What if it is not a duck? Sepsis: An atypical presentation
By: Carley Langley, BS, EMT-B & Rich Lindfors, NRP
When it comes to the realm of EMS, not everything is what it seems. If it looks like a duck, swims like a duck, and quacks like a duck, then it must be a duck…right? Theoretically, the quickest and most straightforward explanation is that yes, surely it is a duck. However, suppose you come across something that looked like a duck, swam like a duck, and quacked like a duck─ but it turned out to be a horse? As any well-seasoned medic can tell you, it is a rarity in the field of EMS for quick explanations, here is a recent case to emphasize early detection and diagnosis of sepsis.
|Could it be…? (Source: WikiCommons)|
A Curious Case of Sepsis
Imagine it is the winter of 2019: the morning weather has all the indications of a great day on duty. The air is crisp and cold; the sun is out with scarcely a cloud in the sky.
You and your partner are debriefing about the night’s calls when you hear the emergency tones sound through the mobile data terminal. You instinctively sit up to attention as a familiar voice comes over the radio, “Medic 89, start priority one reference a fall.” As your partner begins to navigate the early morning traffic emergently, updated information comes through regarding the patient following the communication center’s interrogation: the patient had not fallen, but instead merely needed assistance getting from his house to his car. As a result, the call gets “downgraded” to a non-emergent response (because there were no immediate life threats) and you relax in your seat in preparation for a relaxed public assist.
When you arrive on scene, there is a small gathering of people, but no immediately apparent hazards or life threats. A firefighter waves you into the fray, greeting you with a brief update on the situation. Further information reveals the patient lives alone and has been increasingly ill for the pasts five days with a fever being “controlled” with OTC (over-the-counter) Tylenol®.
Family members present note a decrease in his overall mental status, a decline in his appetite, and a description of symptoms consistent with dehydration. They also indicate to you the patient’s home felt “quite cold” upon entering today and found it odd, as the patient usually kept the house very warm.
When approaching the patient, your primary impression is poor. His eyes only open as you introduce yourself and begin the assessment, and then slowly close back. Reaching out to find a radial pulse, you find there is none palpable. His skin feels cold to the touch, and his breathing is shallow and infrequent. Assessing his mental state, he only knows his name and where he is, and the family indicates he is typically more awake and alert. He seems generally confused, and this is confirmed when he only withdrawals his limbs to painful stimuli.
Attaching the patient to a cardiac monitor reveals a heart rate in the upper forties with 4-lead ECG confirming the bradycardia. Additionally, he is found to be hypotensive with a systolic blood pressure of 90. Every sign and symptom directs you to the conclusion that the patient is suffering from a textbook case of environmental hypothermia. All doubts in your mind about this case are gone when you obtain a tympanic temperature reading “LOW.” Do you agree with the assumption this patient is suffering from environmental hypothermia?
The paramedic began treating the patient for sepsis as a primary impression and secondary to possible environmental hypothermia. Intravenous (IV) access was obtained, and fluids were run immediately. Two 0.5 mg doses of atropine were pushed via IV 10 minutes apart during transport. Cardiac monitor defibrillation/pacing pads were immediately placed on the patient as a precaution, and the patient was transported emergently to the nearest hospital.
You notified the facility of your impending arrival, and as you push the patient on the stretcher into the hospital, a nurse guides you into a nearby hospital room. Asking for the report as she prepares the re-warming supplies at the bedside and adjusts the temperature on the thermostat. You finish your turnover of the patient and share your on-scene findings, including the possibility of sepsis. You receive confirmation as you walk out of the room, the bed light overhead flashes red and the ED intercom keys up. “Code sepsis!” the notice declares the room number for the patient you just delivered as additional nursing staff rush in to assist.
Sepsis: More than a Fever
The hospital certainly believed the patient was critically ill and agreed with your assessment of the patient. As the reader, it has probably been made abundantly clear to you that the patient, despite his classic presentation for environmental hypothermia, was actually in the late stages of sepsis. The hospital was able to stabilize and replete the patient swiftly, and his septic infection tempered with vigorous antibiotics over the course of several days. A week later, the patient was discharged from the hospital and back at his baseline. However, the outcome could have been much more severe if the medics had failed to recognize the (albeit, subtle) indications of advanced septic infection. So, what can we learn from this case?
