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Sepsis: A Deadly Overreaction

  • Definition: Sepsis is a life-threatening organ dysfunction resulting from the body's dysregulated response to an infection.

  • The Greek word "sepsis" means to "decay" or "putrefy."

  • Analogy: If an allergic reaction is like having an infection, sepsis is like anaphylaxis (the body's severe overreaction).

  • Mortality: Death from sepsis outnumbers those from opioid overdose, breast cancer, and prostate cancer combined.

  • Prevalence: More than 85 \% of sepsis cases originate in the community, not the hospital.

  • Leading Infection Sources (Adults):

    • Lung infections (e.g., pneumonia): Approximately 35 \% of cases.

    • Urinary Tract Infections (UTIs): Approximately 25 \% of cases.

    • Gastrointestinal (GI) infections: Approximately 12 \% of cases.

    • Skin infections: Approximately 11 \% of cases.

  • High-Risk Populations:

    • The very old and the very young.

    • Individuals with weakened immune systems (e.g., Cushing's disease due to steroid use, asthma, or COPD patients on steroids who get an infection).

  • Early Community Recognition (Public Health Initiatives):

    • High or low temperature.

    • Any signs of infection.

    • Mental decline.

    • Feeling extremely ill.

  • Systemic Inflammatory Response Syndrome (SIRS) Criteria (EMT/Paramedic Assessment):

    • To suspect sepsis, these criteria must be present with a suspected infection.

    • Heart rate (tachycardia) above 90 beats per minute.

    • Respiratory rate (tachypnea) above 20 breaths per minute.

    • Temperature (fever or hypothermia): Above 38°C or below 36°C.

    • End-tidal carbon dioxide (ETCO2): Below 30 on a capnography reading (indicator of severity and hypoperfusion).

    • A patient must meet 2 or more of these criteria with a suspected infection.

  • Septic Shock: Hypotension refractory to fluid resuscitation.

    • In a hospital setting, patients may receive up to 30 \, cc/kg of fluid.

    • Type of shock: Distributive shock (like anaphylaxis).

    • Prehospital Management:

      • Fluid bolus: Administer 250 to 500 \, cc of intravenous fluids before considering pressors.

      • Pressors: If fluid resuscitation is ineffective and the patient remains hypotensive, norepinephrine (Levofed) is the preferred pressor to address the "tank issue" (vasodilation).

      • High mortality rate up to 40 \%.

    • Mainstay treatment, typically in the hospital, is antibiotics (some EMS agencies are starting broad-spectrum antibiotics for sepsis in the field).

  • EMS Role and Sepsis Alert:

    • EMS providers are in a crucial position to identify early signs of sepsis and raise alarms (similar to STEMI or stroke alerts).

    • Actively check for sepsis criteria, not just rule it out.

    • Communicate "sepsis alert" or "possible sepsis" to the receiving hospital to facilitate rapid intervention.

  • Patient Journey Examples

    • Rusty's Story:

      • Presented with a 104°F (40°C) fever and confusion.

      • Went to urgent care, was sent home, and told to call back if his fever spiked.

      • Later, a doctor from Sweden recognized his condition as sepsis (he had never heard of it).

      • Ultimately lost both legs and hands due to advanced sepsis.

      • Highlight: Missed opportunities for early intervention when SIRS criteria were likely met.

    • Amy's Story:

      • A 30-year-old healthy individual in April 2018.

      • Symptoms: Nausea, drowsiness, headache, vomiting, chills, severe body pain, weakness, fever, abdominal distension.

      • Early medical visits: Tested negative for flu, prescribed anti-nausea medication but couldn't keep it down.

      • First ER visit: After a week of not eating or drinking, severe weakness, pale, unable to talk or walk without pain.

      • Diagnoses: Enteritis, renal insufficiency, dehydration.

      • Prescribed new anti-nausea medication, discharged (in shock given her condition).

      • Returned to ER the next morning, immediately admitted to ICU for severe sepsis.

      • ICU Stay: 5 days, underwent surgery for pus buildup on the small intestine, PICC line, 9 different antibiotics, gained nearly 40 pounds (18.14 \, kg) of fluid weight in 2 days due to renal failure and inability to offload fluid (hypotension, not releasing ADH).

      • Highlight: Even young, healthy individuals can rapidly decline from sepsis, and initial presentations can be easily dismissed.

  • Introduction to Infectious Diseases

    • Many infectious diseases share common generic symptoms (fever, headache, malaise, rash), making differentiation challenging.

    • Treatment often focuses on supportive care and protecting oneself with universal precautions (BSI).

  • Specific Infectious Conditions

    • Measles (Rubeola):

      • Transmission: Airborne, lingering in the air for up to 2 hours.

