80 y/oF AMS

[MarshalFoch]

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

 

[NomadicMedic]

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

 

[Milla3P]

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

DEMedic, you guys do field lactates?

 

[NomadicMedic]

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.

 

[MarshalFoch]

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.

 

[NomadicMedic]

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,

 

[Ecgg]

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.

 

[SpecialK]

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.

 

[MarshalFoch]

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.

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.

 

[SpecialK]

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)

 

[medicdan]

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)

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.

 

[chaz90]

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)

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.

 

[SpecialK]

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

 

[NomadicMedic]

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.

 

[SpecialK]

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.

 

[Arovetli]

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.

 

[NomadicMedic]

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.

 

[Arovetli]

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.

 

[SpecialK]

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
be done after this provided the 'luer' is well cleaned with alcohol.
• If fluid, including a flush, has already been given via the cannula, place
a second cannula (provided this is easily accomplished) and withdraw
blood for culture from the second cannula at the time of insertion.
• If a second cannula cannot be easily placed, withdraw and discard
5 ml of blood from the existing cannula, before withdrawing blood for
culture.
• Use a single adult aerobic blood culture bottle for adults and children
≥ 50 kg or a single paediatric blood culture bottle for children < 50 kg.
• Attach a sharp needle to the syringe containing the blood and insert
into the blood culture bottle. Allow the vacuum to draw in the
required amount of blood. Do not force blood into the bottle under
pressure.
• If you are able to gain IV access but are unable to take a blood culture,
give ceftriaxone

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

 

[VFlutter]

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?