June 2, 2025

Perhaps no topic in medical literature has received as much attention in the past few years as sepsis and septic shock, which are the topics for this month’s continuing education presentation. Over the past 10 years, Critical Care and Infectious Disease experts have offered several revisions and modifications with regard to:

• The definition of sepsis: “Life-threatening organ dysfunction due to dysregulated host response to infection.” 

• Removing “severe sepsis” as an actual category of the sepsis continuum. 

• The nature, origin, and production of lactate in sepsis: Lactate is now believed to be generated as a byproduct of pyruvate overproduction due to endogenous epinephrine stimulation. This refutes the theory that lactate is produced during “anaerobic metabolism.” However, most texts still adhere to the production of lactate as a result of anaerobic metabolism.  

• The cause of acidosis in sepsis (current theories suggest that acidosis in sepsis is not due to “lactic acid” but rather due to chloride and hydrogen ion accumulation and loss of bicarbonate). 

• Recommendations regarding whether invasive monitoring of central venous pressure (CVP) is necessary or beneficial. 

Despite all the flurry of activity and revisions in the sepsis arena, many of the fundamental aspects remain the same. Early identification, immediate resuscitation, and antibiotic administration are paramount, key to patient survival. To this end, the EMS provider must be able to suspect sepsis based on history, including the all-important septic risk factors, physical examination, and ancillary testing. Be aware of the risk factors for sepsis, which include diabetes, chronic renal failure, cancer, post-op patients, those with indwelling devices, and those patients on immunosuppressant medications. Sepsis can be diagnosed at the bedside by an astute EMS provider, nurse, nurse practitioner, PA, or physician. No complicated testing is required for sepsis identification, but early identification is essential to a good outcome. Prompt resuscitative and definitive treatment translates to decreased mortality. Remember: Systemic Inflammatory Response Syndrome (SIRS) + Suspected Infection = Sepsis 

We are all familiar with SIRS criteria as an indicator for the presence of sepsis—any two of these criteria make the patient “SIRS-positive.” Although there are several potential causes of SIRS, such as pancreatitis, burns, overdose, trauma, pulmonary embolism, etc., sepsis should always remain a high-level consideration in the differential diagnosis of a SIRS-positive patient. 

If a patient is SIRS-positive, the clinician must “look for the infection” which may or may not be obvious. Common sources of sepsis include: 

• The urinary tract, especially in patients who have undergone surgery or instrumentation of the urinary tract and those with a Foley catheter. Clues for urinary tract infection include dysuria, hematuria, fever, chills, flank pain, and cloudy urine noted in the Foley collection bag.  

• The respiratory tract, where patients with pneumonia may have fever, chills, productive cough, shortness of breath, and pleuritic chest pain. Physical findings could include increased respiratory rate, low pulse oximetry, accessory muscle use, crackles, or wheezes noted on lung auscultation. 

• The skin and joints, where the EMS provider should examine the skin for signs of erythema, warmth, and tenderness to palpation. Wounds can become secondarily infected, including non-traumatic wounds (infected foot wounds on diabetics, decubiti on debilitated patients), post-surgical wounds, and post-traumatic wounds, such as lacerations and punctures. Signs of septic arthritis (joint infections) include joint swelling, redness, tenderness, and decreased range of motion.  

• The GI tract, where the provider should inquire about vomiting, diarrhea, and abdominal pain. Patients with appendicitis, diverticulitis, ascending cholangitis, acute pancreatitis, mesenteric ischemia and bowel obstruction and perforation are all examples of gut-related sepsis. The physical findings could include diminished bowel sounds, abdominal distention, tenderness to palpation, and guarding. Rebound tenderness indicates peritonitis, which is a serious complication often noted in the patient with abdominal sepsis.  

Early recognition and treatment are key to survival. Treatment includes crystalloid fluids, vasopressors as needed, and early antibiotic administration. More to come next week.  

Stay well,

Andrew Garlisi, MD EMS Medical Director

University Hospitals EMS Training & Disaster Preparedness Institute

June 9, 2025

Sepsis diagnosis can often be challenging. Since signs and symptoms may be subtle at first, emergency providers might miss these clues, which could delay definitive treatment. It is not uncommon for sepsis victims to complain of general weakness and fatigue, which are very nonspecific symptoms. Elderly patients often experience changes in mental status or difficulty ambulating. Sepsis should remain high on the list in the differential diagnosis of nonspecific symptoms, especially in high-risk patients.  

