#EmergencyInsights - Sepsis in the Field: A Practical Guide for EMS Professionals

How to Manage Sepsis in the Field

Sepsis is a critical medical condition resulting from the body’s extreme response to an infection. It can lead to tissue damage, organ failure, and death if not identified and treated promptly. Emergency Medical Services (EMS) professionals play a vital role in the early recognition and management of sepsis, which can significantly influence patient outcomes. This article provides a comprehensive guide for managing sepsis in prehospital settings, catering to seasoned EMS professionals and newcomers.

Understanding Sepsis

Sepsis occurs when the immune system’s response to infection goes into overdrive, causing widespread inflammation, blood clotting, and damage to blood vessels. This results in poor oxygen and nutrient delivery to tissues and organs, leading to potential organ dysfunction.

Common Causes of Sepsis

• Bacterial infections (e.g., pneumonia, urinary tract infections, and skin infections).

• Viral infections (e.g., COVID-19, influenza).

• Fungal infections (less common but significant in immunocompromised individuals).

Signs and Symptoms of Sepsis

Early recognition of sepsis is crucial in the prehospital setting. EMS providers should be vigilant for the following:

• Fever or hypothermia.

• Altered mental status (confusion, lethargy).

• Tachycardia (heart rate > 90 bpm).

• Hypotension (systolic blood pressure < 100 mmHg).

• Tachypnea (respiratory rate > 22 breaths per minute).

• Mottled skin or cyanosis.

• Decreased urine output.

EMS Assessment for Sepsis

A thorough assessment is critical for identifying potential sepsis cases.

Primary Survey

• Airway and Breathing: Ensure the airway is patent and assess respiratory effort. Patients with sepsis often present with tachypnea or dyspnea.

• Circulation: Check for signs of poor perfusion, such as hypotension, weak pulses, and capillary refill time > 2 seconds.

Secondary Survey

• History (SAMPLE): Look for recent infections, surgeries, or hospitalizations. Ask about symptoms like fever, chills, or malaise.

• Focused Assessment: Check for specific infection sources (e.g., lungs, urinary tract, skin).

Vital Signs and Monitoring

• Continuous monitoring of vital signs, including blood pressure, heart rate, respiratory rate, SpO₂, and temperature.

• Blood glucose levels should also be checked, as sepsis can cause hyperglycemia or hypoglycemia.

Sepsis Screening Tools

• qSOFA (Quick Sequential Organ Failure Assessment):

  • Altered mental status (GCS < 15).

  • Respiratory rate ≥ 22 breaths/min.

  • Systolic blood pressure ≤ 100 mmHg.

• Scoring ≥ 2 suggests a high risk of poor outcomes and may warrant aggressive management.

Field Management of Sepsis

Prehospital management focuses on stabilizing the patient, initiating sepsis-specific treatments, and preparing for rapid transport to an appropriate facility.

1. Airway and Breathing

• Administer supplemental oxygen to maintain SpO₂ ≥ 92% (≥ 88% for COPD patients).

• Be prepared to provide advanced airway management for patients with respiratory failure or decreased mental status.

2. Circulatory Support

• Intravenous (IV) or Intraosseous (IO) Access: Establish access as soon as possible.

• Fluid Resuscitation: Administer a bolus of isotonic crystalloid fluids (e.g., normal saline or lactated Ringer’s) at 30 mL/kg for hypotension or signs of hypoperfusion. Monitor closely for signs of fluid overload, especially in patients with cardiac or renal dysfunction.

• Monitor Perfusion: Regularly reassess blood pressure, mental status, and capillary refill to evaluate fluid therapy effectiveness.

3. Medication Administration

• While EMS providers typically do not administer antibiotics in the field, some systems allow prehospital initiation of broad-spectrum antibiotics for suspected sepsis under medical control guidance.

• Consider vasopressors (e.g., norepinephrine) if protocols permit and hypotension persists despite adequate fluid resuscitation.

4. Temperature Management

• Manage hyperthermia with passive cooling techniques.

• Prevent hypothermia in patients with cold environments or after fluid administration.

5. Rapid Transport

• Transport patients to the nearest appropriate facility with the capability for sepsis management, including access to critical care and infectious disease specialists.

• Provide advanced notification to the receiving facility detailing suspected sepsis and the patient’s clinical presentation.

Communication and Documentation

Thorough communication and documentation are critical for seamless handoffs and optimal patient care.

Key Information to Share:

• Suspected or confirmed infection source.

• Vital signs trends.

• Fluids administered (type and volume).

• Mental status changes.

Documentation Best Practices:

• Record all assessments, interventions, and the patient’s response.

• Note the time of symptom onset and any pertinent history.

Challenges in Sepsis Management

1. Differentiating Sepsis from Other Conditions

Sepsis can mimic other conditions like dehydration, heart failure, or an acute exacerbation of chronic diseases. A comprehensive assessment and understanding of patient history are vital to avoid misdiagnosis.

2. Limited Resources in the Field

EMS providers often operate with limited tools and time. Prioritize interventions that stabilize the patient and improve outcomes during transport.

3. Patient Noncompliance or Delayed Recognition

Some patients may minimize their symptoms, delaying EMS activation. Educate patients and their families about the signs of sepsis during interactions when appropriate.

Training and Protocols

EMS agencies should prioritize ongoing education and protocol development to enhance sepsis care.

1. Regular Training

• Provide training on the latest sepsis guidelines, assessment tools, and field management strategies.

• Use simulation scenarios to build confidence and competence in sepsis management.

2. Protocol Updates

• Ensure protocols align with the latest evidence-based practices, such as the Surviving Sepsis Campaign guidelines and the American College of Emergency Physicians (ACEP).

3. Quality Improvement Initiatives

• Implement quality assurance programs to review sepsis cases, identify areas for improvement, and celebrate successes.

Future Directions in EMS Sepsis Care

Advancements in technology and research are transforming prehospital sepsis management:

• Point-of-care testing: Devices to measure lactate levels or detect infection biomarkers may soon become standard in EMS.

• Telemedicine integration: Real-time communication with medical control can enhance decision-making for complex cases.

Conclusion

EMS providers are responsible for managing sepsis in the prehospital setting. Early recognition, prompt interventions, and effective communication can significantly improve patient outcomes. By staying informed about sepsis care advancements and committing to continuous education, EMS professionals—whether seasoned or new to the field—can profoundly impact their patients' lives.

References

1. Singer, M., Deutschman, C. S., Seymour, C. W., et al. (2016). The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA, 315(8), 801–810. doi:10.1001/jama.2016.0287

2. Surviving Sepsis Campaign. (2021). Guidelines on the Management of Sepsis and Septic Shock. Retrieved from https://www.sccm.org/SurvivingSepsisCampaign

3. American College of Emergency Physicians (ACEP). (2023). Sepsis in the Prehospital Setting: A Guide for EMS Providers. Retrieved from https://www.acep.org