What would you do?

[bdoss2006]

So I’ve got sorta a what would you have done/qa me question. So here goes…

89 yof with probable uti. Low back pain and weakness for days, patient states she has a uti. Smell of uti noted. Patient does have a history of UTIs Patient states she’s only drank about 8oz of water today. BP 190/99, hr 85-110 AFIB, clear lung sounds, afebrile. Would you have given fluids due to the possible dehydration? I know BP is a concern, but dehydration itself can raise BP initially. I know fluids are beneficial just for the UTI alone, not considering the dehydration. So would you have given fluids? If so, how much and how fast? How often would you reassess and what would make you change what you were doing on reassessment?

 

[CCCSD]

Dude. Go back to school. We can’t run every call for you.

 

[mgr22]

So I’ve got sorta a what would you have done/qa me question. So here goes…

89 yof with probable uti. Low back pain and weakness for days, patient states she has a uti. Smell of uti noted. Patient does have a history of UTIs Patient states she’s only drank about 8oz of water today. BP 190/99, hr 85-110 AFIB, clear lung sounds, afebrile. Would you have given fluids due to the possible dehydration? I know BP is a concern, but dehydration itself can raise BP initially. I know fluids are beneficial just for the UTI alone, not considering the dehydration. So would you have given fluids? If so, how much and how fast? How often would you reassess and what would make you change what you were doing on reassessment?

It sounds like your priority is to give fluid because you really want to give fluid. You won't cure her UTI with it and you may make her worse.

 

[bdoss2006]

Dude. Go back to school. We can’t run every call for you.

Didn’t ask you to run every call for me. I work all the time so if I wanted every call evaluated I’d be posting plenty more than I have. I’m tired of posting here though. Everyone (primarily you), are old jerks with no helpful feedback. There is nothing wrong with asking people to review what you do. That’s called crew resource management. They might not have taught that back in the good ole days but they do now. By your logic I guess QAs shouldn’t happen either. Everyone should know everything and never have any questions, even when they are new. Get the chip off your shoulder

 

[ffemt8978]

Play nice or become the focus of my complete and undivided attention

 

[VentMonkey]

What I would do may not be what you would (or should) do. I am more conservative in my treatments nowadays though.

Without knowing the full history and presentation (e.g., outward signs of fluid overload and/ or predisposition) maaaybe a judicious fluid bolus, think 250-500 ml max.

But as someone else has already pointed out it could make them worse. Again, not knowing the whole work up, other findings such as temperature, perhaps turgor could be helpful. A Sepsis Alert may actually be more beneficial than just fluids, but the jury may still even be out on that.

Sepsis Alerts in the Pre-hospital Setting: An Observational Retrospective Study of Emergency Medical Services’ Response in Portugal (2020–2023) - PMC

Background Sepsis is a life-threatening condition that demands prompt recognition and intervention to enhance patient outcomes. Early identification and timely treatment, particularly in the prehospital setting, are essential. Objective This study ...

pmc.ncbi.nlm.nih.gov

Also, this probably won’t help with career growth or development…

Everyone (primarily you), are old jerks with no helpful feedback.

True CRM and debriefs can and often do require “constructive feedback” formerly called constructive criticism. Failures, humility, and hard realities foster growth, I don’t think that will ever change regardless of age.

 

[CCCSD]

We called them Tape Reviews in the Old Days and we discussed things, along with the MICN, Base Station MDs, EMS Directors.
We also expected crews to run their calls and understand their protocols and implement proper care. Anyone with that level of confusion would never have been allowed to practice.

BTW: your questions have nothing to do with CRM.

 

[E tank]

No mention of meds/hx, but whatever fluid that runs in in the time it takes to get to the hospital, assuming, again, that you're not extended, won't make a difference in the grand scheme, IMHO. Running in a half liter during transport might even take her pressure down as her vasomotor tone relaxes at the modest rise in blood volume. What you're asking really is just style points.

 

[Akulahawk]

As stated above, a small amount of fluids (250-500 mL) may help some with BP by allowing some vasomotor relaxation. It may also help a little bit with HR, both from the body noting a slight rise in blood volume.

Generally speaking, at my facility, when we get a sepsis alert patient (this one may be one) we usually have a 30mL/Kg fluid bolus to be started, labs including UA, and starting antibiotics within 3 hours (and we're trying for 1 hour) of the alert being called. For some of our patients, this can be 2-3 liters of fluid or more, but not always.

Our county's Sepsis protocol may or may not require a 500 mL NS bolus depending upon what vital signs were obtained, including waveform capnography. If the patient meets the protocol, then a 500 mL NS bolus is to be given regardless of SBP. Up to 4 doses can be given if SBP is, and remains, below 90 mmHg. If it remains below 90 mmHg after 4 boluses, then push dose Epi (5-20 mcg) can be given every 2-5 minutes, titrated to SBP of 90 mmHg or higher. Given the usual transport times, most medics here will never get to administering push dose epi before arrival at an ER.

I should also states that my own personal practice may be a bit different as I have access to a different formulary than the EMS medics do... but I'm also hampered by not being "allowed" to play in the prehospital arena. My ambulance work is basically interfacility only and we use clinical guidelines vs strict protocols. By the time I get involved, I'm going to be reasonably late in the whole process so I am going to be dealing with ER/ICU orders that go well beyond EMS protocols anyway.