Risk factors are a crucial component of a comprehensive history and can contribute to a more robust differential diagnosis. Risk factor assessment is important in patients with possible acute coronary syndrome, thoracic aortic dissection, cardiac tamponade, or pulmonary embolism. The same is true for sepsis. Patients with diabetes, chronic renal failure on dialysis, cancer, autoimmune diseases (Crohn’s, rheumatoid arthritis, psoriasis, lupus, etc.), indwelling devices, frequent hospitalizations, recent invasive procedures, and chronic exposure to healthcare facilities are among the high-risk patients.  

Since sepsis can affect anyone of all ages and has a multitude of presentations, the diagnosis can be difficult. A high index of suspicion, coupled with a concise history and physical examination, goes a long way in pointing to the diagnosis.  

Ancillary testing can be a valuable adjunct in the diagnosis of sepsis, which results in organ dysfunction. The brain is often the target organ that reveals early signs of sepsis. A urinary tract infection in the susceptible chronic nursing home patient frequently manifests as “acute mental status change.” Glucose testing should be obtained in all patients with encephalopathy. Patients could experience hypoglycemia, especially if they are chronically malnourished or if they have had frequent vomiting and reduced food intake. The other extreme, hyperglycemia, can also be a consequence. Patients under the stress of sepsis have increased adrenal cortisol production, which increases blood glucose. Furthermore, endogenous epinephrine production (a consequence of the septic process) breaks down glycogen into glucose.  

The 12 lead EKG may reveal tachyarrhythmias and signs of ischemia in patients with underlying heart disease. Lung dysfunction, as a result of sepsis, could manifest by impairment in oxygen exchange, resulting in a decrease in oxygen saturation on pulse oximetry.  

As systemic perfusion decreases during the septic process, cells are impaired in their ability to produce ATP and carbon dioxide. CO2 reduction is detected by waveform capnography. As ATP energy diminishes, the cells and tissues break down and eventually die. Organ dysfunction is the consequence. Capnography remains a vital indicator of perfusion at the cellular level. Some squads have utilized pre-hospital point-of-care lactate testing. The cause of lactate excess in sepsis is still being debated by experts. Recently, many researchers have postulated that lactate (not lactic acid) is produced by the release of endogenous epinephrine, which breaks down glycogen into glucose. In the past, lactate was believed to be the product of anaerobic metabolism (without oxygen), but in fact, most patients with sepsis have adequate oxygen supplies and still produce lactate. Normally, glucose would be utilized in the metabolic pathway known as glycolysis to make pyruvate, which enters the Krebs cycle. When excess pyruvate is produced, the Krebs cycle pathway is overwhelmed. Some of the glucose excess is therefore converted into lactate. These scientists contend that lactate, not lactic acid, is the actual chemical (the difference is one hydrogen ion in lactic acid, which lactate lacks).  

Regardless of how or why lactate accumulates, it remains an important indicator of sepsis severity, and serial lactate measurements provide insight into patient response to treatment. Thank you to all my EMS and ED colleagues!  

Stay well,

Andrew Garlisi, MD

EMS Medical Director

University Hospitals EMS Training & Disaster Preparedness Institute

June 16, 2025

Sepsis and septic shock are often insidious diseases with subtle initial presentations that masquerade as less ominous conditions. Early symptoms and signs can be nonspecific and non-alarming. General weakness, fatigue, chills, mild change in mental status in the elderly, feeding difficulties, and change in behavior in the infant are signs and symptoms often encountered in the septic patient, which causes delay in diagnosis and definitive treatment. These delays can be catastrophic. 

Case in point: A 42-year-old female presented to the emergency department at 4 pm with abdominal pain, nausea, and vomiting times 3. This woman had been diagnosed with rheumatoid arthritis and placed on Humira. She was an otherwise healthy woman, a mother of two children, working as a freelance journalist.  

She presented with stable vital signs—RR 18, blood pressure 118/68, heart rate 92, temp 37.4, room air pulse oximetry 96% room air. Her physical examination revealed lower abdominal tenderness. The emergency physician ordered an IV fluid bolus, pain medication, Zofran, labs, urinalysis, and a CT scan of the abdomen and pelvis. No orders were entered for continuous monitoring.  

Two hours later, the evening change-of-shift occurred. The ED was full, and multiple patients were handed off to the oncoming physician. Two squads arrived at change-of-shift with one critical patient, immediately consuming the time and attention of the night shift doctor.  

Meanwhile, our 42-year-old patient was still waiting for the CT scan. There were five other patients waiting for CT scans ahead of her. Newly arriving nurses were scrambling to catch up on the influx of patients, which included four patients on hallway stretchers.  

