80 y/oF AMS

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

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.
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Now that is true; how long does a sample take to haemolyse?
 
Ecgg said:
Same was said about 12 lead EKG's why fool around on the scene with expensive diagnostic toys?
Click to expand...

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.
 
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.



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



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

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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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.

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

No.
Click to expand...

It is a more complicated process.
 
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?
Click to expand...

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
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How will any of those lab values change your plan of care?
 
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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]
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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".
 
Chase said:
How will any of those lab values change your plan of care?
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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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I believe Chase was referring more to the other tests you mentioned besides lactate.
 
chaz90 said:
I believe Chase was referring more to the other tests you mentioned besides lactate.
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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.
 
Ecgg said:
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 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?
Click to expand...

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.
Click to expand...

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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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.
Click to expand...
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?
Click to expand...
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.
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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.
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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.
Click to expand...

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.
Click to expand...
Sold.
 
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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?
Click to expand...

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?
Click to expand...

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?
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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.
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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
Empyema

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


Sold.
Click to expand...


Haha fair enough.
 
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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?
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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.
 
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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