1. Patty Duke died from sepsis due to a bowel related infection

2. Objectives Discuss differences between pediatric and adult sepsis
Discuss the three stages of sepsis
Review symptoms and causes of sepsis in both pediatric and adult patients populations

3. Sepsis System updates D50% Shortage Dr. Cichon video
D50% prefill and vial may not be available until December of The system is switching to the D10 administration which is reviewed later in the presentation

4. Definition
The word sepsis comes from the Greek meaning “decay” or “to putrefy”
Defined as the “the presence of pathogenic organisms or their toxins in the blood and tissues.”
Physicians draw from a list of signs and symptoms to make the diagnosis

5. Sepsis Kills 258,000 Americans each year
Named as the most expensive in-patient cost in American Hospitals (24 billion)
40% of patients diagnosed with severe sepsis do not survive
Listed as one of top ten diseases leading to mortality in the United States

7. Causes Aging population Drug resistant bacteria
Americans living longer
Highest risk group people older than 65
Drug resistant bacteria
Root cause of the infections that trigger sepsis
Weakened Immune Systems
More Americans living with weakened immune systems caused by HIV, Cancer treatments or transplant drugs

8. Risk Factors Sepsis is more common and more dangerous if you:
Are very young or very old
Have a compromised immune system
Are already ill, often in an ICU
Have wounds or injuries, such as burns
Have invasive devices
Invasive devices such as intravenous catheters, such as PICC lines, or tracheostomy (breathing tubes)

9. Prevention
Get vaccinated: against the flu, pneumonia, and any other infections that could lead to sepsis
Prevent Infections: cleaning of wounds and scrapes and practicing good hygiene
Time matters: If you have an infection look for the signs of sepsis
Good hygiene-hand washing
Severe infection signs and symptoms like shivering, fever, or very cold, extreme pain or discomfort, clammy or sweaty skin, confusion or disorientation, short of breath, and high heart rate

10. Differential Diagnosis
Syndromes that mimic sepsis include
Hypovolemia
Acute blood loss
Pulmonary embolus
Acute myocardial infarction
Acute pancreatitis
Diabetic ketoacidosis
Adrenal insufficiency

11. Sepsis

12. SIRS
Clinical response to a non specific insult of either infectious or noninfectious origin
SIRS is defined as two or more of the following
Fever of more than >100.4 or less than <96.8
Heart rate of > 90bpm
Respiratory rate of >20
Systemic Inflammatory Response

13. SIRS Non specific and may be caused by: Ischemia Inflammation Trauma
Infection
Or several of these combined
SIRS is not always related to infection
Respiratory distress is the primary patient presentation with SIRS

14. Sepsis
Life threatening condition that arises when the body’s response to infection injures its own tissues and organs
Sepsis is caused by an immune response triggered by an infection
Most common cause is bacterial
May also be caused by fungi, viruses or parasites

15. Sepsis
Defined as severe when the finding occur in association with signs of
Organ dysfunction
Hypoxemia
Oliguria
Lactic acidosis
Elevated liver enzymes
Altered cerebral function
Oliguria absence of urine output

16. Sepsis Common locations for the primary infection include: Lungs Brain
Urinary Tract
Skin
Abdominal Organs

18. Sepsis
In the very young, old and people with weakened immune systems there may be no symptoms of a specific infection and the body temperature may be low or normal rather than high.
Sepsis is a medical emergency

20. Sepsis Vulnerability to sepsis is becoming more widespread due to
More opportunities for infections to become complicated due to:
More people having invasive procedures and transplants and taking immunosuppressive drugs and chemotherapies
Rising antibiotic resistance-microbes becoming immune to drugs that would otherwise control infections

21. Sepsis
Is the patient’s presentation suggestive of any of the following infections?
Pneumonia (cough/thick sputum)
Urinary Tract Infection
Acute AMS/ change in mental status
Indwelling Catheter related
Abdominal pain or diarrhea
Wound Infection
Skin/Soft Tissue infection

22. Severe Sepsis
Defined as sepsis with evidence of organ dysfunction, hypoperfusion or hypotension
Indications if you exhibit one or more of the following signs and symptoms:
Significantly decreased urine output
Abrupt change in mental status
Difficulty breathing
Abnormal heart function
Abdominal pain

23. Septic shock Primary cause is bacteria
Fungi and viruses may also be a cause
Release of toxins from the bacteria and fungi cause tissue damage, hypotension and poor organ function
Researchers believe septic shock causes the formation of tiny clots that block nutrients and oxygen from reaching the vital organs
At some point the body will no longer be able to compensate without assistance . This is the beginning of septic shock