In 1991 the American College of Chest Physicians and the Society of Critical Care Medicine Consensus Conference collaborated to combat this confusion and construct an organized framework. Strictly categorizing the progressively worsening stages of sepsis starting with SIRS (Systemic Inflammatory Response Syndrome), sepsis, severe sepsis and defining specific criteria required for each step is still referenced today (Mayr, Yende, & Angus, 2014).
Even in a country at the forefront of most medical research, “sepsis remains one of the top causes of death and is the number one reason for death amongst non-coronary ICU patients across all U.S. hospitals” (Mayr, Yende, & Angus, 2014). Despite its prevalence throughout the healthcare field, an exact definition of what constitutes “sepsis” has been challenging to identify. The criteria vary by region, facility, practitioner, including its criteria, are within an administrative, scientific, or clinical context.
The terms “sepsis,” “septicemia,” and “bacteremia” are often used by health professionals and EMS personnel to describe a type of a wide-spread (a.k.a. systemic) inflammatory response. While not wholly incorrect, according to the U.S. CDC’s definition, sepsis is “the body’s extreme reaction to an infection” of any origin (Center for Disease Control and Prevention, 2018). When a patient “dies of sepsis,” what it means is a small source of infection or inflammation became so advanced and widespread that ultimately the circulatory system was compromised. As the patient’s tissues received less blood flow, the patient’s organ systems began to dysfunction and fail.
Who is at risk?
In truth, anyone who has an infection (e.g., fungal, bacterial, viral) is at some risk for developing a septic infection until they fully recover. However, some patient populations are a much higher risk including elderly (aged 65+); children younger than one year of age; pregnant women; those who are immunocompromised; people with chronic medical conditions such as heart failure, diabetes, or cirrhosis (Mayo Clinic Staff, 2018). When compared with the rest of the general population, males and people of African-American descent are also at an increased risk for developing sepsis at some point over the course of their lifetime (Center for Disease Control and Prevention, 2018). Also, people with open wounds/injuries or who have recently undergone surgery are also at a heightened risk for developing an infection that could quickly progress to sepsis.
Sepsis can also originate from any part of the body or any tissue inflammation (e.g., pneumonia, influenza, urinary tract infection, open leg wound) and progressively spread. Statistically speaking, the most common sources of sepsis are infections of the respiratory, urinary, and digestive tracts (Mayo Clinic Staff, 2018).
Since 2003 the rates of severe sepsis have begun to progressively increase in the United States (GS Martin, 2003). Unfortunately, this trend is “expected to continue” as a result to a growing aging population (compounded by steadily rising life expectancies), the increasing burden of chronic health conditions, and increased use of immunosuppressive therapies, transplantation, chemotherapy, and invasive procedures (Mayr, Yende, & Angus, 2014). Thus the need to recognize SIRS and sepsis in its earliest stages has become even more critical, and it is the on-scene EMTs and paramedics who arrive first on scene to these patients who can have the most significant impact on reducing the proliferation of severe sepsis and septic shock in the future.
Sepsis is perhaps one of the most common EMS responses, although, many go unnoticed due to other confounding factors and the resulting documentation not supporting the diagnosis. Many septic patients require plenty of IV fluids to replenish their circulatory system and replete against dehydration, as well as an immediate initiation of a regimen of broad-spectrum antibiotics (if the source of infection is unknown) to be administered in a hospital setting under close medical supervision (Mayo Clinic Staff, 2018). After these cultures are obtained from the patient, the specific type of infection identified, and more specifically-target antibiotics initiated.
In the pre-hospital environment, the treatment plan begins with early recognition, early intervention, and rapid activation of the sepsis team at the receiving hospital. Because of this medic’s thorough understanding of sepsis, the patient received IV fluid resuscitation and atropine to combat sepsis. If the patient responds to the medication, the increased heart rate (HR), blood pressure (BP), and mean arterial pressure (MAP) should buy time until arrival to definitive care.
Documenting an atypical case such as this can be one of the most challenging skills EMS personnel encounter.
Table 2. Criteria for SIRS, sepsis, severe sepsis, and septic shock based on the 1991 ACCP/SCCM Consensus Conference.
