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Fever / Sepsis

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Fever / Sepsis Fever / Sepsis History Signs and Symptoms Differential · Age · Warm · Infections / Sepsis · Duration of fever · Flushed · Cancer / Tumors / Lymphomas · Severity of fever · Sweaty · Medication or drug reaction · Past medical history · Chills/Rigors · Connective tissue disease · Medications Associated Symptoms · Arthritis · Immunocompromised (transplant, (Helpful to localize source) · Vasculitis HIV, diabetes, cancer) · myalgias, cough, chest pain, · Hyperthyroidism · Environmental exposure headache, dysuria, abdominal pain, · Heat Stroke · Last acetaminophen or ibuprofen mental status changes, rash · Meningitis Adult Contact, Droplet, and Airborne Precautions Temperature Measurement Procedure B / if available Pediatric General Section Protocols IV Procedure IO Procedure I P If indicated If indicated Temperature NO Greater than 100.4 F YES (38 C) If Suspected infection ? B then proceed to Protocol 72A otherwise Proceed to Protocol Exit to 72A Appropriate Protocol Pearls · Recommended Exam: Mental Status, Skin, HEENT, Neck, Heart, Lungs, Abdomen, Back, Extremities, Neuro · Febrile seizures are more likely in children with a history of febrile seizures and with a rapid elevation in temperature. · Patients with a history of liver failure should not receive acetaminophen. · Droplet precautions include standard PPE plus a standard surgical mask for providers who accompany patients in the back of the ambulance and a surgical mask or NRB O2 mask for the patient. This level of precaution should be utilized when influenza, meningitis, mumps, streptococcal pharyngitis, and other illnesses spread via large particle droplets are suspected. A patient with a potentially infectious rash should be treated with droplet precautions. · Airborne precautions include standard PPE plus utilization of a gown, change of gloves after every patient contact, and strict hand washing precautions. This level of precaution is utilized when multi-drug resistant organisms (e.g. MRSA), scabies, or zoster (shingles), or other illnesses spread by contact are suspected. · All-hazards precautions include standard PPE plus airborne precautions plus contact precautions. This level of precaution is utilized during the initial phases of an outbreak when the etiology of the infection is unknown or when the causative agent is found to be highly contagious (e.g. SARS). · Rehydration with fluids increased the patients ability to sweat and improves heat loss. · All patients should have drug allergies documented prior to administering pain medications. · Allergies to NSAIDs (non-steroidal anti-inflammatory medications) are a contraindication to Ibuprofen. · NSAIDs should not be used in the setting of environmental heat emergencies. · Do not give aspirin to a child. · Agency Medical Director may require contact of medical control prior-B to / EMTMR administering any medication. Protocol 72 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS Suspected Sepsis/Septic Shock-Adult History Signs and Symptoms Differential · Age (common in elderly and very · Hyper or hypothermia · Cardiogenic Shock young) · Rash and/or excessive · Hypovolemic shock · Presence and duration of fever bruising · Dehydration · Previously documented infection or · Chills · Hyperthyroidism illness (UTI, pneumonia, meningitis, encephalitis, cellulitis, abscess etc.) · Myalgia (muscle aches) · Medication/drug interaction · Recent surgery or invasive procedure · Marked decreased urine · Non-septic infection · Immunocompromised (transplant, HIV, output · Allergic reaction/anaphylaxis diabetes, cancer) · Altered mentation · Toxicological emergency · Bedridden or immobile patients · Delayed capillary refill · Prosthetic or indwelling devices · Elevated blood glucose · Immunization status (unless diabetic) Universal Patient Care Protocol Consider Appropriate PPE and/or indicated infections control measures Cardiac Monitor Exit to Appropriate Obvious or suspected infection AND TWO of these SIRS PLACE TWO LARGE BORE IV’S Protocol criteria: · SBP < 90 mmHg Normal Saline 1000ml bolus then reassess SIRS criteria and re- A · Heart Rate > 90/min d NO YES I examine I · Respiratory rate > 20 Repeat 500ml bolus to Max 2 liters as u l long as any SIRS concern for fluid t GCS < 15 · overload M · Temperature > 100.4F or <96.0 F “see pearls” e d Yes i c a l End Tidal CO2 < 26 on at least two consecutive Normal Saline 1000ml bolus then P measurements 5 min apart? reassess SIRS criteria and re- r NO examine o t Yes P Repeat 500ml bolus to Max 2 liters as P o long as any SIRS concern for fluid c Declare Sepsis Alert / CODE SEPSIS during call-in to overload o destination hospital l “see pearls” s Notify Destination per usual procedures or ► Contact Medical Control as needed Pearls · Early recognition of Sepsis allows for attentive care and early administration of antibiotics. · Aggressive IV fluid therapy is the most important prehospital treatment for sepsis. Suspected septic patients should receive repeated fluid boluses (to a max total of 2 liters) while being checked frequently for signs of pulmonary edema, especially patients with known history of CHF or ESRD on dialysis. STOP fluid infusion in the setting of pulmonary edema. · Septic patients are especially susceptible to traumatic lung injury and ARDS. If artificial ventilation is necessary, avoid ventilating with excessive tidal volumes. If CPAP is utilized, airway pressure should be limited to 5 cmH2O. · Attempt to identify source of infection (skin, respiratory etc.) and relay previous treatments and related history to ED physician. · Elevated serum lactate levels are a useful marker of hypoperfusion in sepsis and often become elevated prior to the onset of hypotension. End Tidal CO2 levels are correlated with lactate levels. · Disseminated Intravascular Coagulation (DIC) is an ominous, late stage manifestation of sepsis characterized by frank, extensive bruising, bleeding from multiple sites and finally tissue death. Protocol 72A 10/03/2016 This protocol is unique to the Craven, Jones, & Pamlico EMS Systems.
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