Hello EM friends,
For this week's protocol review, we're going to discuss the pre-hospital world of sepsis care. This one's a BOGO deal and will include the approach for both adults and little adults (pediatrics).
Our EMS colleagues are trained to identify septic patients using very similar criteria to us: 2 SIRS-like + presumed infection. Reference this table to see the differences with our criteria (mainly to increase specificity for correctly identifying septic patients in the field / working with more limited resources):
CFR and BLS crews unfortunately will not be able to offer much in the way of interventions - we're dabbling in the world of critical care. CFRs can assess ABCs/vital signs and administer O2 as necessary. BLS crews can additionally obtain BGMs and treat as indicated; otherwise, they will request ALS assistance if required and transport patients to the hospital.
ALS crews can administer much more in terms of therapeutics - they can perform advanced airway management, cardiac monitoring, EKG evaluation, IV/IO access, crystalloid administration, and adult vs pediatric specific blood pressure management protocols. Before the adult and pediatric protocols branch, paramedics will start by administering both groups a 20 mL/kg IV bolus. If the patient is still hypotensive, the protocols are as follows:
Adults:
Goal: SBP > 90 mmHg or MAP > 65 mmHg
Administer one of the following:
Additional 20 mL/kg bolus
Norepinephrine IV (20 mcg/min max) infusion
Epinephrine 10mcg pushes Q3-5 minutes
Pediatrics:
Goal: age-appropriate BP goals
Activate OLMC to administer one of the following:
Additional 20 mL/kg bolus
Epinephrine 5mcg pushes Q3-5 minutes
Norepinephrine 0.05mcg/kg/min (20mcg/min max) infusion
Over the OLMC phone, we will have the power to authorize Vasopressin infusions to maintain SBP/MAP goals for adults. And again, ALS crews will have to communicate with us to administer any BP support beyond the initial 20 mL/kg bolus for pediatric patients.
More knowledge to be farmed at www.nycremsco.org.
Best,
Zachary Kim, MD
PGY-2 Emergency Medicine