Clinical Cases in Paramedicine. Группа авторов
lungs. The heart rate (HR) and stroke volume (SV) are raised, leading to an increased cardiac output (CO). Vasodilation occurs, allowing the blood vessels to transport a greater blood volume, which eventually leads to reduced preload and reduced SV. The HR increases further to compensate, resulting in tachycardia. Some patients may be on medications that mask tachycardia (e.g. betablockers).Profound vasodilation leads to a ‘relative loss’ in circulating volume and the increased permeability of the blood vessels following the release of histamine results in an ‘absolute loss’ as fluid escapes into the extravascular space. 25% of patients with septic shock present with a normal BP (cryptic shock or occult hypoperfusion) and others may present with relative hypotension (systolic BP >40 mmHg lower than normal systolic BP).In the early stages patients may be warm and flushed as vasodilation leads to an increased blood volume in the peripheries. Heat generated soon becomes lost through the skin, reducing the temperature. In the later stages, the patient begins to peripherally shut down as the body attempts to redirect the blood to its core organs, which results in a further cooling of the skin. Hypothermia/cold sepsis occurs in 10–20% of patients and is more common in elderly patients. The mortality rate for these patients is double that of those with pyrexia.
3 Which groups are most at risk of developing sepsis? Elderly patients (>75 years or frail).Young patients (under 1 year).Immunocompromised patients whose immune system is impaired by medication or illness (e.g. chemotherapy patients) or where immune function is impaired due to medical conditions (diabetes and sickle cell) or medications (immunosuppressants or steroids).Post‐surgery (within the last 6 weeks).Open wounds.Patients with indwelling medical devices (catheters or cannulas).Intravenous drug users.Pregnant women with recent history of miscarriage or termination and post‐delivery.
4 What prompts or tools are used to determine when to screen for sepsis? Guidelines used to recommend use of the modified systemic inflammatory response syndrome (SIRS) criteria, whereby patients presenting with two of more SIRS criteria with a confirmed or suspected infection were deemed to require further investigation to confirm or exclude a diagnosis of sepsis. This screening tool captured those patients presenting with ‘uncomplicated’ sepsis who were otherwise well and were at low risk for clinical deterioration. The definition of sepsis has now been updated so only those with a degree of organ dysfunction or clinical compromise are included. The SIRS criteria are no longer used as a screening tool.The red flag system was developed to be used in conjunction with the SIRS criteria as a guide to which patients needed early intervention. This was to ensure responsible antibiotic stewardship due to the sensitivity of the SIRS criteria. The red flag system is quick to apply and is used by over 90% of UK hospitals.The revised version of the National Early Warning Score (NEWS2) track and trigger system has been shown to be the most effective screening tool for predicting adverse outcomes for patients presenting with sepsis. This has now been incorporated into many systems, where screening is recommended for those with a NEWS2 of greater than 5 with identified risk factors or clinician concerns.
5 Which components of the Sepsis Six apply to the prehospital environment? Oxygen: titrate to maintain SpO2 at 94–98%.Fluids: bolus of 500 mL over 15 minutes if indicated (systolic BP <90 mmHg).Antibiotics: benzylpenicillin for meningococcal septicaemia. Refer to local guidelines regarding the use of broad‐spectrum antibiotics. Not routinely recommended.Lactate: measure lactate if indicated by local guidelines. Not routinely recommended.
LEVEL 3 CASE STUDY
Smoke inhalation
| Information type | Data |
| Time of origin | 02:24 |
| Time of dispatch | 02:25 |
| On‐scene time | 02:30 |
| Day of the week | Friday |
| Nearest hospital | 15 minutes |
| Nearest backup | 10 minutes |
| Patient details | Name: Sam Bryant DOB: 09/09/1990 |
CASE
You have been called to a fire at a residential address for a 30‐year‐old male with smoke inhalation.
Pre‐arrival information
The patient is conscious and breathing and has extricated himself from the fire. He is at the neighbour’s house when you arrive.
Windscreen report
Fire and police units are on scene. The incident has been contained.
Entering the location
The patient is sat on the couch at a neighbour’s house.
On arrival with the patient
The patient is talking to a police officer and appears distressed.
Patient assessment triangle
General appearance
He is alert and has soot around his mouth and nose. He is coughing quite badly.
Circulation to the skin
Normal skin colour.
Work of breathing
Increased work of breathing.
SYSTEMATIC APPROACH
Danger
None at this time – the hazard has been contained.
Response
Alert on the AVPU scale.
Airway
Clear. Soot is noted in the mouth and nose. Singed nasal hairs and hoarse voice.
Breathing
RR: 28. No accessory muscle use. Equal air entry in both lungs, no adventitious (added) sounds on auscultation.
Circulation
HR: 106. The radial pulse is palpable – regular. Capillary refill time 1 second.
Disability
Pupils equal and reactive to light (PEARL), 4 mm.
Exposure
The chest is exposed in a private dwelling to undertake a physical exam – the ambient temperature is warm.
Vital signs
RR: 28 bpm
HR: 106 bpm
BP: 125/82 mmHg
SpO2: 97%
Blood glucose: 5.1 mmol/L
Temperature: 36.6 °C
GCS: 15/15
4 lead ECG: sinus tachycardia
TASK
Look