Download EMS/Nursing 81711 - Texas Tech University Health Sciences Center

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EMS/Nursing
81711/
316011
Healthcare
Research/Sepsis
T. Ryan Mayfield, MS, EMT-P EMS
Educator, Centura Health
Lab Instructor
Arapahoe Community College
Littleton, Colorado
EMS/Nursing
81711/
316011
Objectives
1. Identify components of
the scientific method.
EMS/Nursing
81711/
316011
Objectives
2. Differentiate between
various types of
research studies/methods.
EMS/Nursing
81711/
316011
Objectives
3. Identify patients at high
risk for developing
sepsis.
EMS/Nursing
81711/
316011
Objectives
4. Indicate appropriate
prehospital treatment for
a septic patient.
Scientific Method
 Make
observations/ask
questions
how, what, when,
where, who, which
 WHY??

Scientific Method
Observation:
There are more
psychiatric emergencies
when the moon is full.
Scientific Method
 Do
background research
(borrow from other
people)
Scientific Method
 Construct
hypothesis:
statement of believed
outcome
Scientific Method
 Hypothesis:
psychiatric
emergencies are more
common when the
lunar cycle is in the full
moon phase
Scientific Method
 Test
hypothesis
Scientific Method
 Analyze
data/draw
conclusions
full moon – 13.31
psychiatric patients
per day

Scientific Method

non full moon – 13.32
psychiatric patients
per day
Scientific Method
 Hypothesis
disproved
Scientific Method
 Communicate
(good or bad)
results
Research Bias
 Bias:
a mental leaning,
inclination, partiality, or
prejudice
All graphics can
also be found
under “Course
Resources” online.
Levels of Evidence
Randomized
Controlled Double
Blind Studies
Systematic Reviews
and Meta-analysis
Animal Studies
 Provide
insight into
biology
 For ethical reasons,
some studies cannot be
carried out on humans
Animal Studies
 Computer
modeling is
replacing many animal
studies
Expert Opinion/
Rational Conjecture
 Expert
opinions can
take various forms:
systematic reviews
 pure opinion pieces

Expert Opinion/
Rational Conjecture
 Rational
conjecture
lowest level of
scientific validity
 overall very important

Case
Report/Series
 Case
report: narrative
of an interesting case
Case
Report/Series
 Case
series: report on
a series of patients with
an outcome of interest
Case-Control
Studies
 Patients
who already
have a certain condition
are compared with
people who do not
Group of interest
(e.g. , cancer patients)
Take histories
Compare
histories
Draw
conclusions
Take histories
Comparison group
(e.g., non-cancer
patients)
Cohort Studies
 Patients
who presently
have a certain condition
and/or receive a
particular treatment are
followed over time
Group of interest
(e.g., smokers)
Follow
over time
Comparison group
(e.g., non-smokers)
Follow
over time
Compare
outcomes
Randomized
Controlled Trial
 Patients are
randomized into an
experimental group
and a control group
Patients
Treatment group
Follow-up
Control group
Follow-up
Random
assignment
Compare
results
Double-Blind Study
 Neither
the patient nor
the researcher knows
whether the patient is
receiving the treatment
of interest or the control
treatment
Please take
these pills
These are
Pill A
These are
Pill B
Please take
these pills
(Study Manager)
Patients
Meta-Analysis
 High-level
overview
 A systematic review
that uses quantitative
methods to summarize
the results
Study 1
Study 2
Combined
Results
Study 3
Study 4
Meta-Analysis
Group Problem
 Best
pain relief
PAIN
Scientific Method
 Research
question
What is a better pain reliever
in the prehospital setting,
fentanyl or morphine?
Scientific Method
 Background
studies on pain relief
are hard to do because
very subjective
 lot of expert opinion

Scientific Method
 Hypothesis
“Fentanyl will work better
than morphine.”
Scientific Method
 Test
(fairly easy to do)
Don’t you have to
establish a level of pain
you’re working with?
Scientific Method
 Test
 Analyze
Scientific Method
 Test
 Analyze
 Communicate
results
Evaluate
Published Studies
 Evaluate
stakeholders
Who did the research?
 Who paid for the
research?

