Possible Sepsis

[Handsome Robb]

Learn something new every day. I've always been told ketamine was very hemodynamically stable however I do remember reading to avoid ketamine in septic patients but I didn't see a rationale as to why.

As far as arresting on induction would it generally be secondary to the medications used? Vasovagal response from direct laryngoscopy? Decreased preload from increased intrathoracic pressure? A combination of the any or all of the above? Something I'm missing completely?

I need to get ahold of an anesthesia text.

 

[KellyBracket]

The RR might be high due to acidosis, even if the SaO2 is normal. If the patient is acidotic, BTW, laying the patient flat, let alone Trendelenburg/shock position, will impair ventilation. Head of bed 30 degrees is probably your best bet.

While the literature on the benefit of crystalloids in trauma is mixed, at best, it's a lot clearer about the benefits of IV fluids in sepsis. Grab a wide-bore IV.

 

[Rialaigh]

I agree with most of what has been said already. Two large bore IV's, lots of fluid, Im probably starting neo off the bat on this patient if sepsis is suspected immediately. However I am under no circumstances transporting this patient by air, and most likely not transporting code 3. If sepsis is strongly suspected then there is nothing that will be changed by getting to the hospital 30 minutes or an hour later than normal (Assuming you can start pressors and fluids). Especially given the scenario at hand, I would venture to say the survival rate (depending upon age and past medical history) based on the vitals given assuming sepsis is pretty poor. patients that have that severe of hypotension with respiratory failure already are not very likely to survive regardless of what support they receive in the hospital.

 

[Carlos Danger]

As far as arresting on induction would it generally be secondary to the medications used? Vasovagal response from direct laryngoscopy? Decreased preload from increased intrathoracic pressure? A combination of the any or all of the above? Something I'm missing completely?

Combination of everything, but mostly just a result of the general depressant effects of most of the IV anesthetics. They pretty much all cause loss of SNS tone, and some have direct vasodilatory and/or myocardial depressant effects. That's not usually an issue with healthy patients, but someone who is severely septic or otherwise critically ill needs all the CO they have. A little neo given at induction can be a huge help.

The RR might be high due to acidosis, even if the SaO2 is normal.

The likelihood of severe acidosis may be another reason to delay intubation if at all possible. I have heard of cases of severe metabolic acidosis worsening rapidly and causing arrest when patients like this are intubated. Theory being that if the patient is very tachypneic due to severe acidosis, you will not be able to match their minute volume with a BVETT or transport ventilator, and their acidosis can worsen dramatically as soon as you lower their minute volume.

Have you ever seen anything like that, Dr. Walsh?

I'm not saying we should not provide airway management to someone who clearly needs it. I'm just pointing out some considerations that I think most of us weren't taught in our paramedic programs. At the end of the day, all we can do is follow our protocols and use the meds we have, to the best of our ability.

 

[KellyBracket]

.. If sepsis is strongly suspected then there is nothing that will be changed by getting to the hospital 30 minutes or an hour later than normal ...

This patient needs antibiotics and control of the infectious nidus ASAP. While I wouldn't recommend blowing through red lights at warp speed, they need critical care services emergently.

Although STEMI, stroke, and trauma are seen as the "big emergencies," sepsis is where big differences in mortality can be achieved. Although diesel is not a medicine, there is no reason to accept delays in treatment and transport.

... if the patient is very tachypneic due to severe acidosis, you will not be able to match their minute volume with a BVETT or transport ventilator, and their acidosis can worsen dramatically as soon as you lower their minute volume.

Have you ever seen anything like that, Dr. Walsh?
...

I certainly agree with the principle. We worry about that mostly in bad aspirin overdoses (where even a brief dip in ventilation during intubation can spike the acidosis, and cause cerebral ASA toxicity) or in asthma (where it can be hard to match a young persons ventilatory drive with a machine.

 

[Rialaigh]

This patient needs antibiotics and control of the infectious nidus ASAP. While I wouldn't recommend blowing through red lights at warp speed, they need critical care services emergently.

Although STEMI, stroke, and trauma are seen as the "big emergencies," sepsis is where big differences in mortality can be achieved. Although diesel is not a medicine, there is no reason to accept delays in treatment and transport.



