FIRST IMPRESSIONS:
Sepsis in pre-hospital setting
Bob Zemple, MD
Fellow, Emergency Medical Services
Objectives
1. Identify important sepsis risk factors in
the pre-hospital setting.
2. Understand use and limitations of various
pre-hospital scoring systems to assess
risk of sepsis.
3. Review literature of pre-hospital
interventions and impact on in-hospital
morbidity and mortality.
Friendship
Health and
Rehab
Carilion Clinic
Patient Transport
North Roanoke
County Fire/Rescue
Roanoke Memorial
Friendship
Health and
Rehab
North Roanoke
County Fire/Rescue
~ 5 mins
Carilion Clinic
Patient Transport
Roanoke Memorial
Friendship
Health and
Rehab
North Roanoke
County Fire/Rescue
~15 minutes hot
~20 min cold
Carilion Clinic
Patient Transport
Roanoke Memorial
Friendship
Health and
Rehab
North Roanoke
County Fire/Rescue
~15 minutes hot
~20 min cold
Carilion Clinic
Patient Transport
Roanoke Memorial
Arrival
• Sickly appearing female
• VS: 100.3, BP 90/58, HR 120, RR 28, 94% RA
Arrival
• Sickly appearing female
• VS: 100.3, BP 90/58, HR 120, RR 28, 94% RA
• What to do on scene and during transport?
Interventions
• IV access
• Bolus NS
• POC lactate?
Interventions
• IV access
• Bolus NS
• POC lactate?
• Services near NRV
• Confounder if not careful
Importance of Field Recognition
WORLD SEPSIS DAY
September 13th, 2015
Problems with Field Recognition
Problems with Field Recognition
North American Quail
Problems with Field Recognition
Problems with Field Recognition
Harry Whittington, attorney
Problems with Field Recognition
Dick Cheney
Importance of Field Recognition
• Faster time to IVF[1,2,3]
• 34—52 minutes sooner, or halves time to treat
Importance of Field Recognition
• Faster time to IVF[1,2,3]
• 34—52 minutes sooner, or halves time to treat
• Faster time to antibiotics[1,2,3]
• 62—68 minutes sooner, or halves time to treat
Importance of Field Recognition
• Faster time to IVF[1,2,3]
• 34—52 minutes sooner, or halves time to treat
• Faster time to antibiotics[1,2,3]
• 62—68 minutes sooner, or halves time to treat
• Statute of care for sepsis[4,5]
• Lacks uniformity in pre-hospital world
Importance of Field Recognition
• Remains low rate of initiation of IV
access/fluids
Importance of Field Recognition
• Remains low rate of initiation of IV
access/fluids
• University of Colorado[6]
• 40% severe sepsis hospitalizations by EMS
• Prolonged on-scene time, ~35 minutes
• Only 37% had IV Access
• Inability vs misidentification
Recognition Ability
• Prehospital Sepsis Clinical Project[7]
• Study emailed to EMS list serves
• 15-items, 4 clinical scenarios
Recognition Ability
• Prehospital Sepsis Clinical Project[7]
• Study emailed to EMS list serves
• 15-items, 4 clinical scenarios
• Results
• 47.7% understood differences SIRS/SEPSIS
Recognition Ability
• Prehospital Sepsis Clinical Project[7]
• Study emailed to EMS list serves
• 15-items, 4 clinical scenarios
• Results
• 47.7% understood differences SIRS/SEPSIS
• 9.8% answered all questions/scenarios correctly
Recognition Ability
• Prehospital Sepsis Clinical Project[7]
• Study emailed to EMS list serves
• 15-items, 4 clinical scenarios
• Results
• 47.7% understood differences SIRS/SEPSIS
• 9.8% answered all questions/scenarios correctly
• 64.4% understand usefulness of lactate
Recognition Ability
TAKE HOME
Recognition Ability
• Prehospital Sepsis Clinical Project[7]
• Study emailed to EMS list serves
• 15-items, 4 clinical scenarios
• Results
• 47.7% understood differences SIRS/SEPSIS
• 9.8% answered all questions/scenarios correctly
• 64.4% understand usefulness of lactate
• 97.3% open to web based learning
Our Training
• Varies by service
• LifeGuard specific lectures
• Christiansburg Rescue
• POC lactates and protocol
How to identify?
