Antibiotics

[SpecialK]

From what I understand, there is good evidence that delays to antibiotic therapy increased mortality from sepsis.

By "sepsis with hemodynamic changes" I presume you were talking about septic shock. Yes, these patients do need a good volume of fluid, but that's going to do nothing about treating the actual cause of the infection which has given them sepsis.

There is some risk with the inappropriate administration of antibiotics, but in severe sepsis or septic shock, pragmatically the balance of risk is going to be on administering antibiotics no?

While the evidence is limited, for example there are no randomized trials, antibiotics are carried by many ambulance services in the world. In New Zealand there have been a number of case reports of patients with septic shock who've received early prehospital Ceftriaxone making completely normal recoveries.

You don't want to hand it out to every man and his dog, but it is cheap, easy to administer, and in the absence of ability to test for a specific pathogen and tailor antimicrobial therapy, where's the risk in appropriately administering a broad spectrum antibiotic?

 

[medicsb]

I'm not completely opposed to the idea of EMS-initiated ABx Tx, but I do not think it should be standing order. Med command order all day every day until it can be demonstrated that paramedics can appropriately identify patients in need of early ABx. And even still, it should be studied even if medical control is providing the orders. Over-administration of ABx can be bad and certainly there are many illnesses, intoxications, injuries, etc. that can produce VS that meet SIRS (e.g. seizure, sympathomimetics, heat exposure, dehydration, etc) without the presence of infection. Within a reasonable amount of time, I can usually determine a source - CXR for pulm, urine dip for UTI/pyelo, and a good head-to-toe for skin. Exam or lack of findings in the other three may necessitate LP or CT of abd & pelvis, but at that point starting broad spectrum ABx should be started.

I'd focus more on early identification (SIRS + lactate + EtCO2), fluid boluses, and IV pressors PRN (really, though pressors are rarely needed in the prehospital phase). If the political climate is right, I'd take labs drawn by EMS (could draw extra blue top tubes - the ones for coags - as they can have blood transferred to culture bottles). As an EM doc, I would appreciate a sepsis alert of full VS (incl temp and EtCO2), suspected source, and initiation of of a 30ml/kg fluid bolus in the right patient (one without a h/o severe heart failure). The ideal would be a partially exposed pt. (outer clothes removed) with good IV access and enough of a heads-up that I could summon the right number of RNs, gain a urine sample (by straight cath if need be), Xray tech for the CXR, and rapid head to toe skin exam. If a 30ml/kg bolus was completed prehospital and pt. remained hypotensive (MAP <65), I would move quickly on central venous access, pressors, and ABx initiation.

I swear most medics and EMTs could do the early stuff better than nurses, who are too often hindered by their "need" to gain demographic information before actually initiating care (yes it is a pet peeve of mine when I'm trying to exam a patient and get a good H&P and the nurse keeps interrupting to ask crap like whether the pt. has gotten a flu vaccine or ask if they know their social security number - I know they're required to ask this stuff and pressured by nurse managers and other desk jockeys to get it early, but it DOES often hinder pt. care).

Anyhow, to do this would mean for EMS to slow down a little and to shed the notion that everything should be done on the move. I have no problem with EMS taking 10 minutes to perform a more thorough exam and gain key information if it helps expedite ED care.

 

[Akulahawk]

I'm not completely opposed to the idea of EMS-initiated ABx Tx, but I do not think it should be standing order. Med command order all day every day until it can be demonstrated that paramedics can appropriately identify patients in need of early ABx. And even still, it should be studied even if medical control is providing the orders. Over-administration of ABx can be bad and certainly there are many illnesses, intoxications, injuries, etc. that can produce VS that meet SIRS (e.g. seizure, sympathomimetics, heat exposure, dehydration, etc) without the presence of infection. Within a reasonable amount of time, I can usually determine a source - CXR for pulm, urine dip for UTI/pyelo, and a good head-to-toe for skin. Exam or lack of findings in the other three may necessitate LP or CT of abd & pelvis, but at that point starting broad spectrum ABx should be started.

I'd focus more on early identification (SIRS + lactate + EtCO2), fluid boluses, and IV pressors PRN (really, though pressors are rarely needed in the prehospital phase). If the political climate is right, I'd take labs drawn by EMS (could draw extra blue top tubes - the ones for coags - as they can have blood transferred to culture bottles). As an EM doc, I would appreciate a sepsis alert of full VS (incl temp and EtCO2), suspected source, and initiation of of a 30ml/kg fluid bolus in the right patient (one without a h/o severe heart failure). The ideal would be a partially exposed pt. (outer clothes removed) with good IV access and enough of a heads-up that I could summon the right number of RNs, gain a urine sample (by straight cath if need be), Xray tech for the CXR, and rapid head to toe skin exam. If a 30ml/kg bolus was completed prehospital and pt. remained hypotensive (MAP <65), I would move quickly on central venous access, pressors, and ABx initiation.

I swear most medics and EMTs could do the early stuff better than nurses, who are too often hindered by their "need" to gain demographic information before actually initiating care (yes it is a pet peeve of mine when I'm trying to exam a patient and get a good H&P and the nurse keeps interrupting to ask crap like whether the pt. has gotten a flu vaccine or ask if they know their social security number - I know they're required to ask this stuff and pressured by nurse managers and other desk jockeys to get it early, but it DOES often hinder pt. care).

Anyhow, to do this would mean for EMS to slow down a little and to shed the notion that everything should be done on the move. I have no problem with EMS taking 10 minutes to perform a more thorough exam and gain key information if it helps expedite ED care.

Where I work, we have to do the triage and that's done at the bedside. I agree that there are portions of the Triage and "Patient Data Profile" that can wait. What I want to know is why you're here, what you're allergic to, what medications you take, and the basics of who you are and your age. During the initial assessment/eval, we gather data that also fills out parts of the triage forms we must fill out. Once all the basic stuff is done and we've got the basics done, then we can (and should) go back and gather the rest of the demographics we need. We do spend too much time initially than we should. It takes me about 7 minutes to complete the Triage and PDP forms if I can get all the data quickly. That translates sometimes into a 3-5 minute delay in actually initiating care if I'm the only nurse in the room. If I have more hands to assist me, then we can get things going much more quickly.

 

[usalsfyre]

(and to be careful to prevent contamination, which is a huge issue in a relatively controlled ED environment and almost impossible in EMS)

Last time I checked, my ambulances/aircraft weren't really any dirtier than an ED room. I've worked in both. Preventing contamination is more of a training issue than anything.

 

[VinBin]

Last time I checked, my ambulances/aircraft weren't really any dirtier than an ED room. I've worked in both. Preventing contamination is more of a training issue than anything.

It's not a question of "dirty vs clean." You can prevent contamination in a sewer if you prep the patient and use strict sterile technique. It's a matter of which environment can accommodate that for a majority of blood draws. I have seen many contaminated blood cultures from the ED, but consider doing the same in a moving ambulance, where the majority of the time the counters, drawers, seats, aren't really cleaned as well as they should be. It is a training issue but the situation/environment can make a big difference.