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June 7, 2017
3 scenarios to train for diagnosis, treatment of sepsis
By Aaron Dix
EMS is dispatched to a local residence for a 20-year-old female with foot pain. Medics find the patient sitting in a recliner with her left foot supported by a pillow.
She spent the weekend at the beach and cut her foot on a piece of glass while walking in the ocean. Over the past several days her foot has become increasingly painful, and this morning she developed a fever that hasn’t responded to acetaminophen. She is conscious and alert but weak. Skin is pale, dry and hot. Heart rate 110, respiratory rate 24, blood pressure 100/60. An oral thermometer is not available.
Focused assessment of the patient’s foot reveals a one-inch laceration with no active bleeding that is red, swollen and painful. Swelling is present throughout the bottom of her foot and ankle. Since the patient does not appear to be in any acute distress, the medics suggest that she go to the local urgent care center in the morning and a refusal is obtained.
The next morning, medics are dispatched to the urgent care center for a transfer to the local hospital for hypotension. Upon arrival, the same medics find the above-mentioned patient with a blood pressure of 86/40 and a heart rate of 140. Tympanic temperature of 101.5 was obtained by the urgent care staff. The patient is urgently transported to the local emergency department. During transport, medics infuse 500 mL of normal saline per protocol for the management of medical hypotension.
At the emergency department, blood cultures are drawn, ibuprofen is administered for her fever, and she is admitted to the hospitalist service. Antibiotics for cellulitis from an infected wound are started once she is admitted. Her blood pressure continues to worsen throughout the night, and she is intubated and moved to the ICU. Despite blood pressure support and aggressive antibiotic treatment, the patient dies 24 hours after arriving at the hospital. The young patient in the above description died from septic shock secondary to her foot wound.
Sepsis is manageable with early diagnosis and treatment
A leading cause of death in the United States, sepsis carries a significantly higher mortality rate than both stroke and STEMI . But when identified and treated with antibiotics at the onset of symptoms, sepsis is manageable and survivable.
Early antibiotic treatment is associated with drastically improved outcomes, yet many EMS providers lack the training to readily recognize sepsis and septic shock. Mortality increases an estimated nine percent per hour when antibiotics are delayed after hypotension .
Unlike STEMI and stroke, sepsis recognition does not require a specific exam or new equipment. As a recent study demonstrated, effective EMS sepsis recognition only requires the provider to evaluate respiratory rate, heart rate, temperature and the possibility of an infection . Measuring lactate, while useful in determining the severity of sepsis, is not necessary in the recognition phase.
Simulation education for sepsis recognition
Simulation education can be useful in educating EMS providers, both basic and advanced, in both sepsis recognition and treatment. Here are four learning objectives to use or modify for an EMS sepsis training:
1. Discuss the SIRS criteria and how it relates to sepsis recognition.
Simulation tip: Some simulators have limitations and certain vital signs such as temperature and glucose will not be obtainable utilizing standard EMS equipment. The facilitator will need to provide the correct information when promoted by the participant’s actions, either verbally or through the simulator’s patient monitor. However, all high-fidelity simulators have the ability to provide respiratory rate, heart rate, blood pressure and lung sounds. Providers should be prompted to assess the simulator as a real patient and gather vital signs and history in real time.
Here are three simulation scenarios to use or modify for your EMS training program.
Scenario 1: Standard Sepsis
Facilitators should begin with a non-complicated scenario that easily demonstrates the signs and symptoms of sepsis. The debriefing should concentrate on ensuring that a proper assessment will yield all the necessary information a provider needs to determine sepsis: two or more SIRS criteria and a known or suspected infection. Two common causes of sepsis EMS providers are likely to encounter are pneumonia and urinary tract infections.
Overview: Crew arrives to find a 68-year-old male complaining of shortness of breath. His shortness of breath began after waking six hours earlier and is progressively getting worse. Since lunch he has been unable to ambulate without becoming significantly short of breath. He hasn’t been feeling great over the past several days and has had a productive cough that has occasionally awoken him from sleep.
