Author: Nisha Crouser, MS4 // Editor: Michael Barrie, OSU EM Attending
One of the first questions Emergency Medicine physicians have to ask themselves is “Do I think this patient is sick or not sick?” A simple question, that takes years of practice and experience to answer. Once a patient is deemed “sick” the questions to follow become more difficult, “How sick?” “What should we do next?” The following case presentation helps elucidate some of the difficulties faced in the ED when sick patients arrive and how to act on the dangerous diagnosis of septic shock.
A 58-year-old patient with several past medical problems including hypertension, hyperlipidemia, and heart disease; presents to the ED with a fever and back pain. Upon arrival the patient is a diaphoretic and ill-appearing obese female who is able to follow commands and answer a few questions. It is difficult to obtain a history from the patient and there is no family present to contribute any information. She is tachycardic and hypotensive when placed on the monitor. Given these vitals in combination with her fever, a Septic Shock alert is initiated. The ED is very busy and there is another severely ill patient that the physician is also covering. Several tests are ordered and fluids are started, there is no obvious source of infection. Over the course of the next half an hour, the internal medicine doctors lay eyes on the patient who has now become more unresponsive. As another half an hour goes by, the patient’s skin become extremely mottled and blue. Her oxygen saturation and blood pressure drop precipitously and she goes into asystole.
Sepsis is a syndrome triggered by the body’s response to infection. Septic shock can result and is characterized by a drop in blood pressure despite fluid replacement and/or organ failure. Sepsis is an under recognized cause of avoidable death that kills more patients than the leading causes of cancer.
The barriers to recognition of sepsis and early treatment:
- Symptoms can be vague and ill-defined
- Providers want to establish a clear diagnosis of the infectious etiology
- Patients can deteriorate rapidly if not monitored closely
The solution to this problem begins in the Emergency Department where many patients are seen for the first time in the hospital. The ED physicians become responsible for identifying and starting early treatment for septic patients. Because of the severity of consequences for these patients, multiple treatment initiatives have been developed over time with the most common being SERRI (the Sepsis Early Recognition and Response Initiative). SERRI is an ongoing initiative being implemented in 15 facilities to study the effects of this new sepsis program on patient outcomes and costs. The initiative focuses on four areas including: leadership, education of nurses and second responders, implementation of a screening tool in the electronic health record, and feedback response of the process and data. The screening tool is seen below:
This model along with others has been used across the country in attempts to decrease morbidity and mortality from sepsis. Grant Medical Center uses a similar protocol, which is what helped early identification of sepsis in the case presented.
Unfortunately, the patient coded and after 40 minutes of attempted resuscitation she passed away. The interesting part of this case was the extremely rapid decline of the patient, who entered the ED with the ability to converse and answer questions and then died with a few hours. At the time of death there was still no obvious cause of the infection. Although the Sepsis alert was called in a timely fashion, it seemed as though cardiogenic shock was not in the differential until she coded. Given her cardiac history and probable lack of reserve, she spiraled down faster than the average patient. This case demonstrates that obviously there are still areas of improvement to be made when it comes to dealing with the septic patient and further research is needed to identify life-threatening cases of sepsis before they progress. Additionally, it is important to remember the other causes of shock that may coexist in patients. Again, it is important to always “Say Sepsis” because the condition is common and can be easily missed!
1.National Guideline Centre (UK). Sepsis: Recognition, Assessment and Early Management. London: National Institute for Health and Care Excellence (UK); 2016 Jul. (NICE Guideline, No. 51.) Available from: https://www.ncbi.nlm.nih.gov/books/NBK374137/
2. Jones SL, Ashton CM, Kiehne L, et al. The Sepsis Early Recognition and Response Initiative (SERRI). Joint Commission journal on quality and patient safety / Joint Commission Resources. 2016;42(3):122-138.