Podcast 191 - Sepsis Update w/ Kevin Collopy

Show notes are AI generated from episode transcript

Sepsis has been discussed, debated, and redefined for decades, yet it continues to be one of the most common and deadly conditions clinicians encounter. For EMS providers, it can sometimes feel like a hospital problem. The definitive treatments happen in the emergency department or ICU, so the temptation is to view sepsis as something we simply suspect and transport.

That mindset misses a critical opportunity.

Prehospital recognition of sepsis, particularly septic shock, has real consequences for patient outcomes. Even when EMS cannot deliver the full bundle of therapies, identifying sepsis early and alerting the hospital can significantly shorten the time to treatment and improve survival.

Sepsis Is Still a High-Mortality Condition

Despite advances in critical care, septic shock remains associated with substantial mortality. Unlike many other time-sensitive emergencies, we have not dramatically reduced mortality rates across the board. That means early recognition and early intervention remain essential.

For EMS providers, the biggest impact may come from something deceptively simple: identifying sepsis and notifying the hospital early.

Research has shown that prehospital sepsis alerts can significantly shorten the time from patient contact to antibiotic administration. In some systems, the time from the 911 call to antibiotics has been reduced by more than an hour when EMS alerts the hospital ahead of arrival. That kind of time savings matters when you are dealing with septic shock.

The reality is that many septic patients do not receive antibiotics immediately upon ED arrival. Early recognition by EMS primes the system and gets the process moving sooner.

The Challenge of Diagnosing Sepsis

Part of the difficulty with sepsis is that it is not a single disease. It is a syndrome with a wide range of presentations.

Historically, clinicians relied heavily on SIRS criteria:

• Fever or hypothermia

• Tachycardia

• Tachypnea

• Abnormal white blood cell count

The problem is that SIRS is not specific to infection. Trauma, dehydration, pain, and countless other conditions can trigger the same physiologic response.

The Sepsis-3 definition, introduced in 2016, attempted to address this by defining sepsis as infection with organ dysfunction. It also introduced the SOFA score and the simplified qSOFA screening tool.

Unfortunately, qSOFA has limitations, especially outside the hospital. It is not particularly sensitive and may miss patients early in the disease process.

For EMS providers, the practical approach often comes down to three questions:

1. Does the patient likely have an infection?

2. Do they meet physiologic criteria suggesting systemic illness?

3. Is there evidence of shock or organ dysfunction?

Answering those questions quickly in the field can be challenging, but it remains the foundation of prehospital sepsis recognition.

Finding the Source of Infection

One of the most important elements in diagnosing sepsis is identifying a plausible infection source.

Common prehospital sources include:

• Pneumonia

• Urinary tract infections

• Abdominal infections

• Skin and soft tissue infections

• Post-surgical infections

Sometimes the source is obvious. Other times it is subtle. Fever alone is not enough, and septic patients may not even be febrile.

EMS providers often rely on a combination of clinical clues:

• Altered mental status

• Weakness or malaise

• Tachycardia and tachypnea

• Hypotension

• Patient history of infection or recent illness

While none of these findings are definitive on their own, together they can paint a convincing picture.

Lactate: Helpful but Imperfect

Point-of-care lactate has become increasingly common in prehospital care, but it is important to understand what lactate actually represents.

Lactate is not a marker of infection.

Instead, it reflects global hypoperfusion and metabolic stress. Elevated lactate can occur in many conditions:

• Sepsis

• Trauma

• Hypoxia

• Seizures

• Intense exercise

What makes lactate useful in sepsis is not necessarily the single value, but the trend.

Higher lactate levels correlate with increased mortality risk. However, watching how lactate changes over time can be even more informative. If the number decreases after treatment, perfusion is likely improving. If it continues to rise, the patient may be deteriorating.

For EMS providers, lactate should be interpreted within the broader clinical picture rather than treated as a standalone diagnostic test.

Fluids and Vasopressors: Evolving Strategies

For years, sepsis treatment followed a straightforward philosophy:

Fill the tank first, then squeeze it.

This meant aggressive fluid resuscitation before initiating vasopressors.

While fluids remain important, this approach is increasingly being questioned. Septic shock is primarily a vasodilatory state, meaning the blood vessels lose tone. Flooding the patient with fluids does not necessarily correct that problem.

Excessive fluid administration also carries risks:

• Pulmonary edema

• Worsening ARDS

• Venous congestion

• Increased ventilator requirements

More clinicians are beginning to favor earlier vasopressor use, particularly norepinephrine, when hypotension persists after an initial fluid bolus.

For EMS providers, the key takeaway is that fluid resuscitation should be thoughtful rather than automatic.

The Role of Prehospital Antibiotics

One of the most debated topics in sepsis care is the use of antibiotics before hospital arrival. The evidence suggests that prehospital antibiotics can reduce mortality in patients with septic shock, particularly when the infection source is clear and the patient is hemodynamically unstable.

However, broad antibiotic administration for every suspected infection carries risks:

• Antibiotic resistance

• Adverse drug reactions

• Inappropriate therapy

For this reason, many systems restrict prehospital antibiotics to patients who meet clear criteria for septic shock.

If a patient is stable and the infection source is uncertain, it may be more appropriate to wait for hospital evaluation and targeted treatment.

Why EMS Still Plays a Critical Role

Even if EMS cannot deliver every component of sepsis care, the prehospital team still plays a pivotal role.

Early recognition allows providers to:

• Initiate appropriate resuscitation

• Notify the hospital early

• Trigger sepsis alert pathways

• Shorten time to antibiotics and definitive care

In many ways, sepsis recognition functions similarly to stroke or STEMI alerts. The earlier the system is activated, the faster the patient receives definitive treatment.

The Bottom Line

Sepsis remains one of the most common forms of shock EMS providers encounter.

Recognizing it early, identifying a likely infection source, and understanding the physiology behind septic shock can help guide better decisions in the field.

The interventions may not always be dramatic, but the impact can be substantial. Early recognition, thoughtful resuscitation, and clear communication with receiving hospitals can meaningfully improve outcomes for patients with sepsis.

And for EMS, that is where the real opportunity lies.

Resources Mentioned

• Surviving Sepsis Campaign guidelines

• Sepsis-3 definitions (JAMA, 2016)

• Prehospital sepsis research and recent studies on early antibiotics and ETCO₂