CG19 VERSION 1.2 1/12 Guideline ID CG19 Version 1.2 Title Approved by Sepsis including Meningococcal Septicaemia Clinical Effectiveness Group Date Issued 12/04/2016 Review Date 11/04/2019 Directorate Authorised Staff Medical Ambulance Care Assistant Emergency Care Assistant Student Paramedic Advanced Technician Paramedic (non-ecp) Nurse (non-ecp) ECP Doctor Clinical Publication Category Guidance (Green) - Deviation permissible; Apply clinical judgement 1. Scope 1.1 Sepsis is a medical emergency with devastating consequences and a high mortality rate. It is often under-recognised and frequently under-treated, in both the hospital and pre-hospital environment. This guideline aims to improve the awareness of sepsis amongst clinicians, to enable early recognition and treatment to improve outcomes for patients. 2. Background and Definitions 2.1 Of the 100,000 cases of sepsis each year in the UK, there are an estimated 40,000 deaths. In those who survive sepsis, the damage can be profound and life-altering. 2.2 Sepsis can be defined as a life-threatening organ dysfunction due to a dysregulated host response to infection. Uncomplicated sepsis, such as that caused by flu and other viral infections, gastroenteritis and dental abscesses, is common and can usually be treated in the community. Red Flag sepsis arises when in addition to sepsis, there is evidence of organ dysfunction or tissue hypo-perfusion. If hypo-perfusion remains despite adequate fluid resuscitation, the patient will enter septic shock. Patients with septic shock are very ill, with a mortality rate of 50%.
CG19 VERSION 1.2 2/12 3. Guidance 3.1 Suspecting Sepsis 3.1.1 The successful management of sepsis requires a high index of suspicion and early recognition. A useful summary is provided in Appendix 1. It is important to recognise the types of patients that may be at risk: Extremes of age e.g. premature babies, frail elderly; Diabetes; Immunocompromise e.g. chemotherapy patients, steroid treatment; Indwelling medical devices e.g. catheters; Alcohol and drug abuse; Skin wounds e.g. burns; HIV/AIDS. 3.1.2 Common causes of sepsis include: Pneumonia; Appendicitis; Urinary tract infection; Meningitis; Cellulitis/septic arthritis/infected wound/device; Abdominal pain or distention. 3.1.3 In around 20% of cases, the source of sepsis is unknown.
CG19 VERSION 1.2 3/12 3.1.4 Sepsis may be identified by the presence of a NEWS score of 3 or more, or if they look very sick, with a possible source of infection: 3.1.5 Signs that may indicate Red Flag Sepsis include: Systolic B.P < 90 mmhg Lactate > 2 mmol/l (if available); Heart rate > 130 per minute; Respiratory rate >25 per minute; Needs oxygen to keep SpO2 >92% (88% in COPD); Responds only to voice or pain/un; Non-blanching rash or mottled/ashen/cyanotic skin, lips or tongue; Not passed urine in last 18 hours. 3.2. Pre-hospital Management 3.2.1 Uncomplicated sepsis, where the patient does not have the suspected organ dysfunction or tissue hypo-perfusion that accompanies Red Flag sepsis or septic shock, may be safely managed in the community. 3.2.2 However, it is notoriously difficult to determine patients that can be treated safely in the community, and those who need emergency resuscitation and transfer to hospital. Any patient who has a NEWS score of 3 or more, or looks very sick as described in Para 3.1.4, or has any of the signs of Red Flag sepsis detailed in Para 3.1.5 should be managed as a medical emergency. If there is any doubt, advice must be sought from a senior clinician (ECP, Doctor or the Senior Clinician on-call).