Carefully consider the details of the call before writing your electronic Patient Care Report (ePCR). This case presented during a random selection for review, and when the analysis was complete, there were more questions than answers. After discussing the case with the crew, they explained how this duck on paper became a horse on the scene by knowing the parameters of sepsis and the tools used (see table 2) to distinguish between the two common symptoms. They were able to relate these vitals to treat and get the patient to definitive care properly.
The horse, in this case, is also in the details. The vital signs recorded all lead to environmental hypothermia; however, this may not be the first problem. The same vital signs can lead the reader to septic shock because there is no context within the documentation. There was no context in the narrative leading to sepsis other than the use of Atropine. Details omitted from the report which would have led the reader to sepsis rather than hypothermia.
There is no doubt the entire narrative is essential; there are vital areas where details are crucial to “painting the picture” or “telling the story.” Descriptions for Dispatch/Response and Arrival are examples of this; however, the HART of the narrative is the best avenue for the clinical and treatment explanations.
History is in three parts: chronic, past pertinent, and history of present illness. Together, these begin to focus the picture by providing details for the reader of how the patient lives, their participation level in preventative care and adherence to medication regimen, what happened and why they need emergent care today and other factors leading to your presence.
Second is the assessment; this should match the description provided in the history section. For example, if the report includes a patient with bilateral below the knee amputations (BKA), this should match the assessment. A common concern heard is, “why do I have to be redundant?” Is this being redundant? No, it is not redundancy; this is being thorough, detailed, and descriptive of how BKA’s may be related to the current situation.
Third, the treatment section’s primary goal is to explain what you did, and also why you did not do something. This case of sepsis should have been more descriptive, and because it was not, this call sheet did not demonstrate critical thinking skills and should have.
Finally, the transport section. Explain how you moved the patient from point A to B to C and so on throughout the patient experience. Describing in great detail how a patient was moved only serves to support all of the above and confirm the severity of the patient’s condition.
Sound documentation is required in cases involving any atypical presentation or other distracting illnesses or injuries. The first layer of Quality Assurance is the author of the ePCR and the partner who assists and when complete all crewmembers should read the patient care report and arriving at the same conclusions or identify a vital fact overlooked or omitted.
Most will recover from mild sepsis, whereas the “mortality rates among patients with septic shock are approaching 50%.” (Mayr, Yende, & Angus, 2014). It is important to note current physician’s understanding in regards to the epidemiology of sepsis continues to grow, and the definition and guidelines for identifying and treating SIRS, sepsis, and septic shock are likely to continue to evolve. All EMS personnel, regardless of rank or experience, are encouraged to remain inquisitive and up-to-date on all sepsis-related literature to maximize positive patient outcomes.
*NOTE – The care plan described herein is for a specific patient and their circumstance and is for illustrative and educational purposes ONLY. This article is NOT intended to replace any protocol(s) and should only heighten your recognition of this atypical presentation of advanced sepsis.
Have ideas for future issues? Email Rich Lindfors at firstname.lastname@example.org or call (804) 254-1193.
Center for Disease Control and Prevention. (2018, June 22). What is Sepsis? Retrieved from Center for Disease Control and Prevention: https://www.cdc.gov/sepsis/what-is-sepsis.html
Duck2.jpeg. (2008, May 21). https://commons.wikimedia.org/wiki/File:Mallard2.jpg. Wikimedia Commons.
GS Martin, D. M. (2003). Th Epidemiology of Sepsis in the United States. New England Journal of Medicine.
Heale, R., & Twycross, A. (2018, January). What is a case study? Evidence-Based Nursing, 21, 7-8. doi:10.1136/eb-2017-102845
Johns Hopkins Medicine. (n.d.). What is Septicemia? Retrieved from Johns Hopkins Medicine: https://www.hopkinsmedicine.org/health/conditions-and-diseases/septicemia
Mayo Clinic Staff. (2018, November 16). Diseases and Conditions: Sepsis. Retrieved from Mayo Clinic: https://www.mayoclinic.org/diseases-conditions/sepsis/symptoms-causes/syc-20351214
Mayr, F. B., Yende, S., & Angus, D. C. (2014, January 1). Epidemiology of severe sepsis. Virulence, 5(1), 4-11. doi:10.4161/viru.27372
SEEDREAM, Shutterstock. (n.d.). Sick Old Man Sitting On the Sofa with a Cold. https://www.shutterstock.com/video/clip-9339362-sick-old-man-sitting-on-sofa-cold. Shutterstock.