Sepsis/Septic Shock

This is the protocol for Sepsis/Septic Shock:

Septic Shock

Let’s break it down!

The precise definition of sepsis is “life-threatening organ dysfunction due to a dysregulated host response to infection.”  Any time you have an infection in your body, whether it originates from an infected wound or a swimmer’s ear infection, you’re always at some degree of risk of developing sepsis.  Sepsis is just a way of saying that the localized infection you had has now spread to systemic proportions, affecting the blood and bodily organs.  If a soldier needs antibiotics for a bacterial infection and doesn’t receive them, then sepsis has the potential to occur.

To put in perspective just how lethal sepsis is, it accounts for 1 in 5 deaths globally and it’s the #1 most common cause of death in hospitals in the United States.  And yes, it can kill in as little as 4-6 hours without treatment.  In an austere environment with limited access to equipment, sepsis poses an incredibly dangerous threat to soldiers.

 

There are 4 progressive stages of sepsis, starting from least bad to most bad:

Stage 1: Systemic Inflammatory Response Syndrome (SIRS): Think of this as the “pre-cursor” for sepsis.  Having SIRS simply means that your body is battling an infection, whether it be large or small.  The test is designed to be very sensitive, without much specificity.  In other words, it may have a few false positives, but it’s not likely to ever miss a true case of pre-sepsis.  To satisfy SIRS criteria, you must 2 of the following:

  • Temp >38°C (100.4°F) or < 36°C (96.8°F)
  • Heart rate > 90
  • Respiratory rate > 20 or PaCO₂ < 32 mm Hg
  • WBC > 12,000/mm³, < 4,000/mm³, or > 10% bands

 

Stage 2: Sepsis: For a patient to be diagnosed with sepsis, they have to meet SIRS criteria AND have a confirmed or suspected source of infection.  For example, someone who just finished working out would likely meet SIRS criteria with a heart rate of 110 and respiratory rate of 25, but be denied a sepsis diagnosis unless you found that they had swollen lymph nodes or cellulitis.

Stage 3: Severe Sepsis: This would be Sepsis PLUS one more of the following:

  • End-organ dysfunction: This could be something affecting the brain like altered mental status or something wrong with the skin like mottling.
  • Hypotension: systolic blood pressure less than 90
  • Lactate > 4mmol: …..you know, in case you have lab capabilities on you

 

Stag 4: Septic Shock: This would be severe sepsis with continued hypotension DESPITE and initial fluid bolus. For more on the pathophysiology of septic shock, check out the video below:

Sepsis is caused by an excessive amount of proinflammatory cytokines which initially causes the same symptoms that you would find in any infection, like fever or chills. But when these cytokines spill into the bloodstream, they cause a systemic vasodilatory effect. In other words, all of the blood vessels in the body increase in diameter and become more permeable, leaking fluids into interstitial spaces. This results in hypotension (low blood pressure)

The body attempts to compensate for the lack of perfusion by increasing the heart rate (tachycardia). In addition, the patient may feel short of breath (dyspnea) as the body attempts to offload Co2 to compensate for the growing metabolic acidosis. Without treatment, the patient will eventually deteriorate into profound hypotension and may even develop an altered mental status. 

On occasion, a purpuric skin rash may appear, but this is typically only seen in meningitis patients who slide into sepsis.

The patient in the video below details her harrowing experience with sepsis:

 

Establishing IV or IO access is critical for sepsis patients because of our need to achieve a therapeutic effect from fluids or medications quickly.  Many of the medications in this protocol are best given intravenously.

Next, the patient needs aggressive antibiotic treatment. Sepsis is typically caused by bacterial agents, but there’s no way we’re going to be able to tell which particular pathogen is responsible for it while we’re out in the field. Therefore, we’re going to hit this thing with broad-spectrum antibiotics like Ertapenem and Ceftriaxone that can cover a lot of bugs. 

 

We know that these patients are going to be profoundly hypotensive, so crystalloid solutions like Normal Saline or Lactated Ringers are warranted. However, we have to be judicious with our fluid resuscitation. Septic shock isn’t caused by a lack of volume, it’s caused by vasodilation and leaky vessels. Therefore, any fluid we push into the patient will ultimately be pushed back out into the interstitial spaces after a short period. In addition, normal saline is slightly acidic, which doesn’t help an already acidotic patient. Be sure to only titrate to maintain BP > 90 or palpable radial pulse!

Epinephrine is one of many vasopressors used to help counter hypotension in sepsis. It works by constricting the dilated blood vessels, thus restoring normal blood pressure. Epinephrine is best administered the IV route, but we don’t want to give it in it’s normal 1:1,000 or 1:10,000 concentration via IV (that might hurt or kill them). Instead, we want to dilute it and create a 1:100,000 solution that only has a total of 100mcg instead of the full 1 mg. The video below shows how you can take your standard 1:10,000 bristojet epi and convert it into something we can use:

If epinephrine and fluids fail us, then we can resort to using Dexamethasone. The theory behind administering steroids like Dexamethasone is that by administering an anti-inflammatory, we can reduce the proinflammatory mediators inside the body and ultimately help the patient. It is not routinely recommended to administer steroids to septic patients, but it may be beneficial for those refractory to other treatment modalities.

It is common for patients in septic shock to become mentally altered. Like any patient with altered mental status, we have to be ready to manage their airway, which may include using an NPA, supraglottic airway, or even intubation.

ACLS Experienced Providers | American Heart Tallahasssee

Treating sepsis is considerably difficult. The mortality for sepsis patients ranges between 10-52%, even with intensive treatment, so an Urgent evacuation is warranted  These patients are likely to need aggressive resuscitation, long courses of antibiotics, and constant airway management. Recovery time for sepsis patients vary based on the extent of the infection and the quality of treatment, but most mild, uncomplicated cases will make a full recovery between 3-10 days. In patients with severe cases, about 50% of them will suffer from short/long-term cognitive and physical problems, otherwise known as “Post-Sepsis Syndrome”. 

 

Good luck out there!

 

References

Brandon Simpson, PA-C
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