CG19 VERSION 1.2 4/12 3.2.3 Red Flag sepsis should be treated as a medical emergency using a CABCD approach. Oxygenation, adequate fluid resuscitation and timely transport to hospital, are key to the management of sepsis. 3.2.4 Airway - Check airway for patency and where support is required adopt the stepped approach detailed in Clinical Guideline CG03 - Airway Management. 3.2.5 Breathing - Patients who have sepsis may require high flow oxygen via a nonrebreathing mask to maintain SpO2 of >95%. If the patient does not meet the Red Flag criteria but there is still a clinical suspicion of sepsis, maintain a SpO2 of >95%. For people with chronic obstructive pulmonary disease who are at risk of hypercapnic respiratory failure, aim to achieve a target SpO2 of 88-92%, using capnography where available. Assist ventilations where required; due to toxicity and muscle rigidity ventilation may be difficult. Be aware of the risk of barotrauma and tension pneumothorax. 3.2.6 Circulation - Where signs of hypo-perfusion exist, consider circulatory support through the administration of a sodium chloride 0.9% fluid bolus as soon as IV/IO access is established. JRCALC guidelines recommend the infusion of 1 litre of crystalloid over 30 minutes in adults, repeating once if the patient remains hypotensive. In children, it is recommended that a 20ml/kg bolus of sodium chloride 0.9% is infused, repeated if clinical presentation continues to be compatible with hypovolemia AND signs of poor tissue perfusion, up to a maximum cumulative dose of 40ml/kg. In adult patients presenting with a normal blood pressure, who have one or more Red Flag, consider administering 250ml of sodium chloride 0.9% at the earliest opportunity, if Red Flag/s persists, administer a second dose of 250ml. Do not administer fluids to patients who are hypertensive (systolic of 170mmHg). Do not delay transfer; stop if practicable to insert a cannula and commence fluid therapy en-route. 3.2.7 Disability - Check blood sugar levels as hyper or hypoglycaemia may be present. 3.2.8 Place an ATMIST pre-alert to the receiving Emergency Department, clearly stating that the patient has Red Flag sepsis. Where the transport time to hospital is likely to exceed 25 minutes, the HEMS desk should be contacted to discuss the suitability of the incident for air ambulance attendance.
CG19 VERSION 1.2 5/12 3.3 Meningococcal Disease 3.3.1 The two major clinical forms of meningococcal disease are meningitis and septicaemia. Most patients will have a mixed presentation, but tend to become either profoundly septicaemic or meningitic as the disease worsens. A minority of patients will have pure septicaemia and it is these patients who carry the worse prognosis. Septicaemia Death from cardiovascular failure Meningococcal Disease Meningitis Death from central nervous system failure 3.3.2 There are important differences in the pathophysiology of meningitis and septicaemia which underlie the clinical presentation of the two main presentations. 3.3.3 Meningococcal septicaemia occurs when meningococcal bacteria invade the bloodstream and release toxic products. The condition is the leading cause of death by infection in children and young people. As with any form of sepsis, early recognition and prompt medical treatment is key to survival; treatment becomes less by the minute. Unfortunately, signs and symptoms in the early stages are often subtle: 5 Septicaemic rashes do not necessarily develop at the same rate as the septicaemia; The rapidly evolving haemorrhagic text book rash may be a very late sign and it may be too late to save the child s life by the time the rash is seen; Up to 30% of cases start with a blanching pink rash, which fades with pressure and then becomes purpuric; There may be no rash.
CG19 VERSION 1.2 6/12 3.3.4 In some individuals the meningococcal bacteria cross the blood-brain barrier, producing inflammation and swelling in the meninges and the brain tissue itself. This causes raised intracranial pressure, which can lead to neurological damage and death. 3.3.5 The main symptoms of meningitis are due to the dysfunction of the central nervous system. They may be very hard to assess and parent s anxieties about their state must always be taken seriously: Fever; Headache; Vomiting; Drowsiness/confusion; Seizures; Photophobia (less common in young children); Neck stiffness (less common in young children). 3.3.6 Although the classical features of neck stiffness, photophobia and haemorrhagic rash should be sought, and are useful for ruling in pathology when present, they can be falsely reassuring when absent. The following tests can be used to support clinical assessment when ruling in meningitis; a negative test should not be relied upon to rule out meningitis as all of the tests lack sensitivity. All test for meningism, which can also be present in other differential diagnoses such as sub arachnoid haemorrhage and enchephalitis. 3.3.7 Neck Mobility/Nuchal Rigidity 3.3.7.1 Inability to flex the neck forward due to rigidity of the neck muscles. 3.3.8 Brudinski s Sign 3.3.8.1 Appearance of involuntary lifting of the legs when lifting a patient s head whilst the patient is lying supine. Brudinski s sign is positive when both knees and hips are flexed in response to passive flexion of the neck towards the chest. This reflex is due to exudate around the roots in the lumbar region. 3.3.9 Kernig s Sign 3.3.9.1 Whilst the patient is lying supine each hip is flexed in turn. Attempt to straighten the knee while keeping the hip flexed. In meningitis, this movement is greatly limited by spasm of the hamstrings, which in turn causes pain, leading to resistance.
