The Hudson Valley Septic Shock protocols (as well as all the HV hypovolemia protocols) call for the titration of fluid (and pressors) to a systolic BP of greater than 90 mmhg. Many progressive systems are now using MAP as the target number. For example , Albany REMO calls for maintaining a MAP of >65 rather than chasing a systolic of >90 and this is how it’s done in the ICU as well. The truth is that this is a much better measure as the brain, kidneys and other vital organs need a MAP of 60-70 in order to remain perfused and the systolic alone will not give you that info. For example, a BP of 100/40 has a MAP of 60 while a BP of 88/60 has a MAP of 69 – in the first case the SBP is >90 yet the brain is not being perfused properly while in the second case MAP is 69, even though SBP is only 88.

Capnography is another useful parameter to keep an eye in shock states. Studies have shown that ETCO2 correlates well with Cardiac Output. It is not unusual to have ETCO2 in the 10s and 20s in severe shock states – very useful as monitoring tool to watch for sudden downturn in patient status.

Great lecture: Prehospital Sepsis by Luke Duncan, MD, Albany Medical Center

• Audio Link
  Video Link

Some pearls…

Identifying sepsis early is a key component of good outcomes

Simply saying the word “sepsis”or “septic” on your report will get the patient proper care an hour earlier!

He talks a lot about MAP – that being the new criteria for monitoring BP – much more accurate indicator – needs to be kept above 65 in order to perfuse the brain. Below 60 other end organs are affected as well. Systolic and/or diastolic may not indicate how sick the patient really is. MAP is where its at…(You can find this measurement on the Lifepak 12 /15 in bottom corner of NIBP area)

SIRS criteria for sepsis (Systemic inflammatory response syndrome)

• Tachycardia >90
• Tachypnea >20
• Temp <97°F or >100°F
• ^ White Count (Notice no BP measure here)

SIRS can be diagnosed when two or more of these criteria are present. When SIRS is due to an infection, it is considered sepsis. Noninfectious causes of SIRS include trauma, burns, pancreatitis, ischemia, and hemorrhage

Albany REMO has a great suspected sepsis protocol which uses MAP as one of the criteria. See protocol here – Lots of fluids early on, 2 liters in the field before considering pressors.

Key Points:

• Early identification saves an hour or more
• Early resuscitation saves lives
• Early antibiotics saves lives (Seattle is experimenting with paramedic administered antibiotics)

Copied from Dr. Ex-Medic

I don’t know how much things have improved in more than a decade, but my paramedic text (circa 1997) has exactly 2 references to sepsis or septic shock in its index.  One is a single sentence (not totally correct, though not totally incorrect either, emphasis in original):  ”Septic shock, for example, is caused by the release of an endotoxin from several Gram-negative bacteria.”  The other reference leads to a full page of information, half of it bullet points…in the “Pediatric Medical Emergencies” section.  There is not a single direct reference to adult sepsis in the entire book.  In addition, I’ve not seen any paramedic agencies with sepsis protocols, although they undoubtedly exist. (Current texts have a lot more reference to sepsis and septic shock – ed.)

Recent research might someday change this.  A recent small study looked at just 52 ambulance-delivered patients with severe sepsis; just under half got fluids.  (In case you’re wondering how it took 2 years to get just 52 study patients, the study only looked at patients with severe sepsis–963–then cut out those not brought in by ambulance–down to 216–and further cut out those who didn’t receive “early goal-directed therapy” (EGDT).  Of those final 76, 4 had no EMS tripsheets (!), and 20 were brought in by BLS ambulance, and couldn’t properly be studied for comparison.)

Important bit of information for background purposes:  EGDT is a bundle of treatments intended to be performed early in the patient’s hospital course, with specific treatment goals in mind including blood pressure, central venous pressure, and central venous O2 saturation.

While the numbers were too small to achieve statistical significance, patients receiving prehospital fluid tended to be more likely to achieve these goals within 6 hours of arrival; the data were strongest for the BP goal.  This is despite the fluid group having an average initial SBP 20 points lower, both on-scene and on arrival at the ED.  (Appropriately, then, the apparently sicker fluid group had a higher mortality–but again, not a statistically significant number.)

So is it appropriate for an EMS agency to develop sepsis protocols?  Certainly.  Is it going to help anybody?  Well, this isn’t proof, but a very suggestive hint that it just might.

I’ve been doing my ER internships at a busy ER in NYC and have to agree that nearly every septic patient came in without any sort of fluids running. These are patients that are generally febrile and severely hypotensive. This particular ER has a “Code Sepsis” protocol, but why wait until the ER to start fluids? Some of the patients present with a MAP of 50-60…That can’t be good for long term survival.