# 80 y/oF AMS



## MarshalFoch (May 6, 2013)

Cold response to SNF for suspected UTI.

U/A find pt in bed unresponsive to all stimuli. Carotid pulse present and regular but weak and rapid. Pt is breathing. Nearest staff member states pt's baseline is "foggy/slow", and her last b/p was 70/38 apx. 15 min prior. Pt has a valid DNR/DNI. 

Pt does have diabetes, BGL of 240 which staff states is baseline. Pt has hx of recurrent UTI, and was recently diagnosed w/ a UTI. Pt's pupils are constricted however move away from light. Pt's eyes will track a finger on first movement in front of eyes opened by crew but will stop accommodating after the first sweep in front of eyes. Abdomen -distention, -tenderness, -rigidity.

Skin: Pale, cool, diaphoretic
BP (By Crew): 80/46
HR: 106
RR: 24, Lung sounds clear bilaterally.
SPo2: 96% RA


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## NomadicMedic (May 6, 2013)

Get a lactate, if its >4.0 mmol/L, call a sepsis alert and start bilateral lines and 2L of normal saline.


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## Milla3P (May 6, 2013)

Throw in a temp around 103° and it's all sepsis all the time.

DEMedic, you guys do field lactates?


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## NomadicMedic (May 6, 2013)

Yes. We use it as a soft point of entry into the sepsis protocol and for a marker in our cyanide/smoke inhalation protocol. Little lactate pro meters, correlates well with the ERs lab. They actually listen when we call a sepsis alert.


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## MarshalFoch (May 6, 2013)

Triage certainly agreed, we were BLS. Transported the patient to the nearest hospital (3.5 mi away) without ALS as the only ALS unit had a 10-15 min ETA per dispatch, which in my experience is about 5 minutes off in the wrong direction. Was curious what ALS would have done in terms of assessment that may have sped up pt care, specifically if we should have waited for ALS. From pt contact to through triage was approximately 20 minutes.


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## NomadicMedic (May 7, 2013)

The assessment indicators for sepsis are heart rate >90, BP <90, temp >38.8 or <36 and a serum lactate >4.0 mmol/L. 

I think that the HR, BP, temp, hx of recent UTI and decreased mental status would be a good enough bundle to start down the path toward a sepsis timeout for a BLS provider. Medics would only start fluid, and dependent on protocols, they might not be very aggressive with it. 

The biggest thing is prealerting the ED to let them know a possibly septic patient is inbound, so they don't sit in a hall bed for hours and treatment can be started quickly,


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## Ecgg (May 7, 2013)

MarshalFoch said:


> Triage certainly agreed, we were BLS. Transported the patient to the nearest hospital (3.5 mi away) without ALS as the only ALS unit had a 10-15 min ETA per dispatch, which in my experience is about 5 minutes off in the wrong direction. Was curious what ALS would have done in terms of assessment that may have sped up pt care, specifically if we should have waited for ALS. From pt contact to through triage was approximately 20 minutes.



Assessment you can employ the SIRS criteria (although it has its problems)

SIRS criteria: 2 of the following + suspected or confirmed infection = Sepsis
Temp < 36°C or > 38°C   RR > 24
WCC < 4 or > 12    HR > 90

check the lactate level if you have the proper tools

Early notification

Early fluid resus



The goal if this was septic patient:

Antibiotics within 60 min
Immediate and appropriate fluid resus


Transport was probably the best option.


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## SpecialK (May 7, 2013)

This patient is crook, like life threatening problem crook.

Oxygen
Large bore IV access
Start one litre of fluid wide open
2 g ceftriaxone IV

Load and treat en-route.  I would not wait for backup if hospital could be located faster than backup could arrive, in fact I probably would not even call for backup unless hospital was > 30 minutes away.


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## MarshalFoch (May 7, 2013)

SpecialK said:


> This patient is crook, like life threatening problem crook.
> 
> Oxygen
> Large bore IV access
> ...



