On the topic of Sepsis

Hope all is well up there in the big smoke

Recently I attend the job outline below and there was a disagreement between me and another paramedic around the use of antibiotics for the patient. I keen to hear your guys opinion on this.

History:

  • 75 year old female CA of the brain, patient not on radiation nor going through chemotherapy at the moment. Had recent surgery to remove the CA
  • Ambulance called as patient feels weak and is struggling to get out of bed feels like her legs will give if she walks
  • Located in Balclutha – 1 hour away from hospital
  • Pt states feeling hot/cold at 0500 with shaking which woke her

On arrival:

  • pt lying in bed no pain or discomfort looks pale
  • Appears dry and pale.

On Examination:

  • Pt states feels dry
  • Normal oral intake
  • Urine normal
  • Pt clammy
  • Nil rash
  • no clear source of infection
  • Lungs clear
  • nil nausea, nil vomiting
  • otherwise well
  • states feels well for self
  • Oral mucosa is dry and cracked

Vitals as follows:

  • GCS: 15 (Eye: 4 Verbal: 5 Motor: 6)
  • Heart Rate: 120 bpm Location: Radial
  • Respiratory Rate: 20/min;
  • Blood Pressure: 110/76 Monitor
  • SpO₂: 90 %
  • ECG: 3 lead Initial presenting rhythm: Sinus Tachy
  • Cap Refill:Peripheral: 2 Central: 4
  • Temperature: 38.90 °C (Tympanic)
  • Skin: Pallor (pale)

Patients medications:

  • Loperamide
  • Dexmethsone
  • Omeprazole
  • Zopiclone
  • Betaloc
  • Ferrograd

Is this patient Showing signs of sepsis?or sepsis shock?

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4 Comments Add yours

  1. Andrew O says:

    I think I agree Tats… (unsurprisingly). I think I allured to this before, but sepsis rather than septic shock.

    I think they’d be justified in giving this patient AB’s according to our CPGs, but I don’t agree with it- purely due to the lack of clear site of infection.

    “Sepsis is present when a patient has clear signs of infection and signs of a systemic inflammatory response.
    For example, a patient with cellulitis, a surrounding red area with pain, a temp of 38.5, HR of 120, and normal perfusion, has sepsis” (2016-2018 St John CPGs)

    “Septic shock is the above (abbreviated), with clear signs of shock. For example, a patient with cellulitis, a surrounding area with pain, a temp of 38.5 and a HR of 120, a BP of 110 sys and PCRT of 4s, has septic shock” (2016-2018 St John CPGs)

    This is your patient (I assumed you’ve got the CR times mixed up, and due to that, old mate would’ve been justified in prehospital AB use. One could argue that the site of infection could be multiple and difficult to assess, and due to guidelines like the surviving sepsis one Tatsu put up, we should have early AB use.

    *However*
    For a patient to meet the criteria for septic shock, the cause of the impaired cardiac output needs to be the infection. I don’t think this is the case in this patient. It certainly isn’t helping them, but I don’t know it’s the cause.

    If we were to do a 500ml fluid challenge, would we see a balance in HR/ BP to a more normal range? and if we retake the patient’s temp (I assume you didn’t, Blair) at hospital, is it still 38.5?

    In summation: I think both ways are right, but they’re more likely to have poor cardiac output from a different cause, that may be reversible. Do I think there is any major problems either way? Not really.

    Like

  2. Tatsu Kuwasaki says:

    I’m afraid I won’t be brave enough to give a confident opinion on this but here is my thinking…

    If this was in Christchurch, I would certainly withhold AB (especially being a CA patient).
    However…pyrexia with shakes indicates potential bacterial infection.
    Pt is tachycardic and SBP of 110 may be low for this Pt.
    Slow central CRT with peripheral vasodilation (faster peripheral CRT) is indicative of poor perfusion and warm shock.
    Why SPO2 so low while lung sounds are normal?

    There is a long transport time, so I’d be consulting for AB especially the new types coming in on the new CPG update may be indicated, and also discuss other potential cause of pyrexia i.e. drug reaction.
    Consult because this may also be out of scope by giving AB for sepsis rather than septic shock defined in our CPG.
    Our medical direction is clear that we give AB only for clear septic shock.

    In terms of fluid, I’d start it but won’t be aggressive. Pt has adequate BP to sustain vital organ perfusion.

    Surviving Sepsis Campaign certainly recommends “early” AB when sepsis/septic shock.
    Interestingly, if you follow one of the recommended flowchart, you’d be giving AB for this Pt.
    Check out the flowchart;

    http://www.survivingsepsis.org/SiteCollectionDocuments/Protocols-St-Helens-Adult-Sepsis-Management-Pathway.pdf

    Would love to hear what others are thinking!

    Like

  3. odgersaj says:

    To me- sepsis and dehydration. Yes it’s systemic involvement of a probable infection, but as it stands I don’t think septic shock. It’s missing poor perfusion, or any significant circulatory compromise. After a litre or two of fluids with hypovolaemia from other causes, I think you would find a different patient to be examining…

    Like

  4. Tatsu Kuwasaki says:

    Great case for discussion. Thanks Blair!

    Like

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