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Sepsis: the view from the A&E front line

Posted: 02/08/2021

Following on from Lyndsey Banthorpe’s article on the symptoms of sepsis and common diagnosis pitalls, Emily Hartland continues the sepsis series by discussing sepsis with experienced accident and emergency doctor, Mr John Heyworth, to find out what he typically sees in an A&E setting and how sepsis is both identified and treated in A&E.

What is sepsis?  

Sepsis is the body’s immune system overacting to an infection. Rather than fighting the infection, the body stops fighting and instead turns on itself which can result in tissue damage, organ failure and death. It is a very serious and life-threatening condition which is why it is important to raise awareness of the condition.

Mr Heyworth has over 30 years of experience as an A&E doctor and as an expert witness in clinical negligence claims concerning sepsis. He provides the following commentary on the key symptoms and the issues he experiences as both an A&E doctor and an expert witness.

Common sepsis symptoms reported in A&E

As A&E is often the first place a person will go if they are feeling unwell, A&E staff have to be alert to all sorts of potential conditions, including sepsis.

Mr Heyworth comments: “All clinicians working in emergency departments (A&E) must recognise the importance of sepsis and that this is a time-critical condition in which delays to initiating treatment may have catastrophic consequences for the patient. As such, emergency department clinicians will be expected to trigger the pathway for the treatment of sepsis once this condition is suspected rather than waiting for the diagnosis to be confirmed as this may result in the crucial period of two to three hours being missed during which treatment would have had optimal benefits and reduced the chances of later complications arising.

This approach is important as many patients presenting to the emergency department in the early stages of evolving sepsis will have non-specific symptoms and may at first appear to be relatively well. However, such patients may deteriorate rapidly over a period of a few hours if the possibility of sepsis is not considered and treated aggressively without delay.

Guidance published by the Royal College of Emergency Medicine, the national body responsible for standards in emergency departments, in conjunction with the UK Sepsis Trust, provides a very detailed review of the condition and emphasises the necessity of early suspicion of this condition thus avoiding any delay to initiating treatment.

The symptoms which may be associated with sepsis include the following:

  • a report of fever – feeling hot and then cold
  • the fever may be accompanied by shaking – the medical term is rigors
  • the patient often feels very unwell
  • there may be diarrhoea and vomiting
  • the patient will not want to eat or drink
  • little or no urine will be passed over a period of 12 – 24 hours
  • confusion or unusual speech
  • breathlessness – breathing quickly
  • the skin may become mottled or discoloured with a rash. However, it is important to note that sepsis may be present without any rash or skin discolouration during the early stages.

In children the symptoms are similar and also include the following:

  • there may have been a convulsion or fit episode
  • the skin may become bluish, mottled or pale
  • there may be a rash
  • the child may be lethargic
  • the child will feel abnormally cold to touch
  • the child is not feeding normally
  • there has been repeated vomiting
  • no urine has been passed for 12 hours.

It is clear from the symptoms indicative of possible sepsis described above that these features are very non-specific. Many patients with similar symptoms will not have sepsis but it is crucially important that, where there is any suspicion of sepsis, the patient is assessed in an emergency department without delay to ensure that the correct diagnosis is reached.

It is also important to note that often there is no obvious source of the infection responsible for the sepsis at this early stage. If a patient has infection involving a wound or a joint, then there is usually pain and redness at that site and the source of the infection is apparent. Similarly, if the patient has pneumonia or a urinary tract infection then specific symptoms associated with these conditions will be present. However, many patients will present with sepsis and the origin of the infection is only determined at a much later stage.

As indicated above, it is important not to wait for confirmation of the diagnosis or the infection source before initiating treatment in the emergency department.”

First line A&E treatment

If a patient is identified as being at risk of having sepsis or the patient is known to have sepsis, given that it can progress so rapidly, the timing of initial treatment in A&E is key as this can have a big impact on the patient’s chances of survival and recovery.

Mr Heyworth comments: “When a patient arrives in the emergency department with symptoms which are consistent with possible sepsis, it is crucially important that the clinicians undertake an initial assessment (triage) without any delay. Patients with sepsis, particularly in the early stages of this condition, may self-present to the emergency department - ie they are not all brought in by ambulance- and so A&E clinicians need to be alert to the possibility of sepsis in all patients attending the department with symptoms which are suggestive of this condition.