24. Septic Shock
Primary symptoms include:
Skin discoloration or rash
Tachycardia
Confusion
Lethargy
Chills
Shortness of breath
Includes sepsis induced hypotension (despite fluid resuscitation) and evidence of hypo- perfusion
Hypo perfusion due to massive vasodilation, increased capillary permeability, decreased systemic vascular resistance and hypotension

25. Septic Shock People at higher risk include: Lymphoma Leukemia
Immune system diseases
Diabetes
HIV
Recent infection or surgery
Bone marrow and solid organ transplant
Recent use of steroid medication
Long term antibiotic use

26. Jim Henson Began to feel flu like symptoms on Saturday
Was admitted to the hospital on Tuesday with trouble breathing diagnosed with sepsis
Developed septic shock caused by Group A streptococcus (multiple abscesses in lungs)
Died on Wednesday May 16, 1990 at age 53
Health officials believe the Group A strep is becoming more powerful and is occurring more often
Jim Henson’s death shocked many people who believed that bacterial infections no longer can kill so rapidly

27. Sepsis and Celebrities
Casey Kasem (infected wound)
Mother Theresa (infected pacemaker)
Christian Brando (pneumonia)
Robin Gibb (cardiac complications from sepsis)
Corey Haim (pneumonia)
Muhammad Ali (pneumonia)
George Michael (pneumonia)
Prince Ranier of Monaco (pneumonia)
Leslie Nielson (pneumonia)
Wayne Rogers (pneumonia)
Pope John Paul II (UTI)
Muhammed Ali died from septic shock

28. Scenario
You are called to the local high school for the 17 year old student not feeling well. Upon arrival you are taken to the school nurse’s office where you find him lying on a cot with his left foot elevated on a pillow.
You begin your assessment and the student tells you he cut his foot at practice a few days ago and now his foot is red, tender, hot to touch and hurts when he tries to walk.
He also tells you he feels warm and weak and tired.

29. Scenario S- hurts when he walks, warm, red and hot A- None
M- Albuterol inhaler
P- Cut to the bottom of foot
L- Toast and juice
E- Pain increased with ambulation and feeling weak

30. Scenario Vital Signs Pulse - 100 BP – 98/54 RR -26
Skim warm, flushed ,dry
You examine the foot and note yellow purulent drainage from the wound on the bottom of the foot

31. Scenario
Does this patient have 2 or more Systemic Inflammatory Response criteria?
If yes, what criteria
Is there an actual or potential infection?
If so what is the source?
Treatment?

32. Sepsis Criteria for EMS (3 or more)
Early Recognition in Pre Hospital Setting (Loyola/Edward EMS Systems: Adult Patients)
Sepsis Criteria for EMS (3 or more)
Suspected infection
Respiratory Rate >20 Breaths per minute
Heart rate > 90 Beats per minute
Systolic Blood pressure <90 mm Hg
Documented Fever or history of temp > or <96.8
New onset mental status change
O2 saturation LESS than 90%
If three or more are present suspect sepsis

33. If Sepsis field criteria are present, proceed:
Early Recognition in Pre Hospital Setting (Loyola/Edward EMS Systems: Adult Patients)
If Sepsis field criteria are present, proceed:
1. Administer oxygen to titrate pulse oximetry to a saturation >92%.
2. If there is no concern of fluid overload, and lungs are clear, initiate a 0.9NS 500mL fluid bolus.
3. If there is concern of fluid overload, and the patient is normotensive, initiate fluid of 0.9NS at 20mL/hr.
Notify ECRN of Sepsis criteria during communication and immediately upon arrival in the emergency department.
Exclusion: <18 years of age, Trauma, Cardiopulmonary arrest, Pregnancy, STEMI, Stroke

34. Capnography and Sepsis
Clinical indicator of metabolic distress is lactate monitoring
Quantitative waveform capnography reliable for lactate monitoring in detecting metabolic distress in sepsis patients
Lactate levels rise when organ hypo perfusion occurs
Patient becomes lactic acidotic

35. Capnography and Sepsis
Body’s response is to increase respiratory rate to account for the acidosis
As lactate rises, carbon dioxide levels fall
ETCO2 levels accurate predictor of mortality in patients with severe sepsis or septic shock

36. Capnography
Severe sepsis is characterized by poor perfusion leading to build up of serum lactate and resulting in metabolic acidosis
This results in lower EtCO2 levels
Increased respiratory rate “blows off” CO2 and lowers EtCO2
Patients increase their minute ventilation as a compensatory mechanism in metabolic acidosis

37. Not the O2 saturation is 100% but the capnography reading indicates low CO2 levels coinciding with the increase in respiratory rate to combat the acidosis

38. Pediatric Sepsis
Leading cause of illness and death among U.S. children and worldwide
>42,000 cases annually increasing by 13% per year
4th leading cause behind asthma, appendicitis, and poisonings
7-9% of all childhood deaths are due to sepsis more common than cancer
4th leading cause of death behind asthma, appendicitis and poisonings