History: HTN, previous MI (2002), hypothyroid
Medications: lisinopril, levothyroxine, warfarin
Patient weight/height: 180 pounds/5 feet, 11 inches
Vitals: HR is 130, BP is 106/60, RR is 26/min, SpO2 is 90 percent, glucose 250 mg/dl, temp 101.3 F, ETCO2 30 mm Hg with a normal waveform, and lung sounds are bilateral rhonchi.
Treatment should include oxygenation administration, fluid replacement, sepsis alert and antibiotic therapy if available.
Scenario 2: Differentiating sepsis/pneumonia from the flu
EMS providers must be capable of maintaining a high sensitivity for sepsis patients while limiting false positives. The flu can easily mimic pneumonia, making sepsis recognition more difficult. In this case, the rapid onset, non-productive cough and clear lung sounds make the argument for a flu diagnosis over pneumonia.
Overview: Crew arrives to find a 56-year-old female with sudden onset of high fever, general malaise and a non-productive cough. She woke this morning feeling normal. Her symptoms began suddenly right after lunch and worsened rapidly. She has a frequent non-productive cough, and her fever has not responded to acetaminophen.
History: hyperlipidemia and type 2 diabetes
Allergies: penicillin and naproxen
Medications: simvastatin and metformin
Patient weight/height: 120 pounds/5 feet, 6 inches
Vitals: HR is 100, BP is 118/70, RR is 20/min, SpO2 is 98 percent, glucose 140 mg/dl, temp 103.5 F, ETCO2 40 mm Hg with a normal waveform, and lung sounds are clear.
Scenario 3: Septic shock
Septic shock has a mortality rate near 50 percent and requires aggressive treatment. This case has two main objectives: aggressively treating septic shock and understanding that sepsis can occur in the presence of hypothermia. While approximately 80 percent of septic patients will show hyperthermia, temperature dysregulation, not fever, is the hallmark sign.
ETCO2 can also be discussed as an identifier of severe sepsis or septic shock. Decreases in ETCO2 correlate with elevated levels of lactate and increases in mortality.
Overview: EMS responds to a local nursing home for altered mental status. Patient is a 72-year-old male who was admitted to a skilled nursing facility for rehabilitation following a total hip replacement. Staff states he became altered this afternoon and was unable to ambulate this evening. He was admitted to the facility last night, and very little information is known.
History: hypertension, atrial-fibrillation, and type 2 diabetes
Medications: metformin, lisinopril, amiodarone and warfarin
Patient weight/height: 220 pounds and 5ft 9in
Vitals: HR is 150, BP is 84/50, RR is 22/min, O2 is 96 percent, glucose 280 mg/dl, temp 94.8 F, ETCO2 20 mm Hg with a normal waveform, and lung sounds are clear.
Additional info: Swollen and red surgical incision site on the right hip covered by the gown visible only if inspected.
Treatment: High volumes of normal saline, pressor support (norepinephrine preferred), sepsis alert and antibiotic therapy if available.
In conclusion, simulation training can improve the ability of both advanced and basic providers to diagnose and treat sepsis. Facilitators should concentrate on ensuring a comprehensive patient assessment to identify and treat patients who have a high probability of sepsis. Assess respiratory rate, heart rate, temperature and the possibility of an infection to make an accurate determination of sepsis. Faster recognition and treatment by EMS providers will lead to improved patient outcomes.
1. Cronshaw, 2011. Impact of surviving sepsis campaign on the recognition and management of severe sepsis in the emergency department: Are we failing? EMJ, Volume 12, pp. 296-327.
2. Kumar et al, 2006. Duration of hypotension before initiation of effective antimicrobial therapy is the determinant of survival in human septic shock. Critical Care Medicine, Volume 34, pp. 589-596.
3. Walchok et al, 2016. Paramedic-Initiated CMS Sepsis Core Measure Bundle Prior to Hospital Arrival: A Stepwise Approach, Prehospital Emergency Care, DOI: 10.1080/10903127.2016.1254694