Stop The Clock On Septic Shock With The PALS Algorithm
Stop The Clock On Septic Shock With The PALS Algorithm
by Greta Kviklyte
Life Saver, AMC
Co-authored by Kim Murray, RN, M.S.
posted on Jun 11, 2019, at 7:17 pm
Many medical issues and health concerns derive from infection, trauma and chronic conditions. Among children, the low risk of chronic health problems does not negate the impact of serious medical issues that arise, including sepsis. Although sepsis carries a severe outlook for those that go undiagnosed, the PALS algorithm and immediate life-saving interventions can help health care professionals recognize and treat sepsis before it leads to septic shock and possible loss of life.
Health care professionals need to understand the basics of sepsis and its relationship to septic shock depending on the severity of infection and influence on other bodily systems. Understanding more about this condition can reduce unforeseen risks, including the increased risk of respiratory or cardiac arrest.
What is Septic Shock
Sepsis and septic shock are similar, but septic shock is the most severe complication of sepsis. Septic shock occurs when sepsis progresses past the body’s ability to overcome its adverse effects. Severe cases, also identified as septic shock, are associated with a mortality rate between 20-50%, reports Apollo MD. However, immediate action can reduce risk of mortality. At the same time, the severe effects may lead to an inaccurate diagnosis and increase the risk of prolonged identification and treatment.
Causes of Sepsis
According to the Centers for Disease Control and Prevention (CDC), sepsis is an extreme bodily response to an infection. It occurs when an existing infection spreads through the blood and triggers an unusually strong immune response. Anyone can develop sepsis. The only prerequisite is an existing infection.
For example, an infected tooth or wound may cause septicemia, an infection already by the blood. As the infection continues, its effects begin to impact the bodily functions. The kidneys begin to fail, and the circulatory system becomes unstable. The lungs lose their ability to exchange oxygen, and the entire body falters.
The simplest of infections could lead to sepsis when left untreated. Among children, the risk is greater, says HealthyChildren.Org. A child’s notion of invincibility puts them at risk for injury and accident. While parents can look for risks, not all are visible. Even when the best conditions are met, sepsis could still take hold. Basically, it boils down to treating infections before they spread and lead to additional health problems.
Prevalence of Sepsis in the U.S.
Sepsis affects more than 200,000 people annually in the U.S. More than 75,000 children and infants develop severe sepsis, leading to septic shock as well, and 7,000 do not survive. That is a mortality rate greater than the rate of cancer-related, pediatric deaths per year. Unfortunately, care may come too late for those with sepsis, and even then, health care professionals may focus on the immediate needs, overlooking sepsis as a cause of illness. Left untreated, sepsis will lead to organ failure, tissue death and compounding health problems.
Sepsis also affects demographics differently. Those with weakened immune systems, people over age 65, those with a history of sepsis, known exposure to pathogens and children less than 12 months have the highest risk of sepsis. However, recognizing sepsis earlier in the course of care, such as when performing life-saving care as part of the PALS algorithm, can mean the difference between life and death, especially among children that cannot express their state of well-being.
Symptoms of Sepsis in Pediatric Patients
The best way to prevent septic shock lies in recognizing the symptoms of sepsis. Unfortunately, its symptoms closely mirror the symptoms of any systemic infection. As a result, it is imperative any child that exhibits the symptoms of an infection that cannot be tied to a treatable illness, such as the flu, be screened for sepsis. This may involve blood cultures and routine lab work, including a serum lactic acid levels and complete blood count.
The leading symptoms of sepsis include:
- Rapid heart rate. Tachycardia is the heart’s natural mechanism to attempt to compensate for decreased function of the lungs and organs. As the conditions, each beat grows shorter, and unfortunately, a faster heart rate results in further decompensation.
- Bradycardia. In addition to tachycardia, children of younger age, namely infants, may experience a slower heart rate in the late stages of sepsis.
- Rapid, shallow respiration rate. Fewer respirations lead to a higher carbon dioxide (CO2) level within the blood. The response is to increase heart rate to make up for the decreased lung capacity, but even this contributes to a higher heart rate. It becomes a self-propagating cycle.
- Confusion, disorientation or dizziness. Decreased oxygenation will result in diminished mental capacity, presented as confusion or delirium. In children, this may be characterized by excess lethargy, unusual grandeur or inability to follow a conversation appropriate for one’s age.
- Clammy, cold hands and feet. This is another response mechanism as the body attempts to compensate. This symptom can also be an indicator of poor perfusion as it is one of the easiest areas to check for capillary refill. Using your thumb and finger, press down on the patient’s fingernail until it shifts from red to white. Release and watch for whether the blood restores the reddish hue to the nail. Any delay indicates significant loss of perfusion.
