Page 97 - JSOM Summer 2024

PCC: recognizing critical illness, resuscitation and hemody- Independent Duty Corpsman and two junior Corpsmen, two
namic support, respiratory support, and complication preven- stacked ward beds, and basic point-of-care labs. Available labo-
4–6
tion and management. Therefore, learning the management ratory capabilities include a rapid complete blood count (CBC,
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principles of sepsis and septic shock provides an introduction utilizing QBC STAR (Drucker Diagnostics, Port Maltida, PA,
to core critical care competencies and, by proxy, the principles USA; https://druckerdiagnostics.com), dipstick urinalysis (UA),
described in the PCC CPG. Sepsis was also chosen because finger stick glucose with a glucometer, and fecal occult blood
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infected war wounds have plagued combat casualties as long testing. There is no ultrasound, cardiac monitoring, electro-
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as there has been war. In the Vietnam War, sepsis was the cardiogram, or x-ray capability.
third leading cause of death (11.7%) of in-theater hospitalized
combat casualties, behind head injury (42.5%) and hemor- Patient
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rhagic shock (23.9%). It is likely that in any future conflict A 20-year-old male Sailor presents to DDG Main Medical
involving an LSCO, casualties with contaminated and infected with approximately 12 days of abdominal pain. The Sailor is
war wounds will require PCC at or near the point of injury. new to the ship and joined the DDG during a recent port call
Aeromedical opportunities are also likely to be limited as the several days ago in Guam. The Sailor was treated for consti-
U.S. and Allied Forces are unlikely to have the air superiority pation six days prior at the U.S. Naval Hospital in Guam and
experienced during the last 20+ years of war. In this potential subsequently released after symptoms resolved following ad-
future operating environment, combat casualties with contam- ministration of a saline enema. Now, he complains of severe
inated war wounds will require care at or near the point of abdominal pain and subjective fever. He was brought to medi-
injury for hours to days before MEDEVAC to a higher level cal by his leadership, who is concerned that he seems confused
of care is possible. Therefore, far-forward Role 1 caregivers today. He notes poor appetite for the duration of symptoms,
in any austere environment must understand the principles of nausea, and multiple episodes of emesis over the last 6 hours.
infection prevention and sepsis management.
Past Medical History: Asthma. Not currently on inhalers. Ap-
proximately 12 months ago, he was hospitalized for seven
Epidemiology
days with COVID-19 pneumonia, where he received remde-
Sepsis is defined as life-threatening organ dysfunction caused sivir and dexamethasone and returned to full duty.
by a dysregulated host response to infection. Septic shock is a
subset of sepsis in which underlying circulatory and cellular Time 0 minutes
metabolism abnormalities are profound enough to substan- Presenting vital signs: heart rate (HR) 130 beats per min (bpm);
9
tially increase mortality. Clinically, septic shock manifests as blood pressure (BP) 92/65mmHg; respiratory rate (RR) 30
persistent hypotension requiring vasopressors to maintain a breaths/min; peripheral oxygen (O ) saturation (SpO ) 92%;
2
2
mean arterial pressure (MAP) >65mmHg and serum lactate temperature (temp): 39°C; body mass: approximately 70kg.
>2mmol/L despite adequate volume resuscitation. Any in-
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fection can evolve into life-threatening sepsis or septic shock, Physical Exam: Confused, thinks he is in Recruit Training.
including but not limited to skin and soft tissue infections Opens eyes spontaneously and follows simple commands. Ap-
(SSTI) such as cellulitis, abscesses, and necrotizing soft tissue pears to be in distress, with nasal flaring and increased work
infections. Other common causes of sepsis include gastroin- of breathing. The abdomen is distended, with voluntary guard-
testinal perforations (e.g., appendicitis and diverticulitis), per- ing and diffuse tenderness to palpation; he is most tender in
irectal abscesses, urinary tract infections (e.g., pyelonephritis), the right lower quadrant. Skin is cool to the touch; peripheral
pneumonia, gynecologic infections, and biliary diseases (e.g., capillary refill time (CRT) is greater than 4 seconds assessed at
cholecystitis and cholangitis). The most common diagnoses the ventral surface of his right index finger. (Peripheral CRT
associated with sepsis hospitalizations in active-duty service assessed at the nailbed (Box 1) is as effective as serum lactate
members are pneumonia, pyelonephritis, urinary tract infec- when used to target fluid resuscitation in septic patients). 13–18
tions, post-operative infections, and cellulitis of the lower
extremities. From 2011 through 2020, women had a nearly
twofold higher incidence of sepsis hospitalizations than men BOX 1 Diagnostic Maneuvers and Procedures Utilized in this
and were more likely to have urinary tract infections and py- Sepsis Scenario
elonephritis; men were more likely to have cellulitis. 11 Capillary Refill Time (CRT): 15–20
• The index finger is commonly used. A normal nailbed capillary
refill takes less than two seconds, and the upper limit of normal
Maritime PCC Scenario is less than three seconds.
• Press on the ventral surface of a distal phalanx for 10 seconds.
The following text is a clinical scenario addressed to the Indepen- • Release and time how long it takes for normal color to return on
dent Duty Corpsman or other medical professionals for training the ventral surface of the phalanx.
purposes. It is designed for training and to highlight Role 1 ship- Passive Leg Raise Test (PLR): 21
board medical department capabilities and limitations. • Avoid inducing pain or sympathetic stimulation that will increase
the heart rate.
• Use the bed to place the patient’s head up at 45 degrees. Measure
Setting and record blood pressure after approximately 90 seconds.
A U.S. Navy Arleigh Burke-class guided-missile destroyer (DDG) • Use the bed to place the patient supine at 0 degrees in the
with a crew of 314 Sailors is conducting solo freedom of naviga- recumbent position. Next, raise both legs 45 degrees and hold
tion operations in the Indo-Pacific Command (INDOPACOM) for 90 seconds. Measure and record blood pressure. (It is ideal
Area of Responsibility. Based on the current mission and loca- to use the bed to elevate the legs; if you cannot, manually elevate
the patient’s legs).
tion, any patient would need to wait 72–96h before MEDEVAC • Put the legs back down and raise the head of the bed to 45
to a higher level of care with critical care or surgical capability degrees. Measure and record blood pressure after approximately
is possible. The medical personnel and capability include one 90 seconds (should return to baseline).

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