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

Definitive Signs of Sepsis in the EMS Setting

The definitive signs of sepsis in the EMS setting include fever (>38.3°C) or hypothermia (<36°C), tachycardia (heart rate >90/min), tachypnea (respiratory rate ≥20/min), altered mental status, and signs of tissue hypoperfusion such as decreased capillary refill or skin mottling. 1

Primary Clinical Indicators

Vital Sign Abnormalities

• Temperature abnormalities: Fever >38.3°C (100.4°F) or hypothermia <36°C (96.8°F) 2, 1
• Cardiovascular changes: Heart rate >90 beats per minute 2, 1
• Respiratory changes: Respiratory rate ≥20 breaths per minute or PaCO2 <32 mmHg 2
• Blood pressure changes: Systolic BP <90 mmHg, mean arterial pressure <70 mmHg, or a systolic BP decrease >40 mmHg from baseline 2, 1

Mental Status Changes

• Altered mental status, confusion, or decreased responsiveness 2, 1
• Apathy or malaise 2

Tissue Perfusion Indicators

• Decreased capillary refill (>2 seconds) or skin mottling 2
• Peripheral cyanosis 2
• Significant edema 1

Laboratory Indicators (If Available in EMS Setting)

• Hyperlactatemia (>1 mmol/L) 2
• Leukocytosis (WBC >12 × 10³/μL) or leukopenia (WBC <4 × 10³/μL) 2
• Normal WBC with >10% immature forms 2

Recognition of Severe Sepsis

Severe sepsis is indicated by the presence of sepsis plus evidence of organ dysfunction:

• Respiratory dysfunction: SpO2 ≤90% with or without oxygen, central cyanosis, or signs of respiratory distress 2
• Renal dysfunction: Acute oliguria (urine output ≤0.5 mL/kg/h) 2
• Coagulation abnormalities: Petechiae, ecchymoses, or bleeding from puncture sites 2
• Gastrointestinal dysfunction: Ileus (absent bowel sounds) 2

Recognition of Septic Shock

Septic shock is characterized by:

• Persistent hypotension despite adequate fluid resuscitation 2, 1
• Signs of tissue hypoperfusion 2, 1

EMS Assessment Algorithm

1. Initial Assessment:

   • Check vital signs (temperature, heart rate, respiratory rate, blood pressure)
   • Assess mental status
   • Evaluate skin for perfusion (capillary refill, mottling)

2. Risk Stratification:

   • High risk: ≥2 abnormal vital signs plus altered mental status or signs of poor perfusion
   • Moderate risk: 2 abnormal vital signs
   • Low risk: 1 abnormal vital sign

3. Action Plan:

   • High risk: Immediate transport with pre-notification to receiving facility
   • Moderate risk: Expedited transport
   • Low risk: Transport for further evaluation

Special Considerations

Pediatric Patients

• Pediatric sepsis often presents with signs of cardiac failure and hypovolemia 1
• Key indicators include hyper- or hypothermia, tachycardia (may be absent in hypothermic patients), and at least one sign of altered organ function 2

Pregnant Patients

• Lower threshold for hypotension (SBP <85 mmHg rather than <90 mmHg) 1

Common Pitfalls to Avoid

1. Delayed recognition: EMS provides initial care for over one-third of ED infection patients, including the majority with severe sepsis and septic shock 3. Early recognition is critical for improved outcomes.

2. Overlooking cryptic shock: Patients may have sepsis without hypotension but still show signs of tissue hypoperfusion 1.

3. Focusing solely on fever: Hypothermia can be a sign of sepsis, especially in elderly patients 1.

4. Missing subtle mental status changes: Confusion or altered mental status may be the earliest sign of sepsis, especially in older adults 2, 1.

5. Ignoring the importance of EMS care: EMS systems play a key role in the rapid identification of sepsis, similar to their role in trauma, myocardial infarction, and stroke 3.

Early recognition of sepsis by EMS providers is crucial, as timely interventions including fluid resuscitation and prompt antibiotic administration upon hospital arrival significantly improve patient outcomes 4.