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Rom Duckworth
EMS1.com Columnists
Understand the origins of sepsis criteria and what the new sepsis definitions mean for EMS assessment and treatment of septic patients
It’s more common than a heart attack. It takes more lives than any cancer. It causes the deaths of over 4,400 children per year in the United States. Yet if you asked most health care providers to rate their top five medically preventable causes of death, sepsis probably wouldn’t even make the list [1, 2].
With sepsis responsible for more than 1 million hospital admissions per year in the United States, at a cost of over $20 billion and increasing at almost 12 percent per year, it is no wonder that there is an enormous effort to get this challenging but preventable problem under control [3, 4].
The term sepsis was first coined by Hippocrates in the fourth century, but at the time it referred simply to the breakdown of living tissues [5]. Now, known more commonly as blood poisoning, scientists and clinicians have been trying to come up with better definitions and criteria for sepsis for more than 25 years in an effort to advance the fight against this deadly disorder [5].
“Sepsis is caused when the body’s immune system becomes overactive in response to an infection, causing inflammation which can affect how well other tissues and organs work. When sepsis is recognized early, people can be quickly given the right treatment. However, the signs and symptoms of sepsis can vary and may be subtle which can lead to it being missed if it is not considered early on.”
– National Institute for Health and Care Excellence (NICE) Guidelines [6]
Sepsis has a high mortality rate, variable clinical presentations and few unifying features technically making it a syndrome, a group of body dysfunctions that are commonly found together and that typically progress together, often in a predictable way, but the cause remains a mystery, not a disease where the underlying cause or causes are known.
How EMS can make a difference
EMS providers familiar with anaphylaxis can think of sepsis as progressing in a somewhat similar way. There is an initial injury (say, a bee sting for anaphylaxis or a bacterial infection for sepsis).
While the initial injury is bad, what’s worse is that it triggers an overreaction of the body’s normal immune system (different pathways for sepsis and anaphylaxis, but both are inappropriate over-responses) ultimately resulting in organ dysfunction and cardiovascular collapse (again, the pathways are different but the end results are similar).
Perhaps the biggest difference an EMS provider will notice is that anaphylaxis occurs very quickly and can often be unavoidably obvious. Sepsis tends to progress more slowly, with signs and symptoms that are much more subtle right up to the point of complete cardiovascular collapse.
Fortunately, early recognition of sepsis by sharp EMS providers has been shown to improve time to treatment and early treatment of patients has been shown to greatly improve outcomes [7-13]. However, the challenge is not just that the signs and symptoms can be subtle and easily missed; many physicians disagree as to exactly what clinical indicators to look for. That’s where the shared definition and agreed-upon clinical criteria are helpful.
Sepsis 1.0
The 1991 Chicago Consensus Conference was the first to formally define sepsis, simply calling it, “the systemic response to infection [14].” The clinical criteria were also relatively simple with a diagnosis of sepsis based only on the presence of known or suspected infection and presentation of Systemic Inflammatory Response Syndrome (SIRS) [14], which is defined by the presence of these exam findings.
- Temp >100.4F or 90
- Respiratory Rate >20 or requires Ventilation
- White Blood Cell Count > 12,000/mm3, 10% bands