At 8 pm, the patient was transported to the radiology department for her CT. Labs had been resulted, remarkable only for an elevated white blood count of 15,500 and lactate level 2.4. The oncoming physician had not yet had the opportunity to examine the patient who had been handed off at change-of-shift.  

The patient returned from the CT department. By 9:30 pm, the emergency physician was able to reassess the patient who was complaining of increasing abdominal pain. She exhibited LLQ tenderness and guarding. Noting the elevated white blood count, the physician ordered an IV antibiotic Zosyn and requested that the patient be placed on the cardiac monitor. He ordered repeat vital signs, which revealed a heart rate of 108 and a blood pressure of 102/60. Because of the deluge in CT studies, the radiologists were running behind in CT interpretations.  

Unfortunately, due to staffing issues and an overburdened ED, the nurse (who was also caring for the critically ill respiratory failure patient who required emergency intubation and multiple medications) was not able to place the patient on the cardiac monitor or hang the Zosyn.  

At 10:30 pm, a family member who had just arrived screamed out for help. A nurse and the ED doctor rushed into the room to find the 42-year-old patient lethargic and diaphoretic with a thready pulse. The patient was not on the cardiac or blood pressure monitor. A flurry of activities included vital signs, heart monitor, placement of a second IV line, and an order for two liters fluid bolus. The patient’s blood pressure was 70 systolic. Zosyn was finally initiated. Norepinephrine was ordered. At that time, the radiologist called the ED to alert the staff that the patient had evidence of diverticular abscess and perforation on the CT. The on-call surgeon was paged.  

The patient deteriorated despite resuscitation efforts and expired in the emergency department.  

This case illustrates how a septic patient can present with subtle signs and symptoms and rapidly progress to septic shock and death within hours. This case also demonstrates the importance of risk factor assessment. This young woman was on Humira for rheumatoid arthritis. Humira is an immune modulator (also used in Crohn’s disease, psoriasis, ankylosing spondylitis, etc.) that suppresses the patient’s innate immune system, making her susceptible to infections. Because her symptoms and vitals initially were not dramatic, the staff was lulled into a false sense of security. Cardiac rhythm and vital signs were not closely monitored. The nurses and physician were distracted by multiple other patients and activities in the department. The patient’s nurse was preoccupied with another critical patient who required intubation and post-ventilator intensive care monitoring. Antibiotic administration was seriously delayed. The CT interpretation was delayed. The patient’s deterioration was unnoticed by the staff until a family member raised the alarm. It was the perfect storm for pitfalls and miscues, which resulted in a tragic, preventable death, which happens all too often with sepsis and septic shock.  

Blessings,

Andrew Garlisi, MD

EMS Medical Director

University Hospitals EMS Training & Disaster Preparedness Institute

June 23, 2025

Sepsis and its most severe consequence, septic shock, are time-sensitive, life-threatening illnesses. In previous weeks, we discussed how an astute EMS provider armed with the basic skills of history-taking, physical examination, use of ancillary testing, and differential diagnosis is quite capable of diagnosing sepsis in the field. Early diagnosis and early intervention improve survivability.  

What are the pathophysiological events that are responsible for the vital sign abnormalities, organ damage, and clinical deterioration that invariably occur in the patient whose septic condition is undetected or untreated? The usual culprit is an infectious agent, most often bacterial, although viruses and other pathogens could be involved. Bacterial invasion, with release of endotoxins or exotoxins, triggers a vigorous response from the body’s immune/inflammatory systems. The body’s cellular defense system is stimulated, causing activation of monocytes and neutrophils (white blood cells), as well as tissue macrophages, which engulf and digest bacteria and recruit T lymphocytes to assist in fighting the bacterial invasion.  

In addition to these cells that respond to the invasion, several chemicals are released during the immune/ inflammatory reaction, which include cytokines, proteases, kinins, and reactive oxygen species. Although the purpose of the immune/inflammatory reactions is to contain, suppress, destroy, and remove the invading organisms, often in sepsis these reactions are exaggerated and counterproductive, leading to coagulation, vascular dilation, and vascular injury. These events can lead to a vicious cycle resulting in organ damage, hypotension, and all the clinical signs that healthcare providers battle as they struggle to keep patients alive.  

