Page 127 - JSOM Summer 2022

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sepsis. When assessing temperature, core temperature is de- valuable tool to have in the austere setting. Changes in re-
sirable compared to other methods given that the current sepsis spiratory quality often present on EtCO waveforms, and in
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criteria use core temperature to qualify the diagnosis. Fevers conjunction with other vital signs, will create a more precise
greater than 38°C (100.4°F) are more indicative of active sep- clinical picture for the clinician.
tic response, though low-grade fevers should not be viewed as
a pertinent negative when performing sepsis workup. 30
Identification of Sepsis in the Austere Setting
Blood Pressure Given the limitations of an austere setting, identifying sepsis in
Age-specific blood pressures are calculated with several for- these environments – while challenging – is not impossible. The
mulas; two of the most common formulas are minimum sys- primary identifiers of sepsis in the absence of vital diagnostic
tolic blood pressure (SBP) goal = 70 + (2 × age in years) and resources are independent of the cause of sepsis itself. The pres-
median SBP goal = 90 + (2 × age in years). While this metric ence of febrile or hypothermic illness with a delayed capillary
has been traditionally used, a 2007 study found that these refill, increased respiratory effort or respiratory distress, abnor-
calculations are based on healthy children and may not be mal pulse findings, and cold extremities create a firm differen-
appropriate for critically ill children. The same study also tial diagnosis of sepsis. Additionally, if capillary refill is brisk
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found that SBP and mean arterial pressure (MAP) are closely in the presence of a bounding pulse, febrile illness, and respira-
related to height, concluding that the traditional metric does tory abnormalities, clinicians should be equally concerned for
not appear data-driven and should be adjusted based on clini- sepsis as these are typical findings in the early stages of sepsis
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cal presentation. Besides considering SBP and MAP values, a development. 10,34 Rather than focus diagnosis on the root cause
widened pulse pressure is often observed with a normal MAP behind a septic illness, mortality predictors in conjunction with
in the early stages of sepsis. 3,16,27 clinical presentation have proven effective in detecting sepsis.
The World Health Organization currently utilizes and rec-
Oxygenation ommends this approach. 10,35 Traditional vital sign criteria for
Hypoxia (SpO < 93%) in the presence of a presumed infec- systemic inflammatory response syndrome (SIRS) can still be
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tion (respiratory or otherwise) is an indicator that the patient utilized with this caveat, but clinical findings showing evidence
will require intensive therapies and is directly correlated to of compensation and dysfunction are better suited for detection
poor prognosis and progress. 19,23,30 Low SpO values may also given their direct association degree of compensation and organ
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result from poor circulation, which is indicated by poor capil- dysfunction. Utilizing the patient’s historical findings such as a
lary refill. Poor capillary refill, as discussed earlier, is another change in mental status, progressive weakness, feeding changes,
clinical indicator of inadequate compensation and the need for temperature abnormalities, and urinary findings can be used to
immediate therapies. Oxygen debt in children increases over create a higher index of suspicion. Language barriers can often
time and relates to lactic acidosis. Disturbances in oxygen dis- exist, preventing a clear interpretation of prior events. As such,
sociation based on the degree of acidosis can be challenging to clinical findings remain a priority for accurate diagnosis.
address without laboratory resources. The use of tools such
as end-tidal carbon dioxide (EtCO ) may prove useful when
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assessing for compensation with acidosis. Management
Given that sepsis is an aggressive disease process, it requires
Heart Rate early intervention to create the best possible outcomes. De-
Heart rate (HR) is often elevated in the septic child and is tection and treatment initiation within 1 hour is definitively
usually the result of a compensatory mechanism for maintain- the most critical step in sepsis management. 1,6,13,19,34 Current

ing cardiac output and adequate end-organ perfusion. If the recommendations and guidelines reinforce early detection and
HR is > 20 beats/minute out of the expected range, this is a intervention as key elements in treating septic children. 10,13,19
strong indication of compensation. 3,30,32,33 Peripheral pulses are Given the constraints of an austere environment, this presents
often bounding in early stages, whereas in late stages, they are a series of challenges in which some goals may not be attain-
generally diminished. 27,34 As sepsis progresses and decompen- able. Following identification of the septic or potentially septic
sation begins, the peripheral vasculature will dilate due to a child, treatment should follow rapid primary steps followed
combination of immature vascular tone and loss of catechol- by patient-specific goal-oriented therapy.
amine stores. This ultimately leads to inadequate MAPs, col-
lapsed vasculature, leaky capillaries (hypovolemia), and a host Vascular access should be established first, provided there are
of metabolic disturbances. 4,24,26 not immediate oxygenation issues. If clinicians feel that intra-
venous (IV) access will be necessary but difficult to obtain,
Respiratory Rate intraosseous (IO) access is encouraged and recommended. 10,19
Respiratory rate (RR) will often be elevated, leading to fatigue IO access in children has been proven to be fast, effective, and
and eventually respiratory failure if left unsupported. Respi- safe. 10,19,36 IO devices are commonplace for many prehospital
ratory compensation is often related to change in pH due to clinicians, making it an accessible tool for clinicians. Many chil-
sepsis progression and increasing oxygenation debt. 24,26 Respi- dren will initially present in late stages of sepsis, and sometimes
ratory distress is a frequent chief complaint in septic children, in states of septic shock/MODS with vascular collapse and de-
potentially due to change in respiratory status being more hydration, making it challenging to obtain IV or even central
noticeable than other subtle changes. EtCO monitoring is an access. IO access provides the rapid access needed to allow clini-
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excellent tool for assessing these patients. Recent changes in cians to perform life-saving interventions quickly, and clinicians
adult sepsis criteria have also included EtCO values as indi- should not hesitate to utilize this resource if it is available.
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cators of SIRS and sepsis progression. Nevertheless, despite
no current data-driven metrics supporting the routine use of Following IV/IO access, the priority shifts to the patient’s
EtCO for pediatric sepsis diagnosis, it can be an immensely airway and respiratory status. With children being prone to
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