Sepsis in the Emergency Department

 

Surviving sepsis through the application of research tested guidelines has become the newest campaign now that we ER docs have refined and protocolized our approach to heart attacks and strokes. However, there are lots of medical malpractice cases still occurring because sepsis gets missed or inadequately treated. In a potential sepsis case, some of the key questions that arise are: “Was SIRS suspected and identified?” and “Was the patient actually septic at the time of the Emergency Department visit?”

The Systemic Inflammatory Response Syndrome (SIRS) is a constellation of signs, symptoms & findings that suggest that infection may be the underlying cause of a patient’s presenting problem. Screening for SIRS includes identifying objective and easily measured parameters such as an elevated pulse rate, respiratory rate or temperature, and/or an elevated white blood cell count on a blood draw (two or more abnormalities need to be present to constitute a positive SIRS screen); but it also includes subjective findings such as mental status changes. In the absence of a fever, one might not think to attribute a patient’s presenting symptoms to infection unless one notices that several other vital signs are abnormal, thus, making the patient SIRS-positive.

Sepsis is SIRS plus a suspected or proven source of infection. So, SIRS plus an infiltrate on a chest x-ray = sepsis secondary to pneumonia; SIRS plus lots of pus in the urine = urosepsis; and SIRS plus a painful, swollen joint = sepsis secondary to septic arthritis until proven otherwise. Not putting these findings together into a picture that screams “sepsis” may lead to the diagnosis being completely missed or to the medical management being below the standard of care as in the doctor’s doing too-little-too-late.

Sepsis, identified early-on and treated with antibiotics to destroy the infectious organism and robust hydration to prevent shock, is very survivable. Untreated or poorly treated sepsis leads to severe sepsis, which leads to septic shock, which leads to multi-organ failure and death. Surviving sepsis requires that the emergency physician be a vigilant detective, do an appropriate workup, and apply proven therapeutics aggressively.

Bruce Wapen, MD, FACEP
Emergency Medicine Expert