CASES IN BLS CARE
Careful assessment helps recognize life-threatening infection
By Dennis Edgerly, MEd, EMT-P
You and an engine company arrive to a single family, two-story home. You’re met at the door by a male in his late
20s. He says he called you after coming to check
on his 58-year-old father after he missed their
tee time. He found his father, Matt, lying in
bed and unresponsive.
He leads you upstairs to his father’s bedroom
and tells you his mom died two years ago and
Matt now lives by himself. He isn’t aware of
his dad having any significant medical history.
As you enter the bedroom you see Matt
sleeping. His breathing is rapid and deep. His
skin looks flushed from across the room. You
approach the bedside calling his name. You
shake his shoulder but receive no response.
You gently apply pressure to his fingernail and
he moans as he pulls his hand away.
Matt’s skin is cool and clammy to the touch
and his pulse is rapid, about 120 beats per
minute. Your partner confirms a blood pressure (BP) of 96/42 mmHg. Auscultation of
lung sounds reveals clear air movement on the
left and crackles at the base of the right side.
Pulse oximetry read 88% and a blood glucose
finger stick reads 96 mg/dL. After administering oxygen via a non-rebreather mask, pulse
oximetry reads 93%.
The remainder of the physical exam reveals
a healthy appearing 58-year-old male in good
shape with no obvious surgical scars. A quick
assessment of the bedroom and adjacent bathroom reveals only a bottle of multivitamins for
men. No other medications are found.
The firefighters help you and your partner
carry Matt downstairs to the stretcher. You continue administering oxygen and repeat the physical assessment during transport. Matt’s pulse
climbs to 130 and BP drops to 94/38 mmHg.
He’s unresponsive to any stimulus.
After an 18-minute emergent transport, you
transfer care to the ED. The staff establishes
two IVs and begins rapid administration of
fluid. An ED physician tells you, “It appears
to be septic shock.”
Sepsis is defined as life-threatening organ dysfunction caused by a host’s response to infection.
More simply, sepsis is the body’s overactive and
toxic response to an infection.
Our body’s immune system typically functions to protect us from pathogens such as bacteria or viruses. The inflammatory response
allows the movement of white blood cells to the
area of the pathogen while attempting to isolate
the infection. When the pathogen moves into
the blood stream, the body’s response becomes
systemic, resulting in dilation and hyperperme-ability of all blood vessels—they become larger
and begin to leak.
The systemic inflammatory response syndrome (SIRS) criteria is commonly used to identify a patient with sepsis. SIRS criteria include a
temperature > 100.4 degrees F ( 38 degrees C) or
< 96.8 degrees F ( 36 degrees C), a heart rate >
90 and a respiratory rate > 20. SIRS criteria also
require an elevated white blood cell count—a
value typically unknown by EMS.
As sepsis progresses, it can lead to septic
shock, resulting in altered mental status and
multiple organ failure. Once a patient moves
into septic shock, the mortality rate is greater
than 40%. 1 Aggressive treatment is required
early if these patients are going to survive.
Prehospital providers play an important role
in the course of treatment. First, you must recognize a patient who’s septic or in septic shock.
The SIRS criteria are a good tool to help identify patients with sepsis. Note, however, that not
all septic patients are hot to the touch; some
have a decrease in body temperature. Elevated
heart and respiratory rates in addition to a history of not feeling well are all good indicators
a patient is septic.
When a patient with sepsis has their mean
arterial pressure (MAP) drop below 65 mmHg,
they’re progressing into shock. MAP is calcu-
lated by multiplying the diastolic value by two,
adding the systolic value and then dividing by
three. This is the average pressure in the vascular
system and is a better indicator of perfusion
than just a systolic BP.
In our scenario, Matt had an initial MAP of
60 mmHg, which then dropped to 56. 6 mmHg
indicating he was in septic shock. Because septic shock, a type of distributive shock, drops the
BP by dilating the blood vessels, the diastolic
value tends to drop faster than with other types
of shock. Considering only the systolic value
may lead you to miss a person who’s in septic shock. Most automatic BP machines will
calculate MAP and display it next to the BP.
Once you’ve identified a patient in septic
shock, time is critical. You should evaluate and
maintain the patient’s airway, administering
oxygen as needed. Consider other causes of
altered mental status such as blood glucose
level or chemical intoxication. If it’s within
your scope of practice, establish two IVs and
administer fluid at 30 mL/kg. If the patient’s
BP doesn’t respond to fluid, a vasopressor such
as norepinephrine should be started. Many hospitals have aggressive in-hospital protocols to
treat sepsis, so be sure to inform the receiving
facility as early as possible.
Septic shock can progress quickly, and sepsis
can be subtle in presentation. Use assessment
criteria to help identify a septic patient and
quickly get the patient to definitive care.
Also remember, sepsis is caused by a pathogen you don’t want; take appropriate body substance isolation (BSI) precautions. Be safe. JEMS
1. Singer M, Deutschman CS, Seymour C W, et al. The third international consensus definitions for sepsis and septic shock
(Sepsis- 3). JAMA. 2016;315( 8):801–810.
Dennis Edgerly, MEd, EMT-P, began his EMS
career in 1987. He’s currently the EMS academy director for Arapahoe Community College. You can reach him at dennis.edgerly@