What are the definitive signs of sepsis for Emergency Medical Services (EMS)?

Definitive Signs of Sepsis for Emergency Medical Services (EMS)

The definitive signs of sepsis for EMS providers include fever or hypothermia, tachycardia, tachypnea, altered mental status, hypotension, and signs of tissue hypoperfusion such as prolonged capillary refill and mottled skin. 1, 2

Primary Assessment Criteria

Vital Sign Abnormalities

• Temperature abnormalities:
  • Fever (>38.3°C/100.4°F)
  • Hypothermia (core temperature <36°C/96.8°F) 1
• Cardiovascular signs:
  • Heart rate >90 beats/minute
  • Hypotension (SBP <90 mmHg, MAP <70 mmHg, or SBP decrease >40 mmHg) 1, 2
• Respiratory signs:
  • Respiratory rate >20 breaths/minute
  • Tachypnea or hyperventilation 1

Mental Status and Perfusion

• Altered mental status or confusion 1
• Signs of tissue hypoperfusion:
  • Cold peripheries
  • Prolonged capillary refill time (>2 seconds)
  • Mottled skin
  • Decreased urine output (if known) 2

High-Risk Features

Organ Dysfunction Indicators

• Hypoxemia (if pulse oximetry available)
• Oliguria (if history available)
• Skin changes:
  • Significant edema
  • Decreased capillary refill
  • Mottling 1

Laboratory Values (if available in advanced EMS systems)

• Elevated lactate levels (>2 mmol/L suggests significant sepsis) 1, 2
• Hyperglycemia (>140 mg/dL) in non-diabetic patients 1

Recognition of Sepsis in Special Populations

Pediatric Patients

• Hyper- or hypothermia (rectal temperature >38.5°C or <35°C)
• Tachycardia (may be absent in hypothermic patients)
• Plus at least one of:
  • Altered mental status
  • Hypoxemia
  • Bounding pulses 1

Pregnant Patients

• Modified criteria for pregnant patients (20 weeks to 3 days postpartum):
  • Lower threshold for hypotension (SBP <85 mmHg rather than <90 mmHg) 1

Septic Shock Indicators

Septic shock should be suspected when sepsis is accompanied by:

• Persistent hypotension despite adequate fluid resuscitation
• Evidence of tissue hypoperfusion (altered mental status, decreased urine output, mottled skin)
• Elevated lactate (if measurement available) 1, 2

Common Pitfalls in Sepsis Recognition

Missed Presentations

• Young patients may maintain alertness despite severe cardiovascular collapse 2
• Elderly patients may not mount a fever response
• Immunocompromised patients may have atypical presentations
• Cryptic shock can occur without hypotension but with elevated lactate 2

Differential Diagnosis

• Other causes of SIRS (Systemic Inflammatory Response Syndrome) that may mimic sepsis:
  • Trauma
  • Burns
  • Pancreatitis
  • Pulmonary embolism
  • Myocardial infarction 1

EMS Action Algorithm

1. Identify potential sepsis using above criteria
2. Assess source of infection (pneumonia, urinary tract, skin/soft tissue, abdominal)
3. Initiate treatment:
   • Secure airway if compromised
   • Provide oxygen to maintain SpO2 >94%
   • Establish IV access
   • Collect blood cultures if protocol allows (before antibiotics if possible)
   • Begin fluid resuscitation (20-30 mL/kg crystalloid) 2
   • Consider early antibiotic administration if available and permitted by protocols
4. Transport rapidly to appropriate facility
5. Communicate findings to receiving facility, using terms "suspected sepsis" or "septic shock"

Remember that early recognition and treatment of sepsis significantly impacts mortality. The combination of abnormal vital signs with suspected infection should trigger sepsis protocols in the prehospital setting.