39. Pediatric Sepsis
EMS is likely encountering septic pediatric patients more often than we recognize
Challenge due to the low frequency of pediatric patients encountered
Severity of septic shock is often masked in infants and children due to strong compensatory mechanisms
Normal BP does not mean a pediatric patient is not in shock
Discuss how children compensate
Adults increase stroke volume by increasing strength of contraction and rate when stroke volume decreases.
Pediatric heart has a low compliance and therefore cannot compensate by increasing stroke volume can only increase rate. When they become bradycardic cardiac output has been drastically reduced.
Children rely heavily on rate of respiration to compensate for respiratory difficulties they cannot increase depth due to the inability of the diaphragm to move farther downward against the compact abdominal organs

40. Pediatric Sepsis Recognize signs of poor perfusion
Decrease in mental status
Cold extremities
Delayed capillary refill
Weak pulses, different central and peripheral pulses
Low urine output
Hypotension or low BP
Late sign in children
IF BP IS LOW THEY ARE DECOMPENSATING
Minimum systolic BP by age:<1 month: 60mmHg; 1month to 10 years: 70+(2x age in years); > 10 years: 90 mmHG
Low urine output= how many wet diapers etc.

41. Pediatric Sepsis
Progression in children from simply ill to severely sick to organ failure can happen rapidly
Initial presentation is often non specific especially in younger patients.
Subtle changes in vital signs can be difficult to recognize
Use reference devices for age appropriate vital sign ranges

42. CHART Mnemonic C- Complaint H- History A- Assessment R- Red Flags
T- Treatment
Common initial pediatric complaints that should cause an EMS provider to think sepsis include infections of the ear, respiratory or urinary tract)
JEMS.com/articles/volume 41/issue9 September 2016

43. Pediatric Sepsis
Complaints in pediatric patients that classically point to infection include
Runny nose (yellow/green drainage)
Fever
Rash
Vomiting/diarrhea,
Discharge or pus
Concentrated foul smelling urine

44. Pediatric Sepsis
Small patients may not be old enough to complain of anything
They may only experience vague non specific complaints such as
Extreme sleepiness
Lethargy or irritability
May have no history or obvious signs of infection

45. Pediatric Sepsis
The Pediatric Assessment Triangle (PAT) is considered to be an integral part of the general assessment of a sick child. It is used by PALS, APLS, Pediatric Education for Prehospital Professionals (PEPP), and the Emergency Nursing Pediatric Course (ENPC).Apr 17, 2016

46. Pediatric Assessment Triangle

47. High Risk Patients Malignancy Asplenia (including sickle cell disease)
Bone marrow transplant
Central or indwelling line/catheter
Solid organ transplant
Severe Mental Retardation/ Cerebral Palsy
Immunodeficiency, immunocompromised or immunosuppressed
Asplenia: Absence of a spleen and or its functions.

48. Assessment Criteria
Consider sepsis or septic shock if child has suspected or proven infection and at least two of the following:
Altered mental Status
Extreme or unexplained irritability, delirium, lethargy or floppiness
AVPU = V, P, or U
GCS <11 or recent change >3

49. Assessment Criteria (cont’d)
Body temperature:
< 97 degrees F or >101 degrees F (< 36 degrees C or >38.5 degrees C)
Tachycardia: Use reference guide for age appropriate range
Tachypnea: Use reference guide for age appropriate range
Serum glucose: >180mg/dL
Pediatric patients are very good at masking their level of distress until they reach the point of cardiovascular collapse.
If two or more criteria are met studies have shown this to be accurate in identifying pediatric patients with sepsis

50. RED Flags
Skin pale, ashen cyanotic or mottled or has a non blanching rash
Prolonged capillary refill of >5 seconds
Supplemental oxygen, required to maintain SpO2 > 92%
EtCO2 <32 mmHg
Respiratory: severe respiratory distress, tachycardia, bradycardia, grunting or apnea
These can be identified easily by ED staff and EMS personnel

51. Red Flags Heart Rate: High for age range
Systolic Blood pressure: Hypotensive for age range
<1 month: <60mmHg
1 month to 10 years: <70 +(2 x age in years) mmHg
Older than 10 years: <90mm Hg
Urine output <1mL/kg (dry diapers)
Serum glucose <120 mg/dL or >180mg/dL
Review Broselow Tape

52. Septic Shock Cold Shock Pulses central and peripheral weak
Capillary refill> 3sec
Skin mottled and cool
Mental status altered
Warm Shock
Pulses central and peripheral are bounding
Capillary refill <1sec
Skin is flushed, ruddy,
Mental status decreased, irritability, crying or drowsiness