CG19 VERSION 1.2 7/12 3.3.10 Management 3.3.10.1 These features are more common in adults, older children and teenagers. Small children often present with non-specific features that might otherwise suggest a diagnosis of viral illness. 3.3.10.2 It is essential that any positive or negative findings are annotated on the patient clinical record. 3.3.10.3 These presentations should be managed in the same way as any other form of severe sepsis with an CABCD approach, and a time critical transfer to hospital with an ATMIST pre-alert. 3.3.10.4 Hypovolaemia occurs in meningoccal septicaemia and requires fluid resuscitation in the same way as any other form of severe sepsis. 3.3.10.5 In addition, benzylpenicillin must be administered to all patients who fulfil the JRCALC guidance for its use. Where with the exception of the presence of a rash, the patient meets the JRCALC criteria for administration of benzylpenicillin, the Trust fully supports administration of the drug in the absence of a rash, where the clinician has a high index of suspicion of bacterial meningococcal septicaemia. Withhold benzylpenicillin only when there is a clear history of anaphylaxis after a previous dose; a history of a rash following penicillin is not a contraindication. 3.3.10.6 In the unlikely event of an allergic reaction following administration of benzylpenicillin, manage according to Clinical Guideline CG04 - Allergic Reactions. 3.4 Neutropenic Sepsis 3.4.1 Neutropenic sepsis is a potentially fatal complication of cancer treatments, such as chemotherapy. Mortality rates as high as 21% have been reported in adults. Patients can have neutropenia i.e. white Cell count less than 1 and and neutrophil 0.5 as a result of the cancer therapy, which increases their risk of developing severe infections. Cancer patients can become neutropenic, and not develop severe infections or sepsis. If patient is neutropenic and not showing signs of infection still call 24/7 advice line offered to patient by Acute Oncology service However many do develop this serious complication; suspect neutropenic sepsis in patients having cancer treatment who become unwell.
CG19 VERSION 1.2 8/12 3.4.2 Any of the following features could indicate that a neutropenic patient has an infection and is at risk of septicaemia: Tachypnoea; Tachycardia; Hypotension; Temperature greater than 37.5 o C; Chest pain; Shivering episodes; Flu-like symptoms; Gum or nose bleeds; Vomiting; Diarrhoea (or four or more bowel movements in a 24-hour period); Bruising; Catheter site infections (please note that neutropenic patients are unable to produce the pus normally associated with skin infections). 3.4.3 A neutropenic patient at risk of septic shock can look deceptively well and can deteriorate rapidly. A high index of suspicion is necessary, particularly if a patient who has recently undergone chemotherapy has an increased temperature. Patients who have received treatment within 6-8 weeks are at risk and at higher risk within the first 14days after treatment. 3.4.4 Neutropenic sepsis should be managed in the same way as any other septic patient. Neutropenic sepsis is a medical emergency and all patients should be transported to the nearest Emergency Department with an ATMIST pre-alert. 3.5 Paediatric Sepsis 3.5.1 2-3% of febrile episodes in children below 3 months of age are believed to be caused by sepsis. Paediatric patients have the ability to compensate for illness and maintain normal physiological parameters, until they rapidly decompensate. It is therefore vital that sepsis is recognised before decompensation occurs. Clinical Guideline CG16 - Paediatric Fevers covers the NICE traffic light risk assessment system for feverish children.