I certainly agree with the principle. We worry about that mostly in bad aspirin overdoses (where even a brief dip in ventilation during intubation can spike the acidosis, and cause cerebral ASA toxicity) or in asthma (where it can be hard to match a young persons ventilatory drive with a machine.

my point was based on the scenario given (obviously age dependent still) I think you would be hard pressed to find a critical care doctor that would advise flying this patient to save anything less than an hour. If the sepsis is this bad already the mortality rate is really really high even with excellent supporting care, a helicopter ride or antibiotics in the field will do nothing to change that.



I do agree that EARLY recognition of sepsis would be a huge game changer in the mortality rates. Many many lives could be saved with minimal long term damage if sepsis was recognized early and treated prior to hypotension requiring pressors.

 

[KellyBracket]

The helicopter issue is whole 'nother ball of wax. I'll defer to local guidelines, resources, etc., when it comes to answering if a particular should be flown. Choppers are expensive, dangerous, and often of marginal benefit. I think many of us agree on these broad principles.

That being said, if local guidelines allow or dictate flying certain trauma or STEMI patients, then this patient also should qualify. The mortality is high in hypotensive sepsis patients, but it is precisely these sorts of patients that benefit from rapid intervention. Certainly, there is a far greater chance to improve mortality than is seen with, say, fibrinolytics for acute CVA.

I actually think most CC physicians would choose HEMS for this patient to save an hour. Give me 30 minutes, I'll check with one!

 

[TransportJockey]

If I picked up this patient from the far south end of my county (or the north end of the next county that we run in since we are closer than their EMS) I would fly them. I'd be looking at almsot two hours with the patient to ANY hospital from that area of the county

 

[Carlos Danger]

my point was based on the scenario given (obviously age dependent still) I think you would be hard pressed to find a critical care doctor that would advise flying this patient to save anything less than an hour. If the sepsis is this bad already the mortality rate is really really high even with excellent supporting care, a helicopter ride or antibiotics in the field will do nothing to change that.



I do agree that EARLY recognition of sepsis would be a huge game changer in the mortality rates. Many many lives could be saved with minimal long term damage if sepsis was recognized early and treated prior to hypotension requiring pressors.

Maybe when it comes to someone truly circling the drain, you've reached a point where nothing that you do is going to help, so why bother with anything at all?

But in general, septic shock patients are some of the sickest people who still have a decent chance to make a full recovery, and even though there may be no magic "door to ___" time like there is with trauma, STEMI, AA, and stroke patients, the right care by the right docs and nurses definitely can make a big difference in these patients. That's why they are generally all transferred to a tertiary facility, and quite often by helicopter. It may be hard to quantify and explain but there is generally a lot more aggressive care going on in a tertiary medical ICU than there is in an ambulance or a small-town hospital, and with these patients things do happen immediately on arrival, just like they do with the other time-sensitive patients.

So while I'm in complete agreement that helicopters are way overused (and even as a flight medic and flight nurse, I regularly made that argument long before it was cool), I think that anytime you have a truly critically ill patient, the most rapid transport by the most experienced CCT folks is a good thing.

There is plenty of room for over-triage of patients like this. There is A LOT of stuff flown "just because" and is complete BS, but this would not fall in that category IMO, not by a long shot.

 

[KellyBracket]

Okay, I talked to a CC physician, gave her the scenario of a sick septic patient, who has the potential to get to antibiotics and central lines, etc., 1 hour sooner if the helicopter is called. She said "Call the helicopter, no question."

There's a reason they call it early goal-directed therapy; doing the same thereaputic interventions a few hours later doesn't help nearly as much. EMS and EM should own sepsis - and there are CC doctors out there who agree!

 

[Rialaigh]

Okay, I talked to a CC physician, gave her the scenario of a sick septic patient, who has the potential to get to antibiotics and central lines, etc., 1 hour sooner if the helicopter is called. She said "Call the helicopter, no question."

There's a reason they call it early goal-directed therapy; doing the same thereaputic interventions a few hours later doesn't help nearly as much. EMS and EM should own sepsis - and there are CC doctors out there who agree!

The scenario given in the first post is anything but early. You are in the final stages of sepsis at that point.