      • Prevention: MMR vaccine (Measles, Mumps, Rubella).

      • Incubation Period: Approximately 2 weeks after exposure (asymptomatic but virus circulates).

      • Prodromal Period: lasts about 3 days.

        • Very high fever, cough, conjunctivitis (red eyes), stuffy nose.

        • Enanthem: Koplik spots (rash inside mucous membranes of the mouth).

      • Exanthem: Rash starts on the head and works its way down the body.

      • Recovery: Lifelong immunity due to humoral immune response (B cells create memory cells).

      • Complications: More problematic for infants (higher mortality).

        • Lung issues, intestinal issues, brain issues (encephalitis - inflammation of the brain).

        • Otitis media (ear infection), bacterial pneumonia.

      • Statistics: 1 in 4 patients are hospitalized; 1 in 1000 patients die. 140,000 deaths in 2018.

    • Chickenpox (Varicella-Zoster Virus):

      • Transmission: Airborne and contact.

      • Prevention: Vaccine or prior exposure (chickenpox parties were historically practiced for this).

      • Symptoms: Fever, headache, fatigue, itchy rash, can form scabs if picked.

      • Shingles (Herpes Zoster):

        • Reactivation of the varicella-zoster virus, typically later in life after a dormant period.

        • Symptoms: Usually a one-sided rash (e.g., on torso, neck), burning/tingling pain, sensitivity to light, fever, headache, fatigue.

        • Prevention: Vaccine available for individuals 50 and older.

        • Contagion: Not airborne; fluid from blisters can be contagious (contact transmission).

    • Mumps:

      • Transmission: Droplet.

      • Prevention: MMR vaccine.

      • Symptoms: Swelling of salivary glands under the ears, often on one side.

      • Complications: Meningitis, encephalitis, orchitis (inflammation of testicles), epididymitis (inflammation of the tube connecting to testicles, causing testicular pain/swelling).

    • Whooping Cough (Pertussis):

      • Transmission: Droplet (bacterial).

      • Prevention: DTaP (for infants/children) or Tdap (for adolescents/adults) vaccine.

      • Severity: Most serious in young children, causing coughing fits that lead to apnea, cyanosis, and hypoxia. Children can die from it.

      • Maternal Immunity: Pregnant mothers can receive the vaccine, allowing antibodies to cross the placenta, providing passive acquired immunity to the infant.

    • Influenza (Flu):

      • Transmission: Droplet (viral).

      • Prevention: Annual vaccine (effectiveness varies).

      • Symptoms: Generic (fever, nasal discharge, coughing, headache, malaise, vomiting).

      • Risk: People can die from the flu, particularly the very young, very old, and immunocompromised (e.g., Cushing's patients).

    • Tuberculosis (TB):

      • Transmission: Airborne (less easily caught casually, higher risk in close quarters).

      • Symptoms: Weight loss, night sweats, coughing (often with blood-tinged sputum), fatigue, headache, chest pain.

      • Risk Factors: Higher prevalence in underserved populations (jails, homeless shelters) due to close living conditions and inadequate care.

      • Latent vs. Active: 90-95 \% of people with TB have latent infection (exposed but asymptomatic) rather than active disease.

      • Global Impact: Affects around 2 billion people worldwide.

      • Testing: Intradermal skin test (PPD) to detect exposure.

      • Precaution: Standard surgical mask for patients, not full body suits, unless in extremely close and prolonged exposure.

    • Mononucleosis ("Mono," "Kissing Disease"):

      • Transmission: Direct oral contact (kissing), droplet.

      • Symptoms: Fever, headache, sore throat, fatigue. White patchy splotches on tonsils/throat.

      • Complications: Splenic enlargement and potential rupture (especially with trauma to the left upper quadrant).

    • Strep Throat (Streptococcal Pharyngitis):

      • Symptoms: Sudden onset, pain while swallowing, high fever, swollen lymph nodes (in the neck), typically no cough.

      • Throat can appear with white patchy splotches (similar to mono).

      • Associated Conditions:

        • Scarlet Fever: Strep throat accompanied by a bright red rash and white spots on the tongue.

        • Rheumatic Fever: A serious autoimmune response that can occur 2 to 4 weeks after untreated strep, leading to damage of heart valves.

  • Key Takeaways for EMS

    • Be vigilant for early signs of sepsis, especially in patients presenting with general illness but also meeting SIRS criteria and having a suspected infection.

    • Practice good body substance isolation (BSI) for all infectious cases.

    • Recognize that many infectious diseases have overlapping symptoms; focus on supportive care and identifying critical conditions like sepsis.

    • Specific features (rashes, swelling, unique sounds, lack of cough) can help differentiate conditions.