BLS in Massachusetts, I could only give the first treatment. The hospital was notified when we initiated transport which lasted 6 minutes. We cannot initiate septic alerts, though we strongly suspected septic shock and expressed that. The staff began treatment for septic shock within six to eight minutes or our arrival, delayed by our trip through triage which required us to give a triage report to the triage nurse and obtain vitals from their machines, which are done concurrently by the two different partners.


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## SpecialK (May 7, 2013)

I note the glucometery type blood lactate measurers are becoming more affordable.  

Clearly there is some usefulness in measuring lactate as a biochemical marker of decreased cellular oxygenation (anaerobic metabolism) as occurs in septic shock (amongst other things).

I think however that the money is better spent introducing antibiotics particularly for meningococcaemia and septic shock.  

If we look internationally those services that have introduce them are either using ceftriaxone (AU/NZ) or benzylpenicillin (UK, SA, Ireland)


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## medicdan (May 7, 2013)

SpecialK said:


> I note the glucometery type blood lactate measurers are becoming more affordable.
> 
> Clearly there is some usefulness in measuring lactate as a biochemical marker of decreased cellular oxygenation (anaerobic metabolism) as occurs in septic shock (amongst other things).
> 
> ...



If nothing else, recognizing severe sepsis in the field using lactate allows you to properly notify the hospital, and allow them to have antibiotics prepared when you arrive.


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## chaz90 (May 7, 2013)

SpecialK said:


> I note the glucometery type blood lactate measurers are becoming more affordable.
> 
> Clearly there is some usefulness in measuring lactate as a biochemical marker of decreased cellular oxygenation (anaerobic metabolism) as occurs in septic shock (amongst other things).
> 
> ...



I recently read in the 2012 Delaware EMS report that we are considering introducing antibiotic use in the field for sepsis. I'm not completely sure how long we've been using our lactate monitors here, but I certainly do see their utility in increasing evidence for a sepsis diagnosis prior to arrival at the hospital. 

On a side note, I'm not completely convinced of the ethics of aggressively treating sepsis in a sizeable subset of the septic population I see. Obviously it should be up to the individual regarding the care they receive, but few specify anything beyond DNR or DNI. When I'm 90 years old, I think sepsis would be the way to go. It's painless, you're not aware of what's happening, and you basically die in your sleep. Sepsis treatment really does seem to be improving, but resuscitating Grandma with fluid, hooking her up to multiple pressors, and loading her with antibiotics just for her to linger on in the ICU for another month is questionable to me.


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## SpecialK (May 7, 2013)

The idea of on-the-spot lactataemia testing may indeed have some merit, mostly in patients who are subtly unwell without significant dysthermia whom you are recommending do not need immediate referral/transport to ED or a medical facility.  Whether or not these patients actually have significantly elevated lactate at the early stage of sepsis is something I am not sure of.

However, for somebody who is time critically unwell with septic shock, the idea that you can test for a biomarker to rule in/rule out sepsis but not actually do something about it is kind of like checking a BGL on Nana who is unconscious from hypoglycaemia but not actually having any glucagon or glucose to fix her up.

Ceftriaxone is cheap, generic and non-patented drug, its like adrenaline or salbutamol. not a lot of money to be made on these so the drug companies are not interested in keeping it patented, a vial of ceftriaxone costs about $2 and lasts for ages ... to give 2 g as an IV bolus you need two ampoules each containing 1 g; so you could get away with four in your drug module in total; that's about $8 per module so its not very expensive.

I reckon its worth it anyway


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## NomadicMedic (May 7, 2013)

In Delaware, the sepsis protocol was designed primarily to prealert hospitals and get treatment started. Apparently, in the past, septic patients would be seen at the emergency room as a lower priority patient. Sitting in the hallway for hours before being seen. 

Following some discussions of field ceftriaxone, I don't ever see that happening here. The medical directors are just not interested. It's always a good talking point, but moving that to reality is something that's been in the works for 10+ years.


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## SpecialK (May 7, 2013)

DEmedic said:


> Following some discussions of field ceftriaxone, I don't ever see that happening here. The medical directors are just not interested. It's always a good talking point, but moving that to reality is something that's been in the works for 10+ years.



