IPS:MD - Article Review - Sepsis Care
Dr. Sanford Littwin MD, MBA is the Medical Director for IPSPGH. This article review is provided by Dr. Littwin, and is the first of a new series of article reviews to be published on the IPS:Insights blog.
Article Information
Article Title:
Approaches in prehospital Sepsis Screening – Current methods used in prehospital setting for sepsis screenings and interventions were analyzed for this literature review
Article Link:
Article Authors: KJ Coulter, MF Hintzschel
Summary
A literature review of the screening tools used by different prehospital providers was evaluated for the “quick diagnosis” of sepsis. While these methodologies may be helpful, they generally lack specificity (and likely sensitivity) leading to miss diagnosis.
Sepsis is a life-threatening condition requiring prompt identification and interventions. Even slight delays in the diagnosis lead to increased mortality risk. As with many medical conditions that are often transported to hospitals by EMS providers; Prompt recognition of the symptoms and signs of sepsis is important in the prehospital setting to aid in the ability to act on the presumptive diagnosis and transport the patient towards facilities with the ability to care for sepsis.
The diagnosis of sepsis in the prehospital setting poses some complex challenges. Unlike some conditions with clear and immediate symptoms, sepsis can manifest with a wide range of clinical presentations from subtle changes in vital signs to severe organ dysfunction and patients having secondary issues due to the sequelae of the disease.
Key Takeaways
Clinical assessment by paramedics and EMTs rely on the evaluation of vital signs (such as heart rate, respiratory rate, and blood pressure), as well as looking for signs of infection like fever and localized tenderness. However, these methods can be subjective and have marked variability given variability in level of training (of the first line providers) and the frequency of encountering sepsis in the field.
In the article, the BAS 90-30-90 tool is one in which I believe could be quickly utilized in the prehospital setting. This is due to the fact that it is quick and easy to both teach, and perform in the prehospital setting.
The BAS scale utilizes 3 commonly collected vital signs to return a negative or positive result. Patients with a positive BAS result should be treated with a high suspicion of sepsis.
Blood Oxygen Saturation: Less than 90%
Respiratory Rate: Greater than 30 respirations per minute
Diastolic Blood Pressure: Less than 90 mmHg
While none of the scales available for use in the prehospital setting provide remarkable sensitivity and specificity, the BAS scale is quick and easy to remember for all level of EMS providers.
Our Thoughts
Early identification and interventions in sepsis are critical for improving patient outcomes. In the prehospital setting where time counts, tools need to be deployed to enhance sepsis screening. From clinical assessment to specified screening tools, and possibly, further technological advancements will yield improvements in patient outcomes. Continued research and development of a “gold standard” screening process will enhance the EMT and paramedic abilities on the front line of combating this potentially deadly condition even before the patient reaches the hospital doors.
Additionally, to improve sepsis identification for those on the front line of transporting these patients, several approaches could be explored:
Lactate Measurements:
Point-of-care, lactic testing is increasingly being used in the field. Elevated lactate levels can indicate tissue hypoxia, a common feature of sepsis. Measuring lactate levels can help identify patients at risk for sepsis before other more subjective signs become apparent.
Biomarkers:
Some Studies have investigated the use of biomarkers, such as procalcitonin, C-reactive protein (CRP), and interleukin-6 (IL-6) to aid in sepsis diagnosis. These biomarkers can provide valuable information about the inflammatory responses helping to distinguish sepsis from other conditions.
Machine Learning and Artificial Intelligence:
Emerging technologies, like machine learning, and AI are showing promise in the identification of medical conditions by analyzing a wide range of patient data. Through these modalities, the large array of data acquisition, and the identification of subtle patterns that can indicate conditions like sepsis are being evaluated.
Initiating appropriate interventions early in the prehospital phase is also crucial to improving patient conditions.
In the prehospital setting the interventions that EMTs and paramedics can utilize are:
Oxygen therapy:
Most septic patients require some type of supplemental oxygen therapy to maintain adequate blood-oxygen saturations. Although routinely used by prehospital providers in a multitude of settings, the specific algorithm of care of the septic patient would make this a mainstay in the treatment algorithm.
Fluid Resuscitation:
Intravenous fluids are administered to maintain adequate blood pressure and tissue perfusion. Early fluid resuscitation is a cornerstone in the management of sepsis.
Antibiotics:
If sepsis could be identified with a higher degree of specificity, starting broad-spectrum antibiotics to target specific infection could increase the effectiveness of these agents by virtue of earlier intervention (before the patient arrives at the hospital). Timely administration of antibiotics in the prehospital or hospital setting is another mainstay in the treatment of sepsis to halt its progression (and organ system damage).
Transport to appropriate facility:
Once sepsis is identified, and initial interventions are underway, patients are transported to appropriate healthcare facilities that have the resources to manage sepsis cases effectively.
Early identification and interventions in sepsis are critical for improving patient outcomes. In the prehospital setting where time counts, tools are being deployed to enhance sepsis screening. From clinical assessment to screening tools, and further technological advancements will all aid in improvements in patient outcomes. Continued research and development of a “gold standard” process will enhance the EMT and Paramedic abilities on the front line of combating this potentially deadly condition even before the patient reaches the hospital doors.