53. PALS Guidelines Recognize altered mental status and perfusion
Give oxygen
Support ventilation
Establish vascular access
Fluid at 20cc/kg repeat as needed. Reassess after each bolus
Blood glucose

54. What Should EMS DO?
Airway: May require advanced airway
Breathing: Supportive oxygen ( consider BVM to reduce or eliminate the work of breathing)
Circulation: Rapid vascular access via IV or IO.
Fluid administration 20 mL/kg boluses of normal saline
Hyperglycemia is more common finding but check for hypoglycemia and treat age appropriate
Rapid sequence, delayed sequence or medication facilitated intubation should be used with caution as many induction agents may precipitate cardiac arrest in pediatric patients in septic shock. Ketamine is the preferred induction agent as it maintains cardiovascular stability
Etomidate may block the body’s normal stress response and increase the severity of the septic illness.
Breathing: P)ediatric patients in distress will often be working very hard to breathe. This work increases the patient’s oxygen demand whichmay already be high due to increased metabolism (fever) and the metabolic work to compensate for the devloping shock

55. Scenario
You are called for the 4 year old who has been feeling ill for 5 days with fever of
Child was seen in the ER last night and sent home with Tylenol. Diagnosed with a virus
Child is crying stating his stomach hurts.
Has not been eating or drinking today and minimal intake last several days

56. Scenario (cont’d) Pediatric Assessment Triangle Sick or not Sick?
Appearance= Lethargic
Work of breathing = Rapid and Shallow
Circulation to skin =Pale
Sick or not Sick?

57. Scenario Vital Signs Lungs clear
Heart rate = 150/min
RR= 30/min
Temp = F
Blood pressure= 80/ 46
Pulse oximetry = 92%
Lungs clear
Abdomen slightly rigid, tenderness in right lower quadrant
Not oriented to person, place, name

58. Scenario Dry mucous membranes Skin cool and dry
Capillary refill >3 seconds
Sick or not sick?
Treatment

59. Scenario
Once in the ambulance the child is placed on the monitor and oxygen.
IV was unsuccessful
You begin transport and the child becomes more lethargic and repeat vital signs are now:
BP 70/P
HR: 170
RR 40
Cap refill >5secs
What are your next steps in caring for this child?
Crew should discuss fluid administration, assisting ventilations or possible intubation
Child with diagnosed ruptured appendix and sepsis

60. Broselow Tape
Visual system for mediation doses and equipment selection
Based on relationship between weight and length across all ages
To use effectively have child lying down
Hold red end of tape at child’s head
Run tape down length of body until even with his/her heels
Medications are best dosed by actual body weight

62. Dextrose 10% Option due to frequent shortages of Dextrose 50%
Many diabetics have poor vasculature and dextrose 10% is better for the veins, easier to infuse (less osmotic)
The half life of D50 varies averaging about 30 minutes
D50 administration can result can result in rapid and prolonged hyperglycemia
JEMS March 2007
D50 administration can result in rapid and prolonged hyperglycemia
Vein irritation , extravasation resulting in tissue necrosis and thrombophlebitis can occur

63. Dextrose 10%
Rapid elevation of serum glucose may exacerbate chronic issues in the diabetic
Hyperglycemia, both acute and long term, has been associated with poorer outcomes in patients with
Stroke
Head injury
Post resuscitation outcomes
Sepsis
JEMS MARCH 2007

64. Dextrose 10% Dextrose 10% reduces risks of Vessel injury
Tissue damage from extravasation
Glucose fluctuations are less significant
Minimizes the risk of secondary rebound hypoglycemia

66. Administration Procedure
Equipment:
• IV Start Kit
• 2 sets IV Tubing
• 0.9% NS IV solution 250ml
• D 10% (25g/250ml)
Confirm Right Patient (Drug is indicated)
• Confirm hypoglycemia
• Confirm absence of allergy to the drug (hypersensitivity to corn products)
• Confirm absence of contraindications of the drug: glucose level is normal or high (>60mg/dL)
Prepare Equipment/Medication
• Start peripheral IV line/ Verify patency of primary line (Use of 20 gauge or 22 gauge angiocath recommended) Infuse 0.9NS at 10gtts/min
• Prepare medication for administration
1. Insert IV tubing into D10% IV bag.
2. Open roller clamp & expel air (prime tubing without wasting fluid); close clamp
3. Cleanse port closest to patient on primary IV tubing
4. Attach the secondary set(D10% line) to the primary IV tubing at the port closest to the patient
5. Close flow clamp of the primary IV tubing and open secondary tubing to D10% line to begin infusion

67. Administration Procedure

68. Administration Procedure

69. Administration Procedure

70. Pediatric Dosing Chart

71. Anyone Can Develop Sepsis