I actually used that article you quoted in a paper I wrote for paramedic class on septic shock. I would like to see more research done on prehospital antibiotics, and whether early intubation and respiratory support increases survival (RSI'ing a patient that has no resp distress yet). A lot more education needs to be done, first basic thing would be requiring ambulances to carry thermometers, theres not a single service near me that does....

 

[TransportJockey]

I actually used that article you quoted in a paper I wrote for paramedic class on septic shock. I would like to see more research done on prehospital antibiotics, and whether early intubation and respiratory support increases survival (RSI'ing a patient that has no resp distress yet). A lot more education needs to be done, first basic thing would be requiring ambulances to carry thermometers, theres not a single service near me that does....

Really? Most of the ones in this area do.

 

[KellyBracket]

The scenario given in the first post is anything but early. You are in the final stages of sepsis at that point.

I actually used that article you quoted in a paper I wrote for paramedic class on septic shock. I would like to see more research done on prehospital antibiotics, and whether early intubation and respiratory support increases survival (RSI'ing a patient that has no resp distress yet). A lot more education needs to be done, first basic thing would be requiring ambulances to carry thermometers, theres not a single service near me that does....

There is some evidence for early intubation, just to improve the hemodynamic status, but it only comes after a sequence of other actions in the EGDT algorithm.

I wouldn't consider the patient in the OP's scenario to be in the final stages, actually. First off, we don't know the time course. Second, nothing had been done yet. I wouldn't start getting pessimistic until we had given ≥ 2 liters, dropped a central line, check a CVP, dialed up the pressors, dumped in some broad-spectrum abx, and checked to see if there was any infection that could be cut or sucked out!

 

[VirginiaEMT]

Are you doubting this patient is hypoxic? I know there are a few items in the assessment missing, but with significant hypotension, significantly elevated RR, elevated HR, and 103+ temp, I think oxygen would be a fair assumption... I'd even be willing to take a stab that you'd hear rales when auscultating the lungs.

Agreed!! I would say this is way you wouldn't want TWO large IV lines running fluids wide open like a previous poster stated. I would try to get the BP up with a pressor and fluid.. We don't carry Dobutamine but that would be a great choice. I would have to use Dopamine.

 

[Brandon O]

When a patient's RR is this tachypneic, SpO2 is not going to mean to much except if the person is hypoxic but in this situation the oxyhemoglobin curve will be shifted due to acidosis. That means the SpO2 probably will not be accurate. As a Basic all you have is a NRB mask and a BVM which means you are very limited. The patient will probably over breathe the NRB mask since it is not a high flow device and it is doubtful you will be able to over ride the acidosis and rapid respiratory rate without causing the patient more stress if still conscious.

Hard to say what minute volume the quoted RR "means," and how that corresponds to an SpO2 given unknown pulmonary function. So it'd be nice to know, although admittedly partly for pathophys funsies. (Ever feel like you're performing an assessment just for the case presentation later?)

With no attempt to apply it to the actual patient, there ARE some BLS techniques for really maxing out the breathing patient's oxygen supply. If you're using a non-rebreather in the back of your wahmbulance, and that's what you're committed to using, remember that you can supercharge it by running up the flow rate past 15. Just keep turning the valve until it stops; usually this is, oh, well over 40LPM, and the excess flow helps get a spontaneously breathing patient as close to 100% FiO2 as you're likely to get. Sounds like a rocket ship, and don't try it on a portable tank, of course.

You could also try (and this is better if they're not moving a whole lot of volume) a cannula at relatively high flow -- perhaps 15LPM. It's not real comfortable, but if they're obtunded it's no big deal over a short period, and it does a better job of getting oxygen INTO their pharynx if they're not sucking it in very ambitiously (a mask just lets it overflow; a cannula shoots it into their airway under pressure). You can combine cannula and mask as well if you have two regulators.

Finally, if there's obviously gobs of oxygen getting into the lungs, yet their SpO2 remains low (and you believe it), the problem may be V/Q mismatch (shunt) -- O2's inside the lungs but it's not crossing the membrane to enter the blood. PEEP may be helpful, and in principle you can create it using a plain BVM. But this probably wouldn't be very bright for the described patient, who is having hemodynamic troubles as well. (I will remain agnostic here on whether this somewhat sketchy technique is ever a good idea.)

