From the Guidelines
Pre-hospital management of sepsis requires immediate intervention with fluid resuscitation, broad-spectrum antibiotics, and vasopressors as needed to improve patient outcomes. Sepsis should be identified using tools like the qSOFA score (altered mental status, respiratory rate ≥22, systolic blood pressure ≤100 mmHg) or SIRS criteria (temperature >38°C or <36°C, heart rate >90, respiratory rate >20, white blood cell count >12,000 or <4,000) 1. Once identified, immediate interventions include:
- Obtaining IV access with two large-bore catheters (16-18G)
- Collecting blood cultures if possible before antibiotic administration
- Initiating fluid resuscitation with crystalloids (normal saline or lactated Ringer's) at 30 mL/kg within the first 3 hours, as recommended by the Surviving Sepsis Campaign 1
- Oxygen should be administered to maintain SpO2 >94%, and continuous vital sign monitoring is essential
- If hypotension persists after fluid resuscitation (systolic BP <90 mmHg), vasopressors like norepinephrine (starting at 0.05-0.1 mcg/kg/min) should be initiated if available in the pre-hospital setting 1
- Early broad-spectrum antibiotics should be administered within one hour of recognition; options include ceftriaxone 2g IV plus vancomycin 15-20 mg/kg IV for unknown sources, or tailored regimens if the source is identified 1
- Point-of-care lactate measurement, if available, helps assess severity (lactate >4 mmol/L indicates severe sepsis)
- Rapid transport to a hospital with appropriate capabilities is crucial, with advance notification to the receiving facility to prepare for a septic patient. These interventions are time-sensitive as each hour of delay in appropriate treatment increases mortality by approximately 8% 1.
From the Research
Pre-hospital Management of Sepsis
- The management of sepsis in the pre-hospital setting is crucial for improving patient outcomes 2, 3.
- Early recognition and treatment of sepsis can significantly reduce mortality rates 2, 3.
- The use of emergency medical services (EMS) can help reduce delays in treatment and improve outcomes for patients with severe sepsis 3.
Fluid Resuscitation
- Crystalloids are the preferred fluid for resuscitation in patients with severe sepsis and septic shock 4, 5.
- Balanced crystalloids may improve patient-centered outcomes and should be considered as an alternative to normal saline, if available 4, 6.
- Semi-synthetic colloids are not recommended due to their association with decreased survival 4, 6.
- The role of albumin in the resuscitation of patients with severe sepsis and sepsis is uncertain, but it may be associated with reduced mortality compared to other fluids 6.
Treatment Delays
- Delays in treatment with antibiotics can worsen the prognosis for patients with sepsis, with each hour of delay associated with a worse outcome 3.
- Early goal-directed therapy (EGDT) can also improve outcomes for patients with severe sepsis, and delays in initiating EGDT should be minimized 3.
- The pre-hospital chain of care, including patients, bystanders, dispatchers, and EMS staff, plays a critical role in reducing treatment delays and improving outcomes for patients with sepsis 3.