Stakeholders
Reduced Mortality at a
Community Hospital Trauma
Center: The Impact of
Changing Trauma Level
Designation from II to I. Arch
Surg. 2008 Jan;143(1):22-7;
discussion 27-8.
Funding
Measurement of
Carboxyhemoglobin and
Methemoglobin by Pulse
Oximetry: A Human Volunteer
Study. Anesthesiology 2006;
105:892-7
Funding
Partial support for
laboratory expenses
incurred during this study
was provided by Masimo
Inc.
Evaluate
Population
 Age
Evaluate
Population
 Age
 Gender
Evaluate
Population
 Age
 Gender
 Comorbidities
Evaluate
Population
 Age
 Gender
 Comorbidities
 Numbers
Evaluate
Population
 Age
 Gender
 Comorbidities
 Numbers
 Selection process
Evaluate Study Design
Systematic Reviews
and Meta-Analysis
Randomized
Controlled
Double-Blind
Studies
Evaluate Statistics
 Good
Luck!
Going Forward
 Research
does not
have to be a grandiose
adventure
Going Forward
 Someone
will do
Emergency Medical
Services (EMS) research
 If EMS providers don’t
do it, they will not like
the results
SEPSIS
Why is this
Important?
 Sepsis
estimated 750,000
cases per year
 estimated 215,000
deaths per year

Why is this
Important?

during this
presentation:
● 84 cases will develop
● 24 people will die in the
United States
Why is this
Important?
 CDC death rates (2007)
- 132,968 deaths from
acute myocardial
infarction
SIRS-Systemic
Inflammatory
Response
Syndrome
 Causes
trauma
 severe burns

SIRS
infection
 pancreatitis
 ischemia

SIRS - Signs and
Symptoms
 Two
or more:
temperature: >38° C
°
(100.4 F) or <36 C
(96.8 F)

SIRS - Signs and
Symptoms
 heart rate: >90
beats/minute (outside
factors?)
SIRS - Signs and
Symptoms
 respiratory rate: >20
breaths/minute or
mechanically
ventilated
SIRS - Signs and
Symptoms
 white blood cell (WBC)
leukocyte count:
>12,000 or <4,000 or
>10% immature
Sepsis
 SIRS
with documented
or suspected infection
bacterial
 viral
 fungal
 protozoan

Sepsis
 Common
causes:
pneumonia
 urinary tract infections

Sepsis
abdominal surgery
 cellulitis
 intravenous (IV) drug
use
 ear infections

Sepsis - High
Risk Factors
 Higher risk
 extremes of age
 multiple comorbidities
Sepsis - High
Risk Factors
 recent hospitalization
(2 million hospitalacquired infections
per year)
Sepsis - High
Risk Factors
 Cough present
 Indwelling Foley
catheter
 Wounds/injuries
Sepsis - High
Risk Factors
 Para-/quadriplegic
 Bedridden
 Recent antibiotic use
Sepsis - High
Risk Factors
 Immune compromised
 diabetic
 cancer
Sepsis - High
Risk Factors
 human
immunodeficiency
virus (HIV)
 systemic steroids
Sepsis - High
Risk Factors
 anti-rejection
medications
 powerful
anti-inflammatory
medications
Septic Shock
 Two
of the four SIRS
criteria
 Infection
 Hypoperfusion
Septic Shock
 Define
shock = systolic
less than 90 mmHg
Septic Shock
 Systolic
= pressure
when your heart is
beating (1/3 of the
cardiac cycle)
Septic Shock
 Diastolic
= pressure
when heart is at rest
(approximately 2/3 of
the cycle)
Septic Shock
 Mean
arterial pressure
(MAP)

<65 mmHg considered
shock
Septic Shock
MAP =
(2 x diastolic) + systolic

3
Lactates
Infection
MODS
Lactates
 Cells
usually use
oxygen to make energy
Lactates

when cells do NOT get
the oxygen they need,
anaerobic metabolism
occurs (make energy
without oxygen)
Lactates

by-product: lactic acid
(toxin)
Lactates
A
measure of cellular
profusion NOT blood
pressure
EMS Lactate
Levels
 Prehospital
lactate
meters
look/work like a
glucometer

EMS Lactate
Levels
takes 60 seconds
 developed for
endurance athletes
 lactate ≥4 (shock)

EMS Lactate
Levels
 Three
measures used
for hypoperfusion:
systolic (least effective)
 MAP
 lactate levels

Septic Shock
 Classic
shock
distributive
Septic Shock
cardiac function
compromised
(cardiogenic shock)
 massive fluid shift
(hypovolemic shock)