You can also sit 'em up somewhat, although this is subject to hemodynamic limitations as well.

The only thing I'll say about the patient in the scenario is that sepsis is near the very top of the life-threatening emergencies we can help fix, and should be managed with appropriate vigor.

 

[Clipper1]

Hard to say what minute volume the quoted RR "means," and how that corresponds to an SpO2 given unknown pulmonary function. So it'd be nice to know, although admittedly partly for pathophys funsies. (Ever feel like you're performing an assessment just for the case presentation later?)

With no attempt to apply it to the actual patient, there ARE some BLS techniques for really maxing out the breathing patient's oxygen supply. If you're using a non-rebreather in the back of your wahmbulance, and that's what you're committed to using, remember that you can supercharge it by running up the flow rate past 15. Just keep turning the valve until it stops; usually this is, oh, well over 40LPM, and the excess flow helps get a spontaneously breathing patient as close to 100% FiO2 as you're likely to get. Sounds like a rocket ship, and don't try it on a portable tank, of course.

You could also try (and this is better if they're not moving a whole lot of volume) a cannula at relatively high flow -- perhaps 15LPM. It's not real comfortable, but if they're obtunded it's no big deal over a short period, and it does a better job of getting oxygen INTO their pharynx if they're not sucking it in very ambitiously (a mask just lets it overflow; a cannula shoots it into their airway under pressure). You can combine cannula and mask as well if you have two regulators.

Finally, if there's obviously gobs of oxygen getting into the lungs, yet their SpO2 remains low (and you believe it), the problem may be V/Q mismatch (shunt) -- O2's inside the lungs but it's not crossing the membrane to enter the blood. PEEP may be helpful, and in principle you can create it using a plain BVM. But this probably wouldn't be very bright for the described patient, who is having hemodynamic troubles as well. (I will remain agnostic here on whether this somewhat sketchy technique is ever a good idea.)

You can also sit 'em up somewhat, although this is subject to hemodynamic limitations as well.

The only thing I'll say about the patient in the scenario is that sepsis is near the very top of the life-threatening emergencies we can help fix, and should be managed with appropriate vigor.

Using a device for a way it was not intended will probably not achieve the results you are desiring. Anyone can turn up the NC to blast but then have you look at the way a true hi-flow NC or mask is designed.

Adding PEEP is not going to do anything to meet flow demand. I believe the ARDSnet studies have also provided evidence that just increasing PEEP without delivery of appropriate flow can actually be detrimental.

The NRB plus NC is more commonly used for confused patients who might pull off the mask.

You are giving 100% oxygen in hopes of giving an FiO2 of 1.0 but it is important to use the appropriate device or appropriately use the device used. Know your equipment and know how to use it or the basic principles of delivery. This should also give you a clue about why some things are more "yeah I did that and it sorta worked".

 

[Brandon O]

Using a device for a way it was not intended will probably not achieve the results you are desiring. Anyone can turn up the NC to blast but then have you look at the way a true hi-flow NC or mask is designed.

Here's a bit of evidence (there's lots more out there, just ask):

http://www.rcjournal.com/abstracts/2003/?id=OF-03-257

http://www.ncbi.nlm.nih.gov/pubmed/20400000

Obviously it's better to have more appropriate equipment! But if we had all the most appropriate stuff, it wouldn't be EMS, and it sure as heck wouldn't be BLS...

Adding PEEP is not going to do anything to meet flow demand. I believe the ARDSnet studies have also provided evidence that just increasing PEEP without delivery of appropriate flow can actually be detrimental.

Hey, I'm not advocating it! Especially for this patient, who's hypotensive and of unclear responsiveness. Although if you do get to where you're using the BVM, "peepy" or otherwise, you'll at least be using 100% O2, so most of these other points will be moot.

It's certainly a double-edged sword, and it's hard to know where you are between those edges without being able to measure pressures. I've never tried to do the BVM PEEP trick on a real humanoid. But it's nice to have tools, and even a difficult and dangerous tool can have value in some situations -- and what makes this one cool is that there's basically no other option for BLS folks (except driving fast... and maybe sticking their head out the side window).

