There is a 30-50% possibility that severe infection will develop into sepsis. For the Deployed Med, c this means that a minor laceration can turn into a severe infection and eventually sepsis. According to the National Centre for Health Statistics, the annual incidence of sepsis in the USA rose by 7–8% per year over a period of 8 years starting in 2008. For prehospital providers, sepsis is often neglected. We quickly gloss over sepsis during shock lectures when we discuss the five types of shock: Cardiogenic, Anaphylaxis, Septic, Hypovolaemic and Neurogenic. We use the mnemonic “CASHN” to remember them by. The topic of sepsis is not completely understood by the best ICU doctors and internists in hospitals. If they can’t figure it out, then those of us working in the cold and dark can only follow guidelines and best practice medicine to assess and treat our severely injured casualties.
Enter qSOFA assessment.Luckily, the new 2016 sepsis guidelines have improved our ability as Austere Medics to quickly assess potential sepsis causalities. The Quick Sepsis Organ Failure Assessment is a point-of-care mnemonic that may identify patients with suspected infection who are at greater risk for a poor outcome outside the intensive care unit. It uses three criteria:
- Systolic BP less than 100 mmHg
- Respiratory rate greater than 22 breaths per min
- Altered mental status
Additional assessment skills: There are some tricks to the trade that we can use whilst working in remote areas. We have the qSOFA tool close to hand but we can use other bits of our kit to provide a more fundamental understanding or our casualty.
Urinalysis dipstick to assess sepsis. According to Medscape, if you find protein in the casualties urinalysis there is a 60% chance that it is due to sepsis. Additionally, 64% of sepsis patients had a rise in serum creatinine above 0.3 mg/dL within the first 72 hours of admission.
Waveform pulse oximetry. The dicrotic notch indicates when the aortic valve closes. According to Deranged Physiology, a low dicrotic notch could mean very poor vascular resistance such as found in severe septic shock. Additionally, a narrow waveform indicates vasodilation which is also found in sepsis.
Sepsis Treatment. Treatment for sepsis has also improved with the new guidelines. To make the treatment simple for us prehospital providers to remember the College of Remote and Offshore Medicine have created the following mnemonic:
- Fluids 30 ml/kg in the first 3 hours. Crystalloid first, then maybe albumin. The goal is a MAP greater than 65mmHg.
- Lactate. attempt normalise the lactate levels. >4.0 mmol/L is associated with a 27% mortality rate. Lactate may indicate the presence of endogenous epinephrine which means that slightly elevated lactate levels could be a good thing.
- Antibiotics within 1 hour of the beginning of sepsis
- Sugar. bring glucose levels below 10mmol/L. Also, consider Bicarb if pH is 7.15-7.35. Keep sugar levels above 4mmol/L.
- Hydrocortisone 200mg for patients who are still unstable after fluids and/or blood transfusion
- Epinephrine. Norepinephrine is the first choice, add in epinephrine or vasopressin if needed. Do not use dopamine.
- Diarrhoea management. Sepsis patients will need to be cleaned and hydrated. Enhance your nursing skills.
Blood cultures should be taken before giving antibiotics but as CoROM focuses on the prehospital provider we have not included this requirement in our mnemonic. The same applies to oxygen where anyone with an SPO2 less than 94% will get that drug. Additionally, hypovolaemia should be ruled out.
In conclusion: There is little robust evidence addressing the impact of prehospital interventions on outcomes in sepsis. As medical professionals working in the remote and austere environments, it is up to us to keep pushing sepsis research forward and continue to provide evidence-based learning and training for our deployed medics. We have to provide ICU level of care at the point of injury.
Educate yourself. Keep learning. Your casualties deserve the best medic that you can be.