If your time-to-hospital is quite short (< 30 min) then I suppose you could "do without" just like you could "do without" pre-hospital thrombolysis or rapid sequence induction.

I suppose the number of patients who are going to receive pre-hospital ceftriaxone is quite small, just like the number of patients who need RSI is likely to be quite small, however, for the sake of a $2 ampoule of ceftriaxone that lasts about a year then I don't really see a reason not to introduce it especially considering that anybody presenting to ambulance with septicaemia is already time critically unwell that the earlier we can give them antimicrobial therapy the better.


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## Arovetli (May 7, 2013)

None of the prehospital type lactate meters are presently FDA approved.

Prehospital ABX means prehospital blood cultures. 

Lack of literature, though this is changing.

All of these present major problems for prehospital treatment unless transport time is exceedingly long. 

As others have said, knowledge, recognition, alert of receiving facility, and fluids go along way prehospitally.


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## NomadicMedic (May 7, 2013)

Arovetli said:


> None of the prehospital type lactate meters are presently FDA approved.


 
Actually, the Lactate Pro is still the only handheld lactate analyzer that is FDA CLIA-waived for clinical medical use. 
They've stopped production of this meter, but test strips are still available.


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## Arovetli (May 7, 2013)

DEmedic said:


> Actually, the Lactate Pro is still the only handheld lactate analyzer that is FDA CLIA-waived for clinical medical use.
> They've stopped production of this meter, but test strips are still available.



Yes, that is what I meant by presently.

Without present production, widespread use seems rather unlikely, yes?

Edit: there is a study out of somewhere in Florida linking prehospital etco2 to sepsis, although its more a mortality predictor than an diagnosing tool. But, it would be interesting to see if a prehospital diagnosing criteria could be developed and easily implemented without requiring expensive lactate meters.


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## SpecialK (May 7, 2013)

Arovetli said:


> Prehospital ABX means prehospital blood cultures.



Taking of blood for culture is not hard so I think could reasonably be taught to those clinical people who are going to be administering ceftriaxone.



> *Taking blood for culture*
> • Withdraw 10 ml of blood via a cannula for adults and children ≥ 50 kg
> or 5 ml of blood for children < 50 kg.
> • Withdrawal of blood is best done at the time of cannulation but can
> ...



http://aucklandhems.files.wordpress.com/2012/11/clinical-practice-guidelines.pdf
Pg 68


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## VFlutter (May 7, 2013)

SpecialK said:


> Taking of blood for culture is not hard so I think could reasonably be taught to those clinical people who are going to be administering ceftriaxone.



Blood cultures are not hard to obtain but they are fairly easy to screw up. There is a decent contamination rate even in the hospital setting. Correctly drawing blood cultures takes time and patience and is pretty much impossible to do in a moving ambulance. Is it worth the extra time on scene?


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## Arovetli (May 7, 2013)

They are quite easy to collect.

What is not so easy is convincing the hospital lab to accept that field medics collected it correctly. The standard of attention to detail and proper procedure and  proper documentation required for this is a bit higher that drawing blood for labs.

Some places do it, I think some rural locales have pilot programs perhaps.


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## Ecgg (May 8, 2013)

Blood collection and transport is always at risk of being hemolyzed.


How about Point of Care Testing I-Stat? Results on the spot with ability to transmit.

http://www.abbottpointofcare.com/Products-and-Services.aspx


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## Arovetli (May 8, 2013)

I think just alerting the hospital so they can quickly evaluate the pt upon arrival and activate their internal sepsis protocol is favored over spending more time on scene fooling around with expensive diagnostic toys that there is presently no way to get the cost of such testing reimbursed to the EMS service.

The only paper, I think, on prehospital sepsis tx showed no advantage to paramedic abx tx, although the methodology was not all inclusive.


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## VFlutter (May 8, 2013)

Ecgg said:


> Blood collection and transport is always at risk of being hemolyzed.



No more so than a trip through the pneumatic tube system...