• Work in progress
• Scattered literature for screening tools
Prehospital recognition of severe
sepsis: development and validation of a
novel EMS screening tool[8]
• Amer Jour of EM, 4/2015
• Retrospective cohort
• Single EMS system, urban/public hospital
Prehospital recognition of severe
sepsis: development and validation of a
novel EMS screening tool[8]
• Amer Jour of EM, 4/2015
• Retrospective cohort
• Single EMS system, urban/public hospital
• ID pt at risk
• HR >90, RR >20, SBP <110
Prehospital recognition of severe
sepsis: development and validation of a
novel EMS screening tool[8]
• Amer Jour of EM, 4/2015
• Retrospective cohort
• Single EMS system, urban/public hospital
• ID pt at risk
• HR >90, RR >20, SBP <110
• ~SIRS: w/o WBC/Temp, + SBP
Prehospital recognition of severe
sepsis: development and validation of a
novel EMS screening tool[8]
• Amer Jour of EM, 4/2015
• Retrospective cohort
• Single EMS system, urban/public hospital
• ID pt at risk
• HR >90, RR >20, SBP <110
• ~SIRS: w/o WBC/Temp, + SBP
• Validation: hospital diagnoses sepsis, severe
sepsis, septic shock <48 hours of arrival
Prehospital recognition of severe
sepsis: development and validation of a
novel EMS screening tool[9]
• EMS Transport Characteristics
• Chief concern
• Transport from location
Prehospital recognition of severe
sepsis: development and validation of a
novel EMS screening tool[8]
• EMS Transport Characteristics
• Chief concern
• Transport from location
• EMS Vital Signs
Prehospital recognition of severe
sepsis: development and validation of a
novel EMS screening tool[8]
• EMS Transport Characteristics
• Chief concern
• Transport from location
• EMS Vital Signs
• Abnormal tactile temp
• SBP, HR, O2 sats
• Multivariate Analysis
(Friendship Health and Rehab)
(Friendship Health and Rehab)
(67)
(Friendship Health and Rehab)
(67)
(90)
(Friendship Health and Rehab)
(67)
(90)
13 Points
Prehospital recognition of severe
sepsis: development and validation of a
novel EMS screening tool[8]
Take home
• Interesting tool to use in field following
screening assessment (HR >90, RR >20, SBP
<110) to better identify septic patients
• Elements of EMS page and field impression
significant for risk assessment of sepsis
Choosing the Right Tool
Choosing the Right Tool
• Pt presents with recent use of
ayahuasca….
Choosing the Right Tool
• Pt presents with recent use of
ayahuasca….
• You have no idea what this is.
Choosing the Right Tool
• Pt presents with recent use of
ayahuasca….
• You have no idea what this is.
• Choose the right tool.
Ayahuasca?
Ayahuasca?
Ayahuasca?
Snoop
Dogg?
Ayahuasca?
Snoop
Dogg?
Ayahuasca?
ED PHARMACISTS!!
Kelly McAllister / Lisa Deal
• MAO inhibiting
alkaloid plant
• Hallucinogen
Ayahuasca?
Snoop
Dogg?
Ayahuasca?
Snoop
Dogg?
Choosing the Right Tool
• “Mr. Zemple—I would like to take your
daughter to the middle school dance”
Creeper to date daughter
Creeper to date daughter
Creeper to date daughter
Creeper to date daughter
Creeper to date daughter
Early detection and treatment of patients with
severe sepsis by prehospital personnel[9]
• Study of out Centura Health, Denver, CO
• Journal of Emergency Medicine
• Developed sepsis screening protocol for
identification in the field
• ALSO reviewed false positive/negative alerts
(trained personnel transported 67/112 EMS pts with severe sepsis)
Early detection and treatment of patients with
severe sepsis by prehospital personnel[9]
Take Home
• Clinical impressions difficult to ID sepsis
• Scoring systems leave room for improvement
• False positives/negatives matter!
Arrival to RMH
• En route
• Continued IVF, ECG, alerted concerns of
sepsis
• What effect does this have on outcomes?
Prehospital intravenous access and fluid
resuscitation in severe sepsis: an
observational cohort study[9]
• Journal of Critical Care, 2014
• Retrospective data
• 45,394 pts from 15 different hospital systems
• 1,350 met criterion
• Medium of IVF 500 mL
Prehospital intravenous access and fluid
resuscitation in severe sepsis: an
observational cohort study[9]
Take Home
• Earlier IV access and fluids reduce hospital
morbidity and mortality
• Raises questions as to relevance of transport
time
Our Areas of Improvement
Pick-up Quick 6
1.
2.
3.
4.
5.
6.
Recent hospitalization
Recent antibiotics
Exposure to other sick patients
VS over last 24 hours
Current medication regimen
Direct number of provider caring for patient
Our Areas of Improvement
• Better tools for recognition
• POC lactate?
• More thorough protocols for services with
prolonged transport
• Radio training
• Field sepsis warning
Thank You
Resources
1.
2.
3.
4.
5.
6.
7.
8.
9.
Band, RA et al. Arriving by Emergency Medical Services Improves Time to Treatment
Endpoints for Patients with Severe Sepsis or Septic Shock. Academic Emergency Medicine.
2011; 18:934-940.
Studnek, JR et al. The impact of emergency medical services on the ED care of severe sepsis.
Am Jour of Emer Med. 2012. 30, 51-56.
Wallgren, UM et al. Identification of adult septic patients in the hospital setting: a comparison of
two screening tools and clinical judgment. Euro J of Em Med. 2013.
Fitzpatrick. Improving the management and care of people with sepsis. Art & Science: Serious
Infection.
Sterling, SA et al. Prehospital treatment of sepsis: what really makes the “golden hour” golden?
Critical Care. 2014, 18:697
Editorial. Has the Time for Advanced Pre-Hospital Care of Severe Sepsis Finally Arrived? Am J
of Resp and CC med. 2012, vol 186.
Baez, AA et al. Prehospital sepsis project (PSP): Knowledge and attitudes of the United States
advanced out-of-hospital providers. Prehospital and Disaster Medicine. Vol 28, No. 2.
Polito, CC et al. Prehospital recognition of severe sepsis: development and validation of a novel
emergency medical services screening tool. Am J of Emerg Med (2015),
http://dx.doi.org/10/1016/j.ajem.2015.04.024
Seymour, CW et al. Prehospital intravenous access and fluid resuscitation in severe sepsis: an
observation cohort study. Critical Care 2014, 18:533