Adult sepsis in a pre-hospital environment
Abstract
Sepsis is a syndrome with a high mortality rate, increasing incidence, and a huge financial impact that must be recognised earlier and treated more effectively both in hospital and pre-hospitally. This article serves to focus on the improvements that need to be made in pre-hospital recognition and management in order to maximise patient outcome, as a high standard of care initiated at an early stage has been demonstrated to decrease morbidity and mortality. There are currently no ratified guidelines for pre-hospital practitioners to follow for the management of sepsis, severe sepsis or septic shock, although the authors recognise that steps are being taken to remedy this. Current guidelines for fluid resuscitation also do not currently support the need for aggressive treatment of sepsis and cryptic shock. Improvements need to focus on education around the sepsis syndrome, recognition of sepsis and early, goal-directed treatment for the benefit of our patients and in order to meet the standards required of paramedics as professionals.
Sepsis may be defined as an overwhelming, uncontrolled, systemic inflammatory response, which is mediated by the immune system, the vascular endothelium and inflammatory pathways in response to an infective trigger. An alternative definition is that of a systemic inflammatory response syndrome, (SIRS) in response to a confirmed infectious process (Bone et al, 1992). SIRS may be defined as a systemic response to a variety of initiators, of which infection is one. SIRS alone is not sepsis and neither is it a diagnosis. As can be seen in Figure 1, SIRS can be caused without the presence of an infective agent, as in the case of trauma or burns for example. Also, many people develop infections without developing sepsis. Evidence suggests it to be a combination of the infective agent and the host response, or over-response, which leads to sepsis. It is currently hypothesised that there may be a genetic element, which predisposes some patients to developing sepsis, where others would develop infection without a systemic response (Villar et al, 2004). An aging and increasing population will only increase the occurrence of sepsis in the UK.
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