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.