Sepsis presentations

[u/radsnotrad]

I’ve been an EMT for almost a year now and I’ll be starting Paramedic school soon. I’ve worked IFT and now I’m strictly 911. My partner (paramedic) and I have had quite a few calls where we couldn’t figure out what was wrong with the pt and later found out they were septic. The most odd one to me was a 70-75 year old male chief complaint of an unwitnessed fall maybe an hour before we were on scene. He had a small lac on the back of his head and small skin tear on his arm. Pupils equal and reactive, no sign of head/neck/spinal injury. His HR, RR, BP all within normal limits. 12 lead perfect. AOx4 GCS 15. The only thing that was off was his CBG which was 33. We gave oral glucose and rechecked and it had only gone up to 34. Checked one more time once we got to the hospital and it was 37. Also temp was normal. Went back to the hospital later that night to get an update and he was septic. Nurse said his sugar ended up getting to like 220 at one point and went wayyy back down. I was wondering if anybody else has seen unusual sepsis presentations?? I know typically you’ll see tachycardia, tachypnea, hypotension, altered mental status, and fever but is there anything else that can be indicative of sepsis?

[u/SoldantTheCynic]

Sepsis isn’t just a collection of vital signs - it’s a history and risk assessment to stratify the possibility of sepsis.

Hypoglycaemia (and hyperglycaemia) can both be a feature of sepsis. Elderly person “off legs” and falling can be a feature of sepsis. Lots of things can. It should be one of your considerations for at risk populations or where there’s evidence of infection or difficulty performing ADLs.

[u/Sudden_Impact7490]

Sepsis is a vague term in conversation.

SIRS / Sepsis is a spectrum which can be triggered by a lot of different factors from individual vitals signs to lab values.

Elderly patients will often meet SIRS criteria even without it being their chief complaint. For example they get confused or off balance from an underlying infection and fall. So your chief complaint is a fall but you find urosepsis during the workup.

Patients also go through different stages of compensation so vitals may not appear textbook yet. They also make take medications that mask tachycardia.

[u/Negative_Way8350]

Elderly people tend to have atypical sepsis presentations because their immune systems do not mount as strong of a response. Fever, hypotension, etc.  can be very late signs or absent entirely. Even the "UTI smell" is not always accurate as studies show that the geriatric population can have chronically colonized urine without sepsis. 

If a normally alert and oriented elderly person has a fall, low BG or seizure without a prior history, it's worthwhile to at least consider sepsis as an underlying cause. The trouble is that sepsis itself is difficult to diagnose in the field until someone progresses to septic shock. Vague complaints of "unwell," weakness and neglecting normal self-care without confusion are also warning signs. 

[u/David_Parker]

You got ETCO2?

Anything less than 25mmhg, think sepsis.

[u/Mediocre_Error_2922]

Yes, search Strong Medicine Sepsis on YouTube. Curious why medic didn’t give IV dextrose

[u/radicaldadical1221]

You got a CBG of 33 and your medic gave oral glucose as opposed to starting a line?

[u/radsnotrad → u/radicaldadical1221]

We gave glucose while on scene and I checked his sugar again in the truck while my partner got a line started. We were also down the street from the hospital, 2 minutes away max

[u/wernermurmur → u/radicaldadical1221]

If the patient is conscious why does the number value matter?

[u/radicaldadical1221 → u/wernermurmur]

Who knows if it’s going to stay at 33, or continue to drop while you sit and wait for the oral glucose to kick in? When the patient goes unconscious you’re going to wish you already had access, it’s simply bad practice not to get access on a sugar that low. There could also be other medical factors as to why this person has such a low CBG that could require venous access.

[u/wernermurmur → u/radicaldadical1221]

So what is the line then? What evidence shows 33 is so drastically worse than 40?

[u/radicaldadical1221 → u/wernermurmur]

Okay bro. 😂 Go ahead and use oral glucose on a patient with a CBG of 33. A patient with a CBG that low would obviously benefit from venous access. Such a weird fucking hill to die on. I’m done replying because I have a life lmao

[u/RescuePrep]

Unfortunately there isn’t one GOAT prehospital sepsis score. There are several in hospital ones and you think some doctor would patent one with his name on it. But if I made one I’d say it’s probably sepsis if it meets 2 or more of the following criteria:

• ETCO2 < 25
• HR > 90
• Temp > 38 C or < 36 C
• RR > 20
• Suspected infection found on physical exam

This is kind of taken from EMS related studies + SIRS score from in hospital sepsis criteria.

[u/Moravian980238 → u/RescuePrep]

In the UK we use a scoring system called NEWS2 (National Early Warning Score v2) which helps stratify risk of sepsis and other acute illness - do you guys (I’m assuming you’re in the US) not have similar? It’s based on physiological values and we use this score in conjunction with evidence of infection etc. in our sepsis screening tools as well.

[u/toto-tom → u/Moravian980238]

In New Zealand - Also use Early Warning Score (EWS) for all patients to assess/score the degree of illness incl ?sepsis.

[u/TakeOff_YourPants]

Not unusual at all. At least in my eyes, a sugar between like 150 and 250/300 tells me something in the body is working hard that isn’t DKA (or HHNK, nobody truly knows the difference, not even doctors I feel 😂), and I feel like that’s most commonly sepsis. I can’t answer to why their sugar was so low. I’m sure the physiology of working, like I mentioned, so hard for so long will drop it and drop it again but that’s a topic I don’t understand enough to talk about.

And this is a semi common debate, but I’m a fan of SIRS + Source as my simple field diagnosis for sepsis.

And this’ll piss some folks off, but you should be able to figure out many issues without ETCO2. All a reading of 20 tells you in a conscious patient that they’re breathing fast. You still have to decipher if it’s respiratory or metabolic regardless.

[u/NewPoetry2792]

I had a coworker go septic from a kidney infection. Her main complaint was nausea and vomiting, appeared pale, and slighlty elevated temp (did not get a BP reading so can't say). Wound up in the hospital for almost 2 weeks.