Ecgg said:


> How about Point of Care Testing I-Stat? Results on the spot with ability to transmit.
> 
> http://www.abbottpointofcare.com/Products-and-Services.aspx



What exactly will you be testing for?


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## Ecgg (May 8, 2013)

Arovetli said:


> I think just alerting the hospital so they can quickly evaluate the pt upon arrival and activate their internal sepsis protocol is favored over spending more time on scene fooling around with expensive diagnostic toys that there is presently no way to get the cost of such testing reimbursed to the EMS service.
> 
> The only paper, I think, on prehospital sepsis tx showed no advantage to paramedic abx tx, although the methodology was not all inclusive.



Same was said about 12 lead EKG's why fool around on the scene with expensive diagnostic toys?


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## SpecialK (May 8, 2013)

Chase said:


> Blood cultures are not hard to obtain but they are fairly easy to screw up. There is a decent contamination rate even in the hospital setting. Correctly drawing blood cultures takes time and patience and is pretty much impossible to do in a moving ambulance. Is it worth the extra time on scene?



We're talking about collecting a single, 10 ml aerobic culture bottle's worth of blood here so I don't imagine it would, realistically, take more than a minute? 

Taking of blood for culture is not mandatory anyway, the most important part is the administration of ceftriaxone.



Arovetli said:


> What is not so easy is convincing the hospital lab to accept that field medics collected it correctly. The standard of attention to detail and proper procedure and  proper documentation required for this is a bit higher that drawing blood for labs.



I think this can be easily overcome by teaching people who to do it properly, can't be that hard right? 



Ecgg said:


> Blood collection and transport is always at risk of being hemolyzed.



Now that is true; how long does a sample take to haemolyse?


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## Arovetli (May 8, 2013)

Ecgg said:


> Same was said about 12 lead EKG's why fool around on the scene with expensive diagnostic toys?



Right, and when/if the literature shows a clear advantage such as in the case of 12 leads, I'm sure the climate may change. Right now, it has yet to coalesce in any way that would resemble the STEMI alert process...but perhaps it should and perhaps it will. We shall see how things develop,

And if your service drops the dough on iStats, more power to em.


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## Wheel (May 8, 2013)

SpecialK said:


> We're talking about collecting a single, 10 ml aerobic culture bottle's worth of blood here so I don't imagine it would, realistically, take more than a minute?
> 
> Taking of blood for culture is not mandatory anyway, the most important part is the administration of ceftriaxone.
> 
> ...



You would think, but in the US there are plenty of paramedics that don't do the things they do now well. That's not to say that a progressive, motivated service couldn't do it. They certainly could.


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## Ecgg (May 8, 2013)

Chase said:


> No more so than a trip through the pneumatic tube system...
> 
> 
> 
> What exactly will you be testing for?



pneumatic system let's be generous 5 minutes vs 45-60 minute transport over various terrain hmm seems legit  


It has many functions and not just applicable to sepsis, but for sepsis you can check lactate, PCO2, Pt/Ptt times, PH, sO2, lytes etc..

http://www.abbottpointofcare.com/Customer-Info-Center/User-Documentation.aspx


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## Arovetli (May 8, 2013)

SpecialK said:


> We're talking about collecting a single, 10 ml aerobic culture bottle's worth of blood here so I don't imagine it would, realistically, take more than a minute?
> 
> *No.*
> 
> ...



It is a more complicated process.


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## VFlutter (May 8, 2013)

SpecialK said:


> We're talking about collecting a single, 10 ml aerobic culture bottle's worth of blood here so I don't imagine it would, realistically, take more than a minute?
> 
> I think this can be easily overcome by teaching people who to do it properly, can't be that hard right?



Have you ever done it? Realistically it will take you more than a minute just to set up your supplies.

Are you only going to get an aerobic culture or an anaerobic as well? Are you going to sample just one site or two? How much time in-between samples? 

If you are going to half *** a culture then there really is no point of getting one in the first place.



Ecgg said:


> It has many functions and not just applicable to sepsis, but for sepsis  you can check lactate, PCO2, Pt/Ptt times, PH, sO2, lytes etc..
> 
> http://www.abbottpointofcare.com/Customer-Info-Center/User-Documentation.aspx



How will any of those lab values change your plan of care?


