Identification of Possible Sepsis:

The upper limit of Pediatric HR

• Suspected infection - YES
• Temperature < 36 °C or > 38.3°C (< 96.8°F or > 101°F)
• Heart rate greater than normal limit for age (heart rate may not be elevated in septic hypothermic patients) AND at least one of the following indications of altered organ function:
  • Altered mental status.
  • Capillary refill time < 1 second (flash) or > 3 seconds.
  • Mottled cool extremities.
  • Lactate ≥ 2 or ETCO2 < 25 mmHg, if available.

IF YES TO ALL SEPSIS ALERT CRITERIA, CONTACT RECEIVING HOSPITAL AND REPORT “SEPSIS ALERT”

EMT STANDING ORDERS:

• Routine Patient Care.
• Monitor and maintain airway and breathing as these may change precipitously.
• Administer oxygen as appropriate with a target of achieving 94 - 98% saturation.
• Check finger stick glucose by glucometer.
• Do not delay transport.
• Call for AEMT/Paramedic intercept & Assist them in patient care.

ADVANCED EMT STANDING ORDERS

• Establish IV/IO access. Do not delay transport to start IV/IO.
• IV fluids should be titrated to attaining normal capillary refill, peripheral pulses, and level of consciousness:
  • Administer fluid bolus of 20 mL/kg of 0.9% NaCl reassess patient immediately after completion of bolus.
    • If inadequate response to initial fluid bolus, administer a second 20 mL/kg bolus of 0.9% NaCl by syringe push method; reassess patient immediately after completion of bolus.
    • If inadequate response to second fluid bolus, administer a third 20 mL/kg bolus of 0.9% NaCl by syringe push method; reassess patient immediately after completion of bolus.

PARAMEDIC STANDING ORDERS

• Obtain serum lactate level (if available and trained)
• If Suspected Septic Shock, administer 500 ml of normal saline bolus. Repeat a second bolus of 500 ml of normal saline if systolic BP remains less than 90-100 mmHg. Maximum 2 liters
• Consider Dopamine infusion 5-20mcg/kg/min titrate to maintain a systolic pressure of 90mmHg and above if inadequate response
• Epinephrine infusion 2 - 10 mcg/min infusion IV/IO.
• Continue fluid administration concurrently with pressure administration. Titrate to MAP ≥ 65 (systolic bp ≥ 90).

Note: Reassess the patient after each bolus for improving clinical signs and signs of fluid overload (rales, increased work of breathing, or increased oxygen requirements.)

PARAMEDIC STANDING ORDERS

• If there is no response after 3 fluid boluses, contact Medical Direction and consider:
  • Additional fluids
  • Norepinephrine 0.1 - 1 mcg/kg/min via a pump, titrated to effect (preferred), maximum dose of 2 mcg/kg/min OR
  • Epinephrine 0.1 - 1 mcg/kg/min via pump, titrated to effect.

PEARLS:

• Sepsis is a systemic inflammatory response due to infection. Frequent causes of septic shock include urinary, respiratory, or gastrointestinal infections and complications from catheters and feeding tubes. Patients who are immuno-compromised are also susceptible to sepsis.
• Septic shock has a high mortality and is one of the leading causes of pediatric mortality.
• Aggressive IV fluid therapy and early antibiotics significantly reduces mortality.
• When administering vasopressors, monitor IV site for signs of extravasation.