SHOCK SEPSIS REVELATIONS-GICS evening the
This weeks GICS event was held in Suttie centre as paramedics, doctors, nurses and fireteams gathered to improve understanding of emerging issues in prehospital care. The topic was shock, and as a lowly medical student this was an absolutely brilliant insight into something that while the basics of the physiology has been discussed the extent of the issue had not been disussed nor had the management of sepsis been explained.
Shock is a disorder of reduced tissue perfusion resulting in the accumulation of metabolic products and tissue hypoxia. Low blood pressure, sympathetic activation are typical signs in patients. The clinical picture of a sweaty, ashen patient springs to mind, and as organs begin to suffer, renal failure and ... follow. The physiology is failry simple, picture a system of pipes and a central pump, if blood stops flowing at a normal rate through tissues this is either an issue of the pump, or the pipes. Shock can be broadly categorised as:
Hypovolemic - dehydration, haemorrhage
Obstructive -PE, tamponade
Distributive- toxic and septic
Cardiogenic-MI
In other words, supply fails because the pressure falls to low, as vessels widen, or the blood cannot get out,
However, this is where the tak really got interesting, while MI's and trauma are a favourite topics when considering shock, the really massive and misunderstood issue is sepsis.
What is more, sepsis is just as much a time sensitive diagnosis as MI, if adequate care is given before the patient ever reaches hospital the chances of a good outcome are far higher, and interventions such as antibiotics are cheap, effective and will cause little harm in the case of misdiagnosis. Paramedics and GP's should be carrying ceftriaxone or an equivalent broad spectrum antibiotic and should not be hesitant to administer in cases where there is strong clinical suspician of sepsis.
Before we go any further, we should clarify that sepsis is a spectrum, and when speaking about a patient this term should NOT be used. Instead try and make a judgement call as to what stage the patient is actually at, as this is the difference between a patient who is about to go into multi-organ failure and one that is ticking along at the minute but will go downhill without help.
Pior to even the sepsis stage we have SIRS- systemic inflammatory response syndrome, like the harbringer of doom. SIRS is confirmed if ANY TWO of the following are present:
1.New onset of Confusion or Altered Mental State
2.Temperature >38.3 or <36 degrees
3.Heart Rate >90 beats per minute
4.Respiratory Rate (counted over 60 seconds) >20 breaths per minute
5.POCT (point of care testing, eg a simple portable analyser for blood glucose and lactate) Blood Glucose >7.7mmol/L in the absence of known diabetes
Two or more of these then you are into uncomplicated sepsis, add on evidence of single organ disfunction (such as lack of urine output) severe sepis, add on hypotension and evidence of hypoperfusion and you have septic shock. See image below:
For purposes of documentation and handover, only the followinf terms should be used : Septic shock, Severe sepsis, Red Flag sepsis, Uncomplicated sepsis, No current evidence of sepsis. The speaker recommended that ringing ahead to the admissions is well worth doing and can really aid the speed of treatment delivery.
As white cell counts, blood glucose and lactate are needed for identification of severe sepsis, or spetic shock in prehospital settings a simpler system is used. You really want to know if they have Red Flag sepsis. Red Flag Sepsis is identified if ANY ONE of the following are present: Systolic B.P < 90 mmHg
Lactate > 2 mmol/l (where available)
Heart rate > 130 per minute
Respiratory rate > 25 per minute
Oxygen saturations < 91%
Responds only to voice or pain/ unresponsive
Purpuric rash
A good history can be really helpful. Have they passed urine in the last 24 hours, basically are they in renal failure yet? Is there any evidence of the route infection, eg have they had a productive cough? have they had a recent UTI?
Once all this has been sorted we get down to the nitty gritty, you have your dodgy looking patient in front of you, what are you going to do? The feature image may give it away.. It is the Sepsis 6 care pathway. A bundle of 3 tests and 3 interventions that will make the difference.
This video does a far better job of explaining all this than me so take a look:
A great source of information on sepsis is the Sespsis trust website (from which included images were takem) http://sepsistrust.org/how-can-i-help-mend-sepsis/uk-sepsis-trust-promotional-products/electronic-brand-pack/posters/ It has loads of really nice documents that present simple graphic representations of best practice in each context, (emergency care, GP, paramedic etc). In the end the take home message was, we should be doing more becuase the early recognition, intervention and escalation for the treatment of shock is essential to improve the presently dismal outcome for septic patients.