Early and aggressive intervention is required to provide the septic patient with a favorable chance of survival, which begins in the field. EMS providers are well-equipped with the capacity to make a reasonable diagnosis of sepsis and impending septic shock. Basic tenets of intervention include IV or IO insertion, oxygen, cardiac, and capnography monitoring. Our EMS protocols call for a crystalloid fluid bolus (normal saline) of 20 cc per kg. The fluid boluses can be provided in increments (250 or 500 mL) and repeated. Vital signs should be repeated every 5 minutes. Paramedics should document the clinical response to each fluid bolus.  

Septic shock, the most severe complication of sepsis, carries a high mortality rate. By definition, septic shock is present when a patient remains hypotensive despite an adequate fluid bolus, thereby requiring the use of vasopressors to maintain adequate perfusion. The patient will have elevated lactate levels of 4 or higher, and signs of end-organ impairment will be present. Vasopressors in the field include push dose epinephrine as in our UH protocols, or dopamine. Epinephrine, the most versatile drug in our armamentarium, is not only a vasopressor causing vasoconstriction via vascular alpha-1 activation, but it is also an inotropic agent that increases cardiac contractility, or force of heart contraction. Furthermore, epinephrine is also a positive chronotropic agent, increasing the heart rate. These direct cardiac stimulatory effects occur via activation of beta-1 receptors in the heart. These three epinephrine-related compensatory responses are necessary to combat the vasodilation, cardiac suppression, and hypotension that occur in septic shock.  

Most authorities agree that early antibiotic administration improves survivability based on evidence. The goal for antibiotic administration is within one hour of recognition of sepsis. To this end, some EMS agencies across the country have protocols for antibiotic administration in the field for septic patients. EMS providers were trained to draw blood cultures. A 2020 study in the HCA Healthcare Journal of Medicine showed evidence that prehospital antibiotics improved morbidity and mortality of EMS-transported patients with sepsis. The length of ICU stay was reduced, as well as days on the ventilator.  

Thank you,

Andrew Garlisi, MD

EMS Medical Director

University Hospitals EMS Training & Disaster Preparedness Institute

June 30, 2025

Ketamine is a powerful medication with multiple uses in our protocol, though it is relatively safe. Due to untoward events in our EMS world, including a death in Columbine, CO, and documented apnea in Columbus, OH, the medical directors came together with our leadership and have a program that demands a 100% review of any dose of ketamine over the 10 mg IV pain dose. We are proud to say that with the fine work of our prehospital providers and this oversight led by Jonathan Cameron, we have not had any critical events with the use of ketamine; we’ve had areas of improvement with post-medication monitoring. The number one missed monitoring event is failure to check glucose after sedation. Knowing that a glucose check is mandatory for any of our multitude of altered mental status patients, it goes without saying that any patient requiring sedation needs to have their glucose checked. 

The following is a real case that I reviewed last week. A 29-year-old female was combative and violent at her home. EM0S was unable to provide care and did not want to disassociate this patient, so they administered Ativan (RSI Unit). This didn’t help, especially with this medication taking up to 30 minutes for an IM dose to work. With the situation still dangerous, they administered 250 mg of ketamine. After five minutes, she was still extremely violent and required a second dose of ketamine 250 mg IM. She became sedated but still agitated. Then, they arrived at the Samaritan ED. The ED team monitored her glucose immediately, and her glucose was 50. They administered glucose immediately, and the patient did well. I spoke to the crew, and they had left their glucometer at the residence. Here, there was no harm done as the glucose was at least over 40, but that was just fortunate. I have also had medics tell me, “The patient wasn’t diabetic.” Ketamine can induce both increased and decreased glucose levels. 

If your team is using ketamine, remember what we learned in paramedic class: right patient, right drug, right dose, right time, and right route. We also require two providers present for all medication use, including IVF. Reliable care requires closed-loop communication, and our “speak up” culture requires that we all listen to each other.

Some side effects to be aware of: 

• Allergic reactions (rare) 

• Hallucinations 

• Laryngospasm (Usually in peds and very self-limited and rare) 

• Loss of contact with reality 

• Palpitations (usually self-limited) 

• Salivation (especially with IV chemical-assisted ventilation) 

• Transient hypertension 

• Transient hypotension (not as common as hypertension) 

Post ketamine over the 10 mg pain dose required by protocol: 

• Blood glucose 

• Cardiac monitoring 

• Frequent vitals 

• Pulse ox 

• Capnography 

• ABCs

Ketamine is a very safe medication, and we all use it for pain, intubation, and emergency sedation. Careful post-medication monitoring will allow us to keep this powerful medication aid in our protocol for years to come. 

Sincerely,

Don Spaner, MD