Multiple Organ
Dysfunction
Syndrome (MODS)
 Last
stop before death
 80 - 100% mortality rate
Multiple Organ
Dysfunction
Syndrome (MODS)
 Presence
of altered
organ dysfunction in
the septic patient
Infection
MODS
Pathophysiology
 Bacterial infection
 chemotaxis
 secreted chemical
signal
Pathophysiology
 capillary vasodilation
and increased vascular
permeability
 leukocytes (WBCs)
combat infection
Pathophysiology
 Systemic infection
(can’t maintain
perfusion pressures)
Pathophysiology
 blood vessels dilate
and attack, damaging
tissue simultaneously
Pathophysiology
 more damage to tissue,
tissue sends out signal
needing help
● more vasodilation
● more capillary leaking
● more damage occurs
Pathophysiology
 more damage occurs,
more of the signal gets
sent out
● more capillary dilation
● more leaking
Early
intervention,
early treatment!
Pathophysiology
 Release of
proinflammatory
cytokines (powerful
vasodilators)
Pathophysiology
 Release of
anti-inflammatory
mediators
(inhibit production of
inflammatory components)
Pathophysiology
 Coagulation
 proinflammatory
cytokines cause
endothelium to loosen
anticoagulation
properties
Pathophysiology
exacerbated by venous
blood pooling (takes
blood out of circulation)
 microthrombi form
(organ system
dysfunction/failure)

Pathophysiology
 Remaining blood
 no coagulation
properties
 flows sluggishly
 vessels permeated and
dilated (leaks out)
Pathophysiology
 Respiratory system
 acute respiratory
distress syndrome
(ARDS) - 40% mortality
rate
Pathophysiology
 surfactant production
decreases
● maintains alveolar
tension
Pathophysiology
● lungs are extremely
susceptible to
ventilation-induced
injury
EMS Treatment
 Early

recognition key
history
EMS Treatment
 Early
recognition key
history
 physical exam (look
for infection)

EMS Treatment

strict aseptic practices
(patient already
compromised)
EMS Treatment

fluid resuscitation
● large bore IVs
● 20 mL/Kg bolus
(500 mL increments)
● follow local protocol
for maximum dose
EMS Treatment

every 500ccs listen to
breath sounds in case
they go into pulmonary
edema
EMS Treatment

pulmonary edema
(move to
vasopressors)
EMS Treatment

increased oxygen
demand
● hypermetabolism
● impaired oxygen
extraction
EMS Treatment
respiratory failure
occurs rapidly
 lung-protective
ventilation

EMS Treatment
● slightly increased rate
● slightly lower tidal
volumes
EMS Treatment
● slightly increased rate
● slightly lower tidal
volumes
● oxygen saturation
between 88% and 92%
EMS Treatment
 Pharmacological
support
dopamine 2 - 20 μg/kg
per minute

EMS Treatment
maintain systolic of
90 mmHg or MAP of
65 - 70 mmHg
 may need higher doses

EMS Treatment
 Place
supine with feet
elevated
 NOT Trendelenburg
 may impede breathing
EMS Treatment
 Rapid
transport to the
closest, appropriate
facility
What Can I Do?
“I’m just a lowly EMS
provider.”
EMS Sepsis
Alert
 Goal
identify septic shock
patients
 alert hospital
 start fluid resuscitation

EMS Sepsis
Alert
start vasopressors
(if needed)
 transfer to closest
appropriate facility

EMS Sepsis
Alert

consider emergent
transport
EMS Sepsis
Alert Criteria
 Initiate
sepsis alert for
patients
18 years and older
 NOT pregnant

EMS Sepsis
Alert Criteria
 Two
or more of the
below SIRS criteria:
EMS Sepsis
Alert Criteria
temperature >38 C
(100.4 F) or <36 C
(96.8 F)
 pulse >90
 respiratory rate >20

EMS Sepsis
Alert Criteria
 Suspected
or
documented infection
AND
One of the following:
EMS Sepsis
Alert Criteria
 Hypoperfusion
evidenced by low
systolic <90 and/or MAP
<65
 Lactate ≥4
Thank You
T. Ryan Mayfield
[email protected]
www.ryanmayfield.com
(After December 1)
EMS/Nursing
81711/
316011
Healthcare
Research/Sepsis
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EMS/Nursing
81711/
316011
Release Date:
10/01/2011
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EMS
81711
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Nursing
316011
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Nursing
316011
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Nursing
316011
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Nursing
316011
Conflicts of Interest:
T. Ryan Mayfield, MS, EMT-P has disclosed that no financial interests,
arrangements or affiliations with organization/s that could be perceived as a real
or apparent conflict of interest in employment, leadership positions, research
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Nursing
316011
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Off-label Use:
T. Ryan Mayfield, MS, EMT-P has disclosed that no products with off-label or
unapproved uses are discussed within this activity.
Nursing
316011
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