Page 30 - 2020 JSOM Winter

Infection may take many forms in initial presentation. Com- SIRS is a sign of an inflammatory reaction to a severe physio-
mon examples include viral upper respiratory infections, gas- logic insult. Although no longer part of the definition of sepsis,
troenteritis, urinary tract infections, cellulitis, and pneumonia. SIRS is a useful tool in identifying patients at risk of acute
In addition, infections associated with travel, to include diar- decompensation. The SIRS criteria consist of four indicators:
rhea, vector-borne diseases (malaria, dengue fever, etc.), and
some respiratory pathogens will be particularly common in 1. tachycardia (heart rate >90 beats/minute)
certain areas of the world. A comprehensive history of illness, 2. tachypnea (respiratory rate >20 breaths/minute or PaCo
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to include travel history, should be obtained initially. Many <32mmHg)
infections may be managed adequately without evacuation or 3. fever or hypothermia (temperature >38°C/100.4°F or <36°C/
need for higher levels of medical care. 96.8°F)
4. leukocytosis or leukopenia (white blood cell count
Differential diagnoses of presentations attributed to infections >12,000mm³, <4,000/mm³, or >10% bands). 7
must be considered as well. Sepsis “mimics” anaphylaxis,
gastrointestinal emergency, pulmonary disease including pul- A practitioner in an austere environment may not be able to
monary embolism, metabolic abnormality including hyper- measure all these indicators (especially WBC), but an under-
thyroidism and adrenal insufficiency, toxin ingestion, toxin standing of these features of early sepsis may prompt earlier
withdrawal, vasculitis, and spinal injury. If the condition pro- identification of disease and direct more-timely therapeutic
4
gresses to septic shock, “mimics” may interventions.
include other causes of shock such as W ARNING
myocardial infarction, gastrointestinal qSOFA is the more recent sepsis screen-
bleeding, dehydration, heat injury, and Hypotension is a late sign in sepsis. ing tool; it seeks to identify patients at
hypovolemia secondary to gastrointesti- Do not wait for blood pressure an increased risk of death. The presence
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nal losses. If infection and sepsis are still to fall before initiating treatment of two or more of the following three
prominent in the differential diagnosis and resuscitation in a patient who qSOFA indicators should increase the
after considering these other causes of is showing multiple signs of sys- clinician’s index of suspicion for sepsis:
shock, a focused assessment should be temic infection (fever, tachycardia, 1) altered mental status, 2) tachypnea
pursued, as detailed below. Any patient tachypnea, altered mental status, (>22 breaths per minute), and 3) hypo-
showing evidence of sepsis or septic decreased urine output). Delaying tension (SBP <100mmHg).
shock should immediately be classified intervention until blood pressure falls
as an urgent evacuation priority. can make it harder to get the sys- A more in-depth tool used in the predic-
temic inflammatory reaction under tion of ICU admission shown to be more
control and increase risk of death. effective than qSOFA is the NEWS2 score
Examination
which is based on only clinical measure-
Minimum: “SAMPLER” history (Symptoms/subjective com- ments and assessment. NEWS2 incorporates more variables,
plaints: Allergies to medications; Medications taken or pre- making it less “quick” than the qSOFA. Although not applied
scribed; Past medical and surgical history; Last meal/oral in clinical practice to sepsis evaluation exclusively, it may be a
intake; Events leading up to presentation; and Recent travel). very useful tool in predicting clinical deterioration. The clinical
Initial vital signs on presentation. Trending of vital signs (e.g., variables required to compute a NEWS2 score include respi-
on PFC flow sheet found on the JTS Forms website) when ratory rate, hypercapnic respiratory failure (yes/no), oxygen
looking for signs of severe infection are: fever or hypothermia, saturation (and need for supplemental oxygen), temperature,
increase in heart rate, increase in respiratory rate, and gen- heart rate, systolic blood pressure, and general level of con-
erally later rather than earlier, a decrease in blood pressure. sciousness. These parameters are recorded using a scale system,
Additionally, monitor mental status, Spo , and capillary refill. assigning points between 0 and 3 for each parameter. This tool
2
Complete secondary survey physical exam. Look for systemic has been shown to be superior to qSOFA for detecting sepsis
inflammatory response syndrome (SIRS), quick Sepsis-related with organ dysfunction in the emergency department. 8
Organ Failure Assessment (qSOFA) criteria, and/or a high
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NEWS2 score , listed below. Look for potential sources of in- The following clinical assessment—history and physical exam
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fection. Establish blood type of patient using an Eldon card. findings—should raise the suspicion for early sepsis:
• Better: Above, plus: Addition of simple labs: urine dip- Subjective Assessment
stick, BinaxNOW (malaria), i-STAT (or other point- • Patients with sepsis may report the below complaints,
of-care laboratory) values with vitals monitoring with no other obvious noninfectious source (i.e., bleed-
mentioned above. See i-STAT values in Appendix B. If ing, traumatic brain injury, heat injury).
available, monitor lactate. o Chills and rigors
• Best: Above, plus: Thick and thin smear (malaria), lab- o Confusion
oratory values (including lactate), culture data from o Malaise: feeling weak, with little or no energy
likely source(s).
Objective Assessment
The more indicators of systemic infection, the higher is the sus- Physical exam findings of patients with sepsis may include:
picion for the treating clinician. This is the “whole-patient” • Concerning (or obvious) sources of infection:
approach. A comprehensive problem list will be important to o Wound(s) displaying signs of infection (i.e., pain,
organize patient care. If sepsis is suspected, telemedicine should redness warmth, purulent drainage, swelling)
immediately be initiated (if possible) to help guide both diagnosis o Indwelling catheters (IV/IO/urinary) or devices in
and therapy. Monitor vital signs constantly to guide treatments. less-than-sterile/field environment

28 | JSOM Volume 20, Edition 4 / Winter 2020