Picture the scene…
It is a busy weekday in ED and you have been asked to see a 78 year old brought by ambulance with a diagnosis of ‘sepsis’. They do not have a temperature or tachycardia but are newly confused, tachypnoeic and hypoxic and have been on oral antibiotics in the community for three days for a chest infection.
The nurse looking after them asks what treatment you want to give and “should I move her to Resus?”
To learn about the management of the patient with sepsis in the Emergency Department.
Task 1 – Read
Read this blog post from RCEM Learning.
Task 2 – Listen
Listen to this RCEM Learning Guidelines podcast.
RCEM and UK Sepsis Trust still advocate the use of SIRS to help identify those with an infection. The presence of two SIRS criteria in the presence of infection still means these patients are at risk and may go on to develop sepsis and organ dysfunction. qSOFA is not part of the diagnostic criteria for sepsis but a screening prompt and used alone is not adequate to identify patients in ED at significant risk of either developing sepsis or having sepsis.
NEWS2 (or an alternative local equivalent) is an early warning score that is advocated as an initial trigger to think ‘Could this be sepsis?’. A score of 5 or more should trigger a consideration of and screen for sepsis. This includes an assessment for risk factors.
Task 3 – Discuss
This part of the teaching session should be lead by an experienced clinician. The case provided is merely an example and if possible the learners should be encouraged to discuss patients they have seen in their clinical practice.
Case – A confused 78 year old
A 78 yr old man with ‘sepsis’ has been brought in by an ambulance.
The history from the Ambulance crew is that he has had a productive cough for a week, has been on oral antibiotics from the GP for 3 days but for 24 hours has been increasingly confused, short of breath and lethargic. He is usually independent, has hypertension, takes ramipril, aspirin and a statin and has no allergies.
On initial assessment in Resus his oxygen saturations are 96% on 15l of oxygen, RR 32, HR 95, BP 110/60, temperature 37.4. Examination of the chest reveals crackles and reduced air entry at the right base and the patient is drowsy and confused. He has a NEWS2 score of 9.
1, Is this sepsis? What “red flags” are there?
Anyone with a NEWS2 score of 5 or more needs to have sepsis considered. This patient has a history of a productive cough and has been on antibiotics so it is reasonable to consider the diagnosis of a chest infection.
So far red flags are tachypnoea and altered mental state with a new oxygen requirement.
2,What further information do you need?
Further investigations should include a VBG with lactate, FBC, CRP, U+Es, clotting, blood cultures, Chest Xray, a urine sample for urinalysis and M,C&S.
3, The patient’s lactate is 3.2, blood glucose 12, CXR shows right lower zone consolidation. Does the patient have sepsis? What should you do next?
The patient has an infection with red flags present and evidence of organ dysfunction – this is sepsis.
If you hadn’t already done them he needs the Sepsis 6 starting straight away which you have already done. He also needs a senior review.
4, Remind me – what are the Sepsis 6 again?
I’m sure you know them by now, but repetition is learning!
The Sepsis 6 describe the most effective life-saving treatments that can be delivered within the first hour of recognition of sepsis.
They can be divided into 3 ‘Give’ actions and 3 “Take” actions
1, Give oxygen as appropriate
1, Take blood cultures, bloods and any other samples to help identify the source.
2, Give antibiotics according to trust protocol
2, Take urine – monitor the fluid balance
3, Give intravenous fluids
3, Take a lactate – and repeat if raised
A 4th ‘Take’ action should be take a senior ED clinician to the patient for review.
5, What repeat assessment does this patient need and what improvements should you be looking for? What would be a cause for concern
The lactate needs repeating, urine output should be monitored.
This patient is on Ramipril and has a history of hypertension. Try and find out what his normal BP is as 110/60 is likely low for him.
Look for an improvement in respiratory rate, decreased oxygen requirement and improved cerebration – does his confusion and drowsiness improve as treatment is started?
If his oxygen requirement increases, urine output is low, lactate remains high, drowsiness persists, or HR and BP worsen he may need escalation to critical care. Ensure that a senior ED clinician remains involved in this patient’s care.
Task 4 – Summary
This lesson has addressed what sepsis is and why it is important, how we define and more importantly recognise it and how we should be managing it in ED.
The signs and symptoms of sepsis can be very nonspecific and difficult to recognise. There are some key things that can be done by every clinician however:
- Always think could this be sepsis?
- If it could be sepsis make an assessment and look for markers of severity and risk.
- If these are present instigate the Sepsis 6 and add a 7th step – to take a senior ED clinician to the patient for a review early.
If this session has got you yearning for more and you want to take a deeper dive into all things Sepsis then this panel discussion from SMACC, an international critical care conference, has many of the world’s big players all debating and discussing sepsis in depth.
Task 5 – Reflect
In order to embed today’s learning further, reflect on what you have learnt and record in your portfolio whether it has had any impact (or is expected to have any impact) on your performance and practice.
Was this a topic that you were confident you knew already? Which parts were new to you? Were there elements that you will use on your next clinical shift.
Dscuss this session with your colleagues – were there people who missed it who you can share the highlights with?