The NRB plus NC is more commonly used for confused patients who might pull off the mask. . . . You are giving 100% oxygen in hopes of giving an FiO2 of 1.0 but it is important to use the appropriate device or appropriately use the device used

Let's say instead that it's great to have a variety of tools available for increasing FiO2, to understand how they work, and to apply them (individually or in combination) with respect to their strengths and your situational needs. I've done blow-by with a 60LPM mask on patients who wouldn't tolerate anything on their face, for instance.

Notwithstanding any issues of policy or legality (and admittedly those might pertain), the gear doesn't care how it's used; the patient only cares if his problems are solved.

 

[Clipper1]

Here's a bit of evidence (there's lots more out there, just ask):

http://www.rcjournal.com/abstracts/2003/?id=OF-03-257

http://www.ncbi.nlm.nih.gov/pubmed/20400000

Obviously it's better to have more appropriate equipment! But if we had all the most appropriate stuff, it wouldn't be EMS, and it sure as heck wouldn't be BLS...



Hey, I'm not advocating it! Especially for this patient, who's hypotensive and of unclear responsiveness. Although if you do get to where you're using the BVM, "peepy" or otherwise, you'll at least be using 100% O2, so most of these other points will be moot.

It's certainly a double-edged sword, and it's hard to know where you are between those edges without being able to measure pressures. I've never tried to do the BVM PEEP trick on a real humanoid. But it's nice to have tools, and even a difficult and dangerous tool can have value in some situations -- and what makes this one cool is that there's basically no other option for BLS folks (except driving fast... and maybe sticking their head out the side window).



Let's say instead that it's great to have a variety of tools available for increasing FiO2, to understand how they work, and to apply them (individually or in combination) with respect to their strengths and your situational needs. I've done blow-by with a 60LPM mask on patients who wouldn't tolerate anything on their face, for instance.

Notwithstanding any issues of policy or legality (and admittedly those might pertain), the gear doesn't care how it's used; the patient only cares if his problems are solved.

If someone requires 60 L/m via mask, time to move on to adjusting their toleration for something on their face through pharmacological means. I doubt if any hospital can have someone hold "blowby" for several hours. Blowby O2 is an ineffective way to deliver the appropriate FiO2. Room air is surrounding the "blowby". Anything off the patients face also proportionately decreases FiO2 rapidly. Also note in the article you posted the devices were studied for delivery of FiO2 and not how high the flow goes. That was my point. Regardless of the gear you must understand a few basic principles of delivery.

It is also my understanding from reading these forums and actually seen it done by EMTs on a BLS truck, CPAP provides "PEEP". But, some prehospital devices many not be able to meet both demand and oxygenation.

 

[Brandon O]

If someone requires 60 L/m via mask, time to move on to adjusting their toleration for something on their face through pharmacological means. I doubt if any hospital can have someone hold "blowby" for several hours.

Ah, perhaps we're speaking past each other. I had in mind a BLS field situation as described by the OP. Obviously if you have more resources available (better means of airway management, pharmacotherapy, etc), they'll be more effective than any "stretch and squint" BLS solution. On our humble trucks the question is often how effective you can be with what's available, not what would be optimal if you had it.

Also note in the article you posted the devices were studied for delivery of FiO2 and not how high the flow goes. That was my point.

Could you clarify what you're referring to by "flow"? I'm afraid I'm not catching your drift.

It is also my understanding from reading these forums and actually seen it done by EMTs on a BLS truck, CPAP provides "PEEP".

I have heard of BLS systems that can deploy CPAP, but they are a rarity.

 

[STXmedic]

Agreed!! I would say this is way you wouldn't want TWO large IV lines running fluids wide open like a previous poster stated. I would try to get the BP up with a pressor and fluid.. We don't carry Dobutamine but that would be a great choice. I would have to use Dopamine.

I was one of the posters advocating running two lines....

The patient may have rales, but the patient also has near nothing in their vasculature. The wet lungs that you'd hear aren't from the patient being fluid overloaded; they're from a fluid shift caused by an increase in membrane permeability (or pneumonia...). The patient still needs fluid, and a lot of it. Pressors aren't going to do you much good if the patient is significantly fluid depleted.