Page 29 - 2020 JSOM Winter

Sepsis Management in Prolonged Field Care

28 October 2020

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Justin Rapp, 18D *; Sean Keenan, MD ; Daniel Taylor, EMT-P, TP-C ; Andrea Rapp, RN, 68W ;
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Michael Turconi, PCP, FMR, OR ; Ryan Maves, MD ; Michael Kavanaugh, MD ;
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Devan Makati, MD ; Doug Powell, MD ; Paul Loos, 18D ; Simon Sarkisian, DO ;
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Ankit Sakhuja, MD ; Dan Mosely, MC ; Stacy Shackelford, MD 14
Introduction
This Role 1 prolonged field care (PFC) guideline is intended for 1. early recognition (including an awareness that the magni-
use in the austere environment when evacuation to higher level tude of injury or illness has the potential to lead to shock);
of care is not immediately possible. A provider must first be 2. identification of the cause of shock; and
an expert in Tactical Combat Casualty Care (TCCC). The in- 3. early, decisive treatment of the cause and initiation of
tent of this guideline is to provide a functional, evidence-based cause-specific resuscitation.
and experience-based solution to those individuals who must
manage patients suspected of having or diagnosed with sepsis Severe infection is often a greater risk than trauma in the PFC
in an austere environment. Emphasis is placed on the basics of environment. Trauma-associated sepsis is an important sub-
diagnosis and treatment using the tools most familiar to a Role set of sepsis in the military population, with a potential for
1 provider. Ideal hospital techniques are adapted to meet the casualties to develop severe wound, respiratory, urinary, and
limitations of austere environments while still maintaining the bloodstream infections related to their initial injury and initial
highest standards of care possible. treatment procedures (IV/IO catheters, foley catheters, etc.).
Up to 38% of trauma-related sepsis is bloodstream related. In
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Sepsis and septic shock are medical emergencies. Patients sus- the trauma patient, the manifestation of sepsis is often several
pected of having either of these conditions should be imme- days after initial presentation which makes sepsis particularly
diately evacuated out of the austere environment to higher relevant in the PFC environment over a Role 1 with greater
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echelons of care. These patients are often complex, requiring medevac capability. Early antibiotic therapy and hemody-
24-hour monitoring, critical care skills, and a great deal of namic resuscitation with fluids and vasopressors are the key
resources to treat. Obtaining evacuation is the highest treat- initial therapies for the septic patient. Source control is simi-
ment priority for these patients. This Clinical Practice Guide- larly critical and may require surgery. When this is not possible
line (CPG) uses the minimum, better, best paradigm familiar in the PFC environment, the patient must be supported and
to PFC and gives medics of varying capabilities and resources transported to a location with surgical capability as rapidly
options for treatment. as possible.

Sepsis Management Goals
Sepsis Definitions
Sepsis management goals should include the following: 1
Sepsis: Life-threatening organ dysfunction caused by a dysreg- • Early suspicion and recognition
ulated host response to infection (Sepsis-3 definition, adopted • Source identification
by Surviving Sepsis Campaign in 2017). 1
• Early antimicrobial therapy
• Resuscitation
Septic Shock: Persistent hypotension requiring vasopressors • Source control
to maintain mean arterial pressure (MAP) > 65mmHg and • Patient monitoring through trending patient information
having a serum lactate > 2mmol/L despite adequate volume • Early telemedicine consultation
resuscitation.
• Evacuate to definitive care
Shock is one of the most common complications of severe in- Early Suspicion and Recognition
jury or illness. Shock is separated into four different classes: 1)
hypovolemic (including hemorrhagic), 2) cardiogenic, 3) ob- GOALS: Recognize sepsis and review the differential diagno-
structive, and 4) distributive. Septic shock is a form of distrib- sis; identify systemic infection before it progresses to decom-
utive shock. The hallmark of managing shock is: pensated shock; and identify patients who require evacuation.

*Correspondence email and affiliations are given on page 39.

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