The approach to patients with suspected sepsis in the emergency department is as follows:

  • the patient will undergo an assessment by a triage nurse
  • the target time for triage is 15 minutes from arrival at the emergency department. However, it is generally recognised that many departments are very busy and it is understandably not always possible to achieve this timescale. However, in any patient with features which are consistent with possible sepsis, the triage assessment should occur within 30 minutes of arrival.
  • the triage nurse will review the presenting symptoms
  • the triage nurse will also review the patient’s past medical history to establish whether the patient is particularly vulnerable to sepsis. For example, they may be immunocompromised because of pre-existing cancer, diabetic or receiving treatment with medication which may reduce their response to infection.
  • the triage nurse will undertake a set of observations of the vital signs including pulse rate, blood pressure, respiratory rate, oxygen saturations, temperature and the level of consciousness as judged by the Glasgow Coma Score.

The features which the triage nurse will be looking for in the examination which are suggestive of possible sepsis are as follows:

  • increased heart rate – above 90 beats per minute
  • increased respiratory rate - above 20 breaths per minute
  • low blood pressure
  • high systemic temperature – more than 38°C or lower than 36°C.

If the triage nurse identifies any features consistent with sepsis, then the patient will be allocated a very urgent priority to be seen by a doctor in the emergency department as soon as possible. The doctor will review the history and undertake an examination to establish the nature of the patient’s condition and identify the likely source of the infection.

If a suspicion of sepsis is confirmed, then the next steps are described in the ‘Sepsis Six’ as follows:

  • give oxygen
  • take blood samples for blood cultures – this will allow the bacteria responsible for the infection to be identified and inform the correct type of antibiotic
  • give intravenous antibiotics
  • give intravenous fluids
  • measure various components of infection in the blood – particularly lactate
  • monitor urine output.

The key interventions are intravenous administration of antibiotics and fluids.

The type of antibiotics given will be informed by pathways in the local hospital guidelines. However, the general principle is to give a broad-spectrum antibiotic which is expected to cover the bacteria most likely to be responsible for infection. When the result of the blood cultures is known and/or the origin of the infection is confirmed, then the antibiotic treatment may change to ensure that the most appropriate antibiotic treatment is given.

The expectation is that intravenous antibiotics should be given in patients with suspected sepsis within 60 minutes of this condition being considered. However, in busy emergency departments it is reasonably not always possible to comply with such a prompt timescale . Notwithstanding these issues, the principle is that treatment with antibiotics should be given without delay once sepsis is suspected.

The next steps in the patient’s care would be determined by confirmation of the diagnosis of sepsis and when the likely source of the infection is identified. However, most patients with confirmed sepsis will be admitted to the intensive care unit (ICU) or high dependency unit (HDU) for careful observation and detailed monitoring over a period of at least 24 – 48 hours. Patients with some features of systemic infection but without septic shock may be managed in a medical ward, although they will be very carefully observed and monitored to check for any features of deterioration which would then prompt transfer to the ICU.”

When things go wrong

If sepsis is not diagnosed and treated quickly, the consequences can be devastating and lead to limb amputation and even death. In some cases, the A&E care provided falls below an acceptable standard and amounts to negligence.

Mr Heyworth comments: “The most common areas in which the expected standard of care regarding sepsis is not achieved in my experience are as follows:

  • failure by the triage nurse to suspect sepsis and arrange prompt review by a doctor in the emergency department
  • delays to triage because of the overall level of activity in the emergency department
  • delays until the patient is seen by a doctor due to the level of activity in the emergency department
  • failure by the doctor to appreciate the features of the presentation being consistent with possible sepsis
  • delay in the administration of antibiotics – again often a product of the level of activity in busy emergency departments
  • failure to give sufficient intravenous fluids
  • failure to regularly and frequently observe the patient’s vital signs (heart rate, blood pressure, respiratory rate, oxygen saturations, level of consciousness and urine output) and their response to treatment
  • failure to arrange early review by the intensive care or critical care outreach teams.

As indicated above, the time-critical nature of sepsis mandates interventions at all stages being undertaken without delay.”

Complications following sepsis

If treated promptly, most people will make a full recovery from sepsis but it can take several months for symptoms such as fatigue, shortness of breath, loss of appetite and psychological effects, such as depression, to resolve.

Due to how quickly sepsis affects the body’s organs and tissues, those who have not been diagnosed and treated promptly may never fully recover and may have to live with significant long-term symptoms.

In some cases, sepsis can result in the need for limb amputation leading to a life-long disability and a requirement for long-term rehabilitation such as physiotherapy and for aids and equipment such as prosthetic limbs and mobility aids.

Continue to follow the Penningtons Manches Cooper sepsis series, with part 3 discussing septic arthritis with orthopaedic surgeon, Andrew Unwin.

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