HISTORY AND PHYSICAL EXAM

Minimum: “SAMPLER” history (Symptoms/subjective complaints: Allergies to medications; Medications taken or prescribed; Past medical and surgical history; Last meal/oral intake; Events leading up to presentation; and Recent travel). Initial vital signs on presentation. Trending of vital signs (e.g., on PFC flow sheet found on the JTS Forms website) when looking for signs of severe infection are: fever or hypothermia; increase in heart rate; increase in respiratory rate; and, generally later rather than earlier, a decrease in blood pressure. Additionally, monitor mental status, SpO2, and capillary refill. Complete secondary survey physical exam. Look for Systemic Inflammatory Response Syndrome (SIRS), quick Sepsis-related Organ Failure Assessment (qSOFA) criteria5 and/or a high NEWS2 score6, listed below. Look for potential sources of infection. Establish blood type of patient using an Eldon card.

- Better: Above, plus: Addition of simple labs: urine dipstick, BinaxNOW (malaria), i-STAT (or other point-of-care laboratory) values with vitals monitoring mentioned above. See i-STAT values in Appendix B. If available, monitor lactate.
- Best: Above, plus: Thick and thin smear (malaria), laboratory values (including lactate), culture data from likely source(s).

The more indicators of systemic infection, the higher the suspicion for the treating clinician. This is the “whole-patient” approach. A comprehensive problem list will be important to organize patient care. If sepsis is suspected, telemedicine should immediately be initiated (if possible) to help guide both diagnosis and therapy. Monitor vital signs constantly to guide treatments.

The Systemic Inflammatory Response Syndrome (SIRS) is a sign of an inflammatory reaction to a severe physiologic insult. Although no longer part of the definition of sepsis, SIRS is a useful tool in identifying patients at risk of acute decompensation. The SIRS criteria consist of four indicators:

1. tachycardia (heart rate >90 beats/minute)
2. tachypnea (respiratory rate >20 breaths/minute or PaCO2 < 32 mmHg)
3. fever or hypothermia (temperature >38°C/100.4°F or <36°C/96.8°F)
4. leukocytosis or leukopenia (white blood cell count >12,000/mm³, <4,000/mm³, or > 10% bands).7

A practitioner in an austere environment may not be able to measure all these indicators (especially WBC), but an understanding of these features of early sepsis may prompt earlier identification of disease and direct more-timely therapeutic interventions.

qSOFA is the more recent sepsis screening tool; it seeks to identify patients at an increased risk of death.5 The presence of two or more of the following three qSOFA indicators should increase the clinician’s index of suspicion for sepsis: 1) altered mental status, 2) tachypnea (>22 breaths per minute), and 3) hypotension (SBP <100mmHg).

A more in-depth tool used in the prediction of ICU admission shown to be more effective than qSOFA is the NEWS2 score which is based on only clinical measurements and assessment. NEWS2 incorporates more variables, making it less “quick” than the qSOFA. Although not applied in clinical practice to sepsis evaluation exclusively, it may be a very useful tool in predicting clinical deterioration. The clinical variables required to compute a NEWS2 score include respiratory rate, hypercapnic respiratory failure (yes/no), oxygen saturation (and need for supplemental oxygen), temperature, heart rate, systolic blood pressure, and general level of consciousness. These parameters are recorded using a scale system, assigning points between 0-3 for each parameter. This tool has been shown to be superior to qSOFA for detecting sepsis with organ dysfunction in the emergency department.8

The following clinical assessment – history and physical exam findings – should raise the suspicion for early sepsis:

SUBJECTIVE ASSESSMENT

- Patients with sepsis may report the below complaints, with no other obvious non-infectious source (i.e. bleeding, traumatic brain injury, heat injury).
- Chills and rigors
- Confusion
- Malaise: feeling weak, with little or no energy

OBJECTIVE ASSESSMENT

Physical exam findings of patients with sepsis may include:

- Concerning (or obvious) sources of infection:
  - Wound(s) displaying signs of infection (i.e. pain, redness warmth, purulent drainage, swelling).
  - Indwelling catheters (IV/IO/urinary) or devices in less-than-sterile/field environment.
- Temperature of >38°C/100.4°F or < 36°C/96.8°F.
- Cool skin, cyanosis, delayed capillary refill time (>3 seconds).
- Abnormal vital signs, particularly tachycardia (> 90 bpm), sustained hypotension (systolic blood pressure <90 mmHg), tachypnea (>20/min).
- Low urine output (oliguria).
- Altered or worsening mental status (confusion, lethargy).
- Rash, purpura (meningococcemia, Rocky Mountain spotted fever, other rare etiologies).
- Meets the SIRS Criteria; qSOFA criteria and/or high NEWS2 score (see above).
- Lab specific values. (See Appendix B.)

NOTE: Typical symptoms may not be present in some patient populations. Signs of sepsis may be attenuated and/or muted in the elderly, delayed manifestation in the very young, or masked in pregnancy due to the normal physiologic changes and absence of a febrile response in up to 50% of pregnant patients.