levels may reflect derangement in perfusion, metabolism or gas exchange. EtCO2 levels decline in the setting of both poor perfusion and metabolic acidosis. To compensate for metabolic acidosis, patients increase their minute ventilation. This increased respiratory rate “blows off” carbon dioxide and lowers EtCO2. At the same time, poor tissue perfusion decreases the amount of blood flow to the alveoli of the lungs, reducing the amount of carbon dioxide that can be exhaled—the most dramatic demonstration of this process is during cardiac arrest. Therefore, EtCO2 is inversely proportional to lactate: As lactate levels rise in septic patients, EtCO2 levels drop. (Hunter, 2014, p. 2)
In patients with suspected sepsis, any capnography reading of less than < 24 mmHg should be considered severe sepsis and possible septic shock. Furthermore, capnography can be monitored to assess the impact of therapies designed to improve perfusion.
Hunter, C. (2014, March 3 ). Use end-tidal carbon dioxide to diagnose sepsis. Journal of Emergency Medical Services, 1-5.
International Consensus on Sepsis
In February 2016, findings were published in The Journal of the American Medical Association after a task force with expertise in sepsis pathobiology, clinical trials, and epidemiology came together to study current sepsis information. The task force was formed by the Society of Critical Care Medicine and the European society of Intensive Care Medicine (Angus & Singer, 2016, p. 801).
Definitions and clinical criteria were reevaluated and assessed and then finally a lot of septic issues were rewritten or made increasingly clear.
Key Findings of the Taskforce are:
· It is now misleading to excessively focus on inflammation when dealing with sepsis.
· It is now misleading to depend on the SIRS criteria models.
· Many of the current sepsis definitions were found to be redundant and it was recommended they not be used any longer. i.e., ‘Severe Sepsis’
Understanding sepsis more in depth requires one to understand that sepsis is a syndrome of biochemical abnormalities, pathologic and physiological abnormalities that is induced by infection. In the United States alone sepsis accounted for more than $20 Billion in total US hospital costs in 2011 (Angus & Singer, 2016).
Sepsis is now the leading cause of death in the hospitalized patient (Deutschman & Tracey, 2014, p. 463). Sepsis now has over 1,000,000 new cases annually within the United States, and unlike most illnesses, it has up to a 50% mortality rate (Deutschman & Tracey, 2014)
There is no specific treatment for sepsis, no specific medications for sepsis and sepsis drains billions from society due to the patient having to spend weeks and sometimes months with hospitalization. There is no specific patient with sepsis, it spans across all age groups, nationalities, genders, etc.
Thursday, March 9, 2017
qSOFA vs. SIRS
One tool that has been used for years in the identification of sepsis is ‘SIRS’. SIRS is defined as, ‘Systematic Inflammatory Response Syndrome’. SIRS Criteria was created to define a clinical response to an infection or noninfectious origin. SIRS Criteria guidelines were used to help identify possible sepsis.
The problem though, “sepsis is now recognized to involve early activation of both pro- and anti- inflammatory responses and it is this that makes it difficult to use SIRS Criteria. Also, SIRS criteria (Heart rate, body temperature, respiratory rate, white blood cell count) can be present in patients that will have no infection present at all, thus the use of SIRS Criteria should be limited (Angus & Singer, 2016).
qSOFA SCALE
SOFA (Sequential Organ Failure Assessment) score has been widely used to track a patient’s health while hospitalized in intensive care units. SOFA is merely a scoring system that when used, will determine how severe a patient will be and what the patient’s extent of organ failure and damage they may have. SOFA is not used to manage a patient while they are hospitalized but rather to clinically characterize the patient as a whole.
While SOFA is used for hospitalized patients, qSOFA has been created to characterize the patient in the field.
qSOFA (quick Sequential Organ Failure Assessment) was introduced by the Consensus Group in February 2016. It is now recommended that SIRS and MODS criteria no longer be used, but rather implement a much simpler and quick assessment tool called qSOFA.
To formulate a score from qSOFA one must score positive for the following 3 criteria after it has been determined the patient has or possibly has an infection:
· New/Worsened Altered Mentation
· Respiratory Rate Greater than 22
· Systolic BP Less or Equal to 100
If the patient has a positive qSOFA score then field personnel must implement critical and urgent care for the patient utilizing rapid fluid challenge and the implementation of vasopressors if necessary.
Modern Sepsis Review
When
it comes to Sepsis, EMS providers must go against most training that says,
“treat your patient and not your monitor”.
When dealing with patients with a recent infection, fracture or a
history of similar conditions and are currently showing signs of sepsis, appropriate
and timely recognition of sepsis is the key to turning a medical condition with
a current mortality rate of approximately 50%, into a call where lives are
truly saved and leave people leading independent, normal lives in the aftermath. While possible septic patients may present
with being conscious, and alert enough to have the 911 EMD System generate the
call as a ‘Sickness’ with an “Alpha” determinate where the responder responds non-emergency,
the patient may very well be entering a state of shock that they will never
survive. Unless the patient is evaluated
correctly with the use of qSOFA and capnography (Etco2) and appropriate
treatment given, the chances of survival is minimal. Sepsis is responsible for the deaths of
nearly 20 Million people around the world each year. Sepsis is one of the most highly misdiagnosed
medical conditions in modern medicine and a condition with one of the highest
mortality rates even when it is diagnosed correctly. With quick field recognition, correct
screening and treatment combined with rapid transportation, we can reduce
mortality rates substantially.
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