3.5.2 Other signs that may indicate sepsis in children include: Reduced appetite, feeding or fluid intake; Irritability; Lethargy; Diarrhoea; Dry nappies/reduced urine output; Bulging or sunken fontanelle; Reduced tone; Skin rashes; Prolonged capillary refill time; Mottled, cool and discoloured peripheries. CG19 VERSION 1.2 9/12 3.5.3 Management of paediatric sepsis relies on the same key principles as for adult sepsis; timely recognition, a CABCD approach, fluid resuscitation and time critical transfer to hospital. 4. Incident Closure 4.1 All patients with suspected severe sepsis or septic shock must be conveyed to an Emergency Department. 5. Documentation 5.1 In line with Trust Policy, a Patient Clinical Record must be completed and annotated appropriately. Any deviation from this guideline must be recorded, with any potential or actual adverse event reported through the incident reporting system.
CG19 VERSION 1.2 10/12 6. References 1. National Institute Clinical Excellence (2011) Neutropenic Sepsis: Prevention and Management of Neutropenic Sepsis in Cancer Patients (CG151). NICE. 2. Clinical Knowledge Summaries (2012) Menigococcal Septicaemia. Available from: http://www.cks.nhs.uk/meningitis_bacterial_meningococcal_ septicaemia [Accessed 4th November] 3. National Institute Clinical Excellence (2011) Feverish Illness in Childres: Assessment and Initial Management in children younger than 5 years (CG47). NICE. 4. Joint Royal Colleges Ambulance Liaison Committee Pre-Hospital Guidelines. JRCALC 5. Meningitis Research Foundation (2004) Lessons from Research for Doctors in Training. MRF. 6. Bickley, S (2013) Bates Guide to Physical Examination and History taking 11th edition: London, Wolters Kluwer Health.
CG19 VERSION 1.2 11/12 Appendix 1 - Sepsis Screening Tool Prehospital Sepsis Screening and Action Tool To be applied to all non-pregnant patients over 16 years of age who have a suspected infection or have clinical observations outside normal limits which could indicate sepsis. 1. Is the NEWS score 3 or above? OR does patient look very sick? Y N Low risk of sepsis Use standard protocols N 2. Could this be an infection? For example: Pneumonia Urinary Tract Infection Abdominal pain or distension Meningitis Cellulitis/ septic arthritis/ infected wound/ device Y 3. Is any ONE red flag present? Systolic B.P < 90 mmhg Lactate > 2 mmol/l (If available) Heart rate > 130 per minute Respiratory rate > 25 per minute Needs oxygen to keep SpO 2 >92% (88% in COPD) Responds only to voice or pain/ un Non-blanching rash or mottled/ ashen/ cyanotic skin, lips or tongue Not passed urine in last 18 hours Y Red Flag Sepsis This is time critical, immediate action is required. Resuscitation 250ml boluses crystalloid (Max 500mls in normotension (do not administer in patients with a systolic of 170 or above)) Max 2000ml in Hypotension (care in CHD) Oxygen to maintain saturations >94% (88% in COPD) Record lactate (if available) N Y Any moderate risk criteria? Relatives concerned about change in mental state Acute deterioration in functional ability Neutropnenic Rigors Immunosuppressed Trauma, surgery or procedure in last 6 weeks Clinical signs of wound, device or skin infection Respiratory rate 21-24 OR breathing hard Heart rate 91-130 Systolic B.P 90-100 mmhg Not passed urine in last 12-18 hours Temperature < 36 C Y Immunocompromised N Sepsis likely Transport to emergency department Communicate likelihood of sepsis at handover Communication Pre-alert receiving emergency department: Patient has Red Flag Sepsis Convey to emergency department (or other agreed destination) Handover presence of Red Flag Sepsis
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