 

[E tank]

...including waveform capnography. If the patient meets the protocol, then a 500 mL NS bolus is to be given regardless of SBP.

Is this an intubated patient? What ventilation mode?

 

[Akulahawk]

...including waveform capnography. If the patient meets the protocol, then a 500 mL NS bolus is to be given regardless of SBP.

Is this an intubated patient? What ventilation mode?

This is not an intubated patient. The protocol asks about EtCO2. One can obtain this from an EtCO2 equipped nasal cannula. So, no vent mode is necessary with these patients. In the field, few have vents so vent mode is manual if the patient is intubated. Then again, if the patient is intubated in the field here, there are bigger problems going on.

 

[E tank]

This is not an intubated patient. The protocol asks about EtCO2. One can obtain this from an EtCO2 equipped nasal cannula. So, no vent mode is necessary with these patients. In the field, few have vents so vent mode is manual if the patient is intubated. Then again, if the patient is intubated in the field here, there are bigger problems going on.

Yeah, just saying using ETCO2 through a nasal cannula to determine fluid responsiveness is about as good as flipping a coin.

 

[Akulahawk]

Yeah, just saying using ETCO2 through a nasal cannula to determine fluid responsiveness is about as good as flipping a coin.

This has less to do with "fluid responsiveness" and more to do with how the EMS system determines whether a sepsis alert is called in the field and THEN how they're to deal with it. If a patient meets their sepsis alert criteria, they're required to initiate a 500 mL bolus regardless of what the blood pressure actually is. Subsequent boluses are based on BP. What I like much less is the blanket 30ml/kg fluid bolus in-hospital orders for a sepsis alert unless the patient has something else that allows the physician to justify NOT doing that much fluid. It's not that I'm opposed to flooding patients with fluids, rather I want resus fluids to stay in the vasculature.

 

[VentMonkey]

Amazing. It’s almost like this thread is chock full of input, discussion, and conversation from seasoned providers that younger ones could glean from…

…buncha grumpy ol’ *******s.

 

[Akulahawk]

Amazing. It’s almost like this thread is chock full of input, discussion, and conversation from seasoned providers that younger ones could glean from…

…buncha grumpy ol’ *******s.

Seasoned providers? Where?

 

[E tank]

This has less to do with "fluid responsiveness" and more to do with how the EMS system determines whether a sepsis alert is called in the field and THEN how they're to deal with it. If a patient meets their sepsis alert criteria, they're required to initiate a 500 mL bolus regardless of what the blood pressure actually is....

I actually looked up some pre hospital sepsis protocols, and sure enough, right behind MAP/SBP, RR and lactic acid was end tidal CO2 less than/equal to 25. The one I was looking at (can't remember whose) said any ONE or more meets criteria, which means the least reliable, least objective and most prone to artifact by an order of magnitude, ETCO2 via NC alone is a treatment trigger. Making that an inclusion criteria on the same level as, say, lactic acid, I would say is odd. Treating someone for sepsis who is not septic in the field is a pretty low stakes deal given the alternative, but still....

 

[VentMonkey]

I feel like when I was a ground paramedic there was a point when Sepsis Alerts were gaining traction in the prehospital setting, albeit brief.

Fast forward to 2026 and I don’t know that they ever kept their momentum. I mean it isn’t like we’re seeing a large bulk of scene retrievals for sepsis criteria or concern like STEMI’s and Strokes.

The irony however is on the backend, how commonly patients are moved to tertiary care with sepsis, often times in conjunction with their primary diagnoses.

And, because EMS still does (IMO) a shoddy job at educating, let alone researching and following up on said research, this seems to have been put into the same pigeon hole as countless other trendy items in EMS.

With that, I still see many clinicians who are wholeheartedly wrapped up in an SBP in spite of adequate perfusable MAP’s and ETCO2’s that may fit the bill for the patient that’s in front of them (i.e., metabolic derangements). Good discussion though.

 

[DrParasite]

I feel like when I was a ground paramedic there was a point when Sepsis Alerts were gaining traction in the prehospital setting, albeit brief.

Fast forward to 2026 and I don’t know that they ever kept their momentum. I mean it isn’t like we’re seeing a large bulk of scene retrievals for sepsis criteria or concern like STEMI’s and Strokes.

I am so far removed from patient care, that I couldn't tell you if Sepsis Alerts were still around, or if they actually had any impact... If I remember correctly, Sepsis alerts were around, but I think EMS was dealing with patients who were already super sick, so it was mostly just notification and supportive measures... but I might be completely wrong on that one.

however, I did find some research from smarter people than I....

EMS Sepsis Resources | CDC

https://www.sciencedirect.com/science/article/abs/pii/S0735675722002650

https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2821277

https://www.sepsis.org/wp-content/uploads/2024/02/EMS-Fact-Sheet-2024-02-06_sk.pdf

Sepsis Treatment in the Field: What EMS Providers Need to Know

Learn essential EMS sepsis care: From fluids to handoff, discover what to do—and avoid—when every second counts in the field.

www.impactems.com

Advances in Data-Driven Early Warning Systems for Sepsis Recognition and Intervention in Emergency Care: A Systematic Review of Diagnostic Performance and Clinical Outcomes

Improving Outcomes in Sepsis

Standardizing the prehospital approach to sepsis patients may benefit the overall system of care, the authors write.

www.jems.com