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## Arovetli (May 8, 2013)

Ecgg said:


> It has many functions and not just applicable to sepsis, but for sepsis you can check lactate, PCO2, Pt/Ptt times, PH, sO2, lytes etc..
> 
> [/url]



How fun would it be roll up on a critical scene and tell your EMT partner to get you a chem12, CBC, lytes stat.

It would be like being on the show ER, not to mention instantly upping your street cred.

At least until you started getting 911 calls with a CC of: "Need my istats checked".


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## Ecgg (May 8, 2013)

Chase said:


> How will any of those lab values change your plan of care?



Since you are attempting to find "gotcha" moment to showcase your expertise, ill bite.


*SIRS Criteria (≥ 2 meets SIRS definition)*
Temp >38°C (100.4°F) or < 36°C (96.8°F)?	 Yes
Heart Rate > 90?	 Yes
Respiratory Rate > 20 or PaCO2 < 32 mm Hg	 Yes
WBC > 12,000/mm>3, < 4,000/mm>3, or > 10% bands?	 Yes
http://www.mdcalc.com/sirs-sepsis-and-septic-shock-criteria/

Even though SIRS criteria has many problems (which I am certain you can list) it's a good refence point.

Many patients in nursing homes and geriatric population will be on some type of a beta blocker so you may not get a HR >90 all the time, In addition there was a study http://www.ncbi.nlm.nih.gov/pubmed/7674528 that had like ~18 percent of confirmed septic patients to be normothermic. Not many places carry nasal prongs ETCO2 detection. This leaves us respiratory rate only which we can check. So iStat can check blood chemistry for a much stronger confirmation.

Plan of care will change  
1) Initiation of proper fluid resus 
2) Transmission of lab data to receiving so they can call the pharmacy and have the antibiotics available either on arrival or close to arrival. Instead of sending for blood and cultures and getting it back in an hour then calling pharmacy and waiting another hour. 
3) Rapid transport 

How is that?


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## chaz90 (May 8, 2013)

I believe Chase was referring more to the other tests you mentioned besides lactate.


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## Ecgg (May 8, 2013)

chaz90 said:


> I believe Chase was referring more to the other tests you mentioned besides lactate.



They will confirm presence, extent and progression of the distributive shock.  PCO2, PH, HCO3 if there is an acidosis are kidneys compensating?  (has it been going on for days or not), Clotting time prolonged? Possible DIC progression. Elevated K? Cell lysis. SVO2 tissue O2 demand, PO2 oxygenation.

These are objective figures that confirm your assessment findings. If the attending is seeing these figures and I call in with my subjective findings and vitals etc. and ETA. I have a feeling "sepsis? heh we will see when you get here" is not something I will be hearing over the phone.


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## VFlutter (May 8, 2013)

Ecgg said:


> Since you are attempting to find "gotcha" moment to showcase your expertise, ill bite.
> 
> 
> *SIRS Criteria (≥ 2 meets SIRS definition)*
> ...



I am not trying to showcase my "expertise", it is a legitimate question. If you are not able to correct any of the problems you discover with your testing then the value of that test is greatly diminished. 

1) What do you mean by "proper" fluid resuscitation? What IV fluids do you carry besides NS? Are you going to attempt to correct those electrolyte abnormalities you discovered with the Istat? Is your fluid resuscitation really going to be that different than without those labs?

2) Would transmission of lab data be helpful? Sure, but not necessary. I think vital signs, history, and physical is enough to call a sepsis alert. Most hospitals are pretty aggressive with sepsis care, a strong confirmation won't mean much more than a prudent suspicion.  It really does not take that long to get the ball rolling. If a patient was brought in by family with severe sepsis it would not take 2 hours for them to get antibiotics. 

3) The majority of EMS provides rapid transport for every patient so that is kind of a mute point. 

Not necessarily directed at you but there is a difference between SIRS, septicemia, sepsis, and septic shock. They tend to be thrown around like they are interchangeable. 

