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Sepsis Decision Pathway: Recognition

Cameron Berg, MD FAAEM and Rob Orman, MD
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19:08
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Nurses Edition Commentary

Mizuho Spangler, DO, Lisa Chavez, RN, and Kathy Garvin, RN
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04:59

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EM:RAP 2015 August Summary 1 MB - PDF

Managing sepsis has become simpler over the past year, but early aggressive intervention is still essential.

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Matthew D. -

The major challenge in sepsis screening is having a good working definition of sepsis, and modified SIRS + suspected infectious source is sorely lacking. Simple definitions aren't always the best ones. We can't define away clinical complexity. 28 year-old man with viral gastroenteritis with some dehydration? Asthma exacerbation with URI trigger in a 23 year-old woman? 21 year-old man with pharyngitis? All three can very easily meet criteria and get called "sepsis", but this just isn't the the same high mortality disease entity that we should really mean when we use that word. All three of these patients need a good thorough history and exam. Treatment should be tailored to the patient. Yes, these three patients may well turn out to have more going on, but do these patients really benefit from being called "septic" at triage?

c. berg -

The short answer, I think, is yes. These three patients may well benefit from that label in triage.

While I agree that informed clinical judgment is the gold standard (after H&P, testing, and re-evaluation). Many practice environments don't have the benefit of outstanding clinicians and limitless resource availability.

For most of us, sepsis is the most dangerous condition that see, and it behooves our patients to recognize it early. I'd rather over-screen upfront for a condition like this...one that requires judgment.

Best,
Cameron

Matthew D. -

Thanks for the response.

I agree that we don't have unlimited resources. This is precisely why I don't want the triage nurse drawing blood on strep throat patients before they are even seen by a provider. I want, and in fact need, that nursing effort directed elsewhere in my department. When we apply tests indiscriminately to low prevalence populations, we get more false positives than true positives. "SIRS positive" begets lactate. Marginally elevated lactate begets blood cultures and often unnecessary antibiotics, longer ED stays, and possibly even needless admission. It wouldn't surprise me if sepsis mortality begins to "fall" in some hospitals because they start calling all sorts of conditions "sepsis", that previously would have been called "diarrhea", "vomiting", "GI bleed"... you name it.

Now in your protocol, you briefly alluded to the fact that a provider can, once they see the patient, opt out. That is obviously essential, but of course you can't un-see the elevated lactate on the asthmatic, and there is inevitably going to be pressure to squander more time, resources, and tests. With the issue of core measures, this pressure can be considerable. I've seen such things take on a life of their own. To say that some environments don't have the benefit of outstanding clinicians may be true. I cannot imagine that taking patients with asthma, food poisoning, and pharyngitis, and labeling them as "sepsis" before any (non-outstanding) clinician has even seen them could possibly help matters.

To paraphrase "The Princess Bride": People keep using that word "sepsis" at triage. I do not think it means what they think it means...

Torree M., M.D. -

Dr. Berg,
For the modified SIRS criteria to use in triage, where were those derived from? Is there literature support for using just vital sign parameters to identify SIRS?

Morris G. -

I'll reiterate Torree M. Can you list the study that supports the modified SIRS criteria. On a quick google search I was unable to find this. I would really like to trigger my BPA without waiting for WBC's.
Thanks!

Robert M. H., M.D. -

Would you share what instrument you use to measure POC Lactate?
Thanks

c. berg -

Hey, sorry for the delayed reply.

We've developed specific bits/episodes prompted by your excellent questions. Modified SIRS comes from Stop Sepsis. See their lit. Others are using. POC Lactate = venous blood on iSTAT. There are some capillary sample models available.

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Quality Review Gets Septic Full episode audio for MD edition 252:40 min - 352 MB - M4AEM:RAP 2015 Août Résumé en Francais Français 62:21 min - 57 MB - MP3EM:RAP 2015 August Canadian Edition Canadian 31:42 min - 29 MB - MP3EM:RAP 2015 August Aussie Edition Australian 58:17 min - 53 MB - MP3EM:RAP 2015 Agosto Resumen Español Español 76:59 min - 71 MB - MP3EM:RAP 2015 August MP3 306 MB - ZIPEM:RAP 2015 August Summary 1 MB - PDFEM:RAP Español Agosto 2015 2 MB - PDFEM:RAP 2015 August Board Review Questions 223 KB - PDFEM:RAP 2015 August Board Review Answers 239 KB - PDF

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