Again, do not mistake my questioning as an attempt to strut my stuff. I am trying to create a discussion.



Ecgg said:


> They will confirm presence, extent and progression of  the distributive shock.  PCO2, PH, HCO3 if there is an acidosis are  kidneys compensating?  (has it been going on for days or not), Clotting  time prolonged? Possible DIC progression. Elevated K? Cell lysis. SVO2  tissue O2 demand, PO2 oxygenation.
> 
> These are objective figures that confirm your assessment findings. If  the attending is seeing these figures and I call in with my subjective  findings and vitals etc. and ETA. I have a feeling "sepsis? heh we will  see when you get here" is not something I will be hearing over the  phone.



All that information is great to know but that is not be the priority for EMS. You likely will have more important tasks to complete instead of studying those labs and discussing them with Doctor. None of that information will change anything you, as a paramedic, are going to do. But if you have an hour transport and nothing better to do than sure why not. 

If you call report stating "60 y/o male, temp. 102, HR 120, BP 88/50, RR 30, ALOC, recent UTI/PNA" I doubt many attendings will be waiting for labs.

How often are you going to have a patient that is asymptomatic or with subclinical presentation with critical labs? i.e hemolysis, coagulopathy, acidosis


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## Ecgg (May 8, 2013)

Chase said:


> I am not trying to showcase my "expertise", it is a legitimate question. If you are not able to correct any of the problems you discover with your testing then the value of that test is greatly diminished.


I am not able to correct ACS STEMI as they require Cath Lab to correct this problem yet I have diagnostic tool to check for it, is the value of that test greatly diminished?




Chase said:


> 1) What do you mean by "proper" fluid resuscitation? What IV fluids do you carry besides NS? Are you going to attempt to correct those electrolyte abnormalities you discovered with the Istat? Is your fluid resuscitation really going to that different than without those labs?


Fluid bolus vs fluid challenge vs IV Pump set infusion rate using MAP to titrate pressors? 




Chase said:


> 2) Would transmission of lab data be helpful? Sure, but not necessary. I think vital signs, history, and physical is enough to call a sepsis alert. Most hospitals are pretty aggressive with sepsis care, a strong confirmation won't mean much more than a prudent suspicion.  It really does not take that long to get the ball rolling. If a patient was brought in by family with severe sepsis it would not take 2 hours for them to get antibiotics.


So http://www.ncbi.nlm.nih.gov/pubmed/16625125 
Effective antimicrobial administration within the first hour of documented hypotension was associated with increased survival to hospital discharge in adult patients with septic shock. Despite a progressive increase in mortality rate with increasing delays, only 50% of septic shock patients received effective antimicrobial therapy within 6 hrs of documented hypotension.

What is your facility time from triage to antibiotic admin? 



Chase said:


> 3) The majority of EMS provides rapid transport for every patient so that is kind of a mute point.


I only transport lights and sirens (rapid transport) if there is medical necessity. Other than that it's safe slow ride to the hospital. If I have the tools to determine it is in fact sepsis I am going lights and sirens.



Chase said:


> Not necessarily directed at you but there is a difference between SIRS, septicemia, sepsis, and septic shock. They tend to be thrown around like they are interchangeable.



There is also:
Bacteremia
Endotoxemia
Pyemia
Empyema 

Let's be thorough and find more. (They are all infection)



Chase said:


> Again, do not mistake my questioning as an attempt to strut my stuff. I am trying to create a discussion.


Sold.


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## Handsome Robb (May 8, 2013)

Ecgg said:


> I am not able to correct ACS STEMI as they require Cath Lab to correct this problem yet I have diagnostic tool to check for it, is the value of that test greatly diminished?



I think there is a place for it in those systems that have longer transport times, but in urban and even suburban systems our time with the patient is so short we have other things we need to do. A POC lactate test would be nice to help the hospital with a baseline number though I do agree there.



> Fluid bolus vs fluid challenge vs IV Pump set infusion rate using MAP to titrate pressors?



Again, with a longer transport time definitely. If you're using pressors absolutely. But it goes back to transport times. Even transporting routine on the long end of average I'm 15 minutes to a hospital. 



> So http://www.ncbi.nlm.nih.gov/pubmed/16625125
> Effective antimicrobial administration within the first hour of documented hypotension was associated with increased survival to hospital discharge in adult patients with septic shock. Despite a progressive increase in mortality rate with increasing delays, only 50% of septic shock patients received effective antimicrobial therapy within 6 hrs of documented hypotension.
> 
> What is your facility time from triage to antibiotic admin?



 It goes back to drawing cultures before the antibiotics. Many systems won't even accept labs drawn in the field. It was discussed earlier Sony don't wanna go over it again as I think it was covered pretty decently.

As far as door-to-antibiotic time I have no idea. We don't call sepsis alerts but in my experience they act pretty quickly when we bring these patients in. We have a good relationship with our hospitals, they generally listen if we have an opinion.



> I only transport lights and sirens (rapid transport) if there is medical necessity. Other than that it's safe slow ride to the hospital. If I have the tools to determine it is in fact sepsis I am going lights and sirens.



Even with lights and sirens its a nice slow ride to the hospital, otherwise I agree. What I don't agree with is needing a tool to tell me that. I trust my judgment and clinical knowledge and assessment skills to form a solid differential. If I have enough evidence that I have a time sensitive patient on my hands I don't need a number telling me that. Confirmation is awesome but I still agree with the question of how much is it really going to change?




> There is also:
> Bacteremia
> Endotoxemia
> Pyemia
> ...


 

Haha fair enough.


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## Arovetli (May 8, 2013)

Robb said:


> What I don't agree with is needing a tool to tell me that. I trust my judgment and clinical knowledge and assessment skills to form a solid differential. If I have enough evidence that I have a time sensitive patient on my hands I don't need a number telling me that. Confirmation is awesome but I still agree with the question of how much is it really going to change?



Just wanted to point out that right now, even with the best clinical acumen and diagnostic criteria and scoring systems like SIRS, there still must be some type of objective lab in the diagnostic mix.
This was the basis of why lactate was thrown into the mix to begin with.

AFAIK, UC Denver is on the leading edge of the prehospital sepsis stuff, and are in the middle of a big trial. It may help all interested to google search them and read a bit on what they've got going on.

But even there, it is all fluids and notification of the hospital. It is probably a better use right now in urban systems to streamline and optimize the hospitals response to a sepsis patient hitting their doors.


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## Akulahawk (May 8, 2013)

Way back when, I used to take septic patients to the ED all the time. The majority of the really sick patients I had back then were this exact population. Prehospital labs? Back then it was limited to blood glucose testing. Based on what we saw going on with the patient, I'd call in with whatever problem was bothering the patient at the time and I'd usually add-in that I suspected sepsis in those cases. Guess what? The ED usually had time to get people there quickly, quietly, efficiently, and be waiting for our arrival instead of doing an evaluation and realizing the same thing... and then having to call the team right away.

That was also before the idea of SIRS really came into being. Much has changed since then...


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## Handsome Robb (May 8, 2013)

Arovetli said:


> Just wanted to point out that right now, even with the best clinical acumen and diagnostic criteria and scoring systems like SIRS, there still must be some type of objective lab in the diagnostic mix.
> This was the basis of why lactate was thrown into the mix to begin with.



This is a very good point. I see no reason why even urban EMS systems can't do POC lactate testing. Like myself and others have said it probably wouldn't change much, potentially more aggressive fluid resuscitation which wouldn't be a bad thing, and nipping the ER in the ***. The problem is, and it's been pointed out, the only FDA approved device isn't manufactured anymore.

I'm all for forward movement in EMS. I think that there are patient populations we can truly make a difference in morbidity and mortality, such as these patients we're discussing m, but unfortunately we're limited by the tools provided to us. 

I'm not sure if our ERs use iSTATs or anything similar for bedside lactates when we bring these patients in. In my experience its a STAT lab draw with cultures, fluids and sometimes antibiotics if there's a real solid case prior to the labs coming back.


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