- Shortness of breath or extreme pain, which is often characterized by extreme crying in infants. Shortness of breath exacerbates the problem, resulting in hyperventilation and worsening pain. Furthermore, shortness of breath could be a step on the way to bradycardia. It all depends on the unique case, medical history and current degree of infection.
- Nausea and/or vomiting. Decreased organ function will further contribute to inability to perform basic activities, including involuntary activities, such as poor peristalsis. The build-up of material in the gastrointestinal tract leads to this sensation, comparable to the symptoms of colic.
- Fever or even low temperature in infants. Since infants have limited muscle tone, which gives rise to poor ability to compensate, they suffer from a higher risk of poor outcomes from sepsis. This refers to the muscle tone within body organs, especially the heart.
Given the potential health risks associated with sepsis, health care professionals should consider sepsis as a potential factor in any instance of respiratory or cardiac distress or arrest. After all, sepsis contributes to the causes of arrest, most importantly poor perfusion of tissues.
Why Recognizing Sepsis Promotes Survival
Delays in recognizing a problem, even when EKG results and breathing appears as expected, contribute to poor patient outcomes. Remember children with a pulse well below normal limits, such as 60 beats per minute, is considered pulseless electrical activity. The same concept applies to instances of hyperventilating and tachycardia. Rapid respirations may result in a perfusion that is too low to maintain homeostasis.
An infection spreads until an immune response can keep the bacteria or virus from spreading. In the case of bacterial infections, an antibiotic provided the hole of predefined markers that augment the body’s natural immunity. Antiviral agents function in a similar manner, blocking a virus’ mode of replication. Unfortunately, the viral or bacterial levels in someone suffering from sepsis are too great to manage without intervention. As soon as treatment begins with the appropriate medication, the infection begins to slow and retreat. Yet, the damage may already exist. Therefore, it is imperative that caregivers act upon suspected cases of sepsis and those to which no indicators exist. Faster treatment with antivirals or antibiotics amounts to greater chances of survival. Furthermore, treating the underlying cause of distress, sepsis, helps to prevent a person from returning to extreme distress, including arrest.
The PALS Algorithm and Sepsis
The PALS algorithm provides a general roadmap for the treatment of poor perfusion caused by tachycardia. Now any treatment involving PALS will include measures to treat the reversible causes of arrest, such as hypotension and hypovolemic shock. When those measures do not apply and a cause of tachycardia cannot be immediately identified, health care professionals turn to a specific subset of the PALS algorithm. As explained by ECCGuidelines.Heart.Org, the first step of this part of the PALS algorithm is the evaluation of the QSR interval to determine its length. If greater than 0.09 seconds and the child exhibits mental compromise, additional signs of shock and decreased blood pressure, follow synchronized cardioversion protocols.
In other words, administer electric shocks, and if necessary, sedate the child. However, cardioversion should not be delayed in favor of sedation, especially if the child does not yet have an IV or IO access.
How to Reduce the Risk of Subsequent Distress After Sepsis
The biggest steps to reducing risk of such subsequent sepsis complications focus on completing treatment for the full prescribed term and reporting any symptoms to a health care provider. Furthermore, those that have endured sepsis have an increased risk of developing it later when subsequent infections occur.
In addition, health care professionals should administer antibiotics within one hour of a sepsis diagnosis. Depending on the cause, it may be necessary to increase fluid bolus volume to 200 mL per kg, while continuing the administration of multiple antibiotics to cover all possible infections. Once the cultures return from the lab, the antibiotic regimen will be refined to best treat the unique infection. The goal of initial treatment is to implement a broad medication regimen to prevent the worsening of symptoms and impact. As noted by Medscape, it is important to ensure all medications are administered in a timely manner and without delay after cardioversion and continuation of the PALS algorithm. Any delay in initial treatment could lead to worsening of sepsis, bradycardia and tachycardia, as well as increase the risk of a pathogen becoming a superbug and unresponsive to available antibiotics.
Four Additional Measures to Improve Septic Shock Recovery
Health care professionals can follow a few additional steps to reduce risk of complications following sepsis. These steps are typical infection control guidelines within the health care facility and include:
1. Ensure clean care settings. Maintaining clean care settings is about much more than just janitorial works. It includes checking in-room medical devices for cleanliness, replacing suction canisters frequently and advising everyone with a suspected illness, regardless of the cause, to avoid visiting the patient.
2. Use proper, sterile technique. This is the most obvious measure, using a sterile technique to prevent the introduction of pathogens to the body when administering IM, IV or IO medications or changing sites, as well as when performing wound care.
3. Wash your hands frequently. Handwashing is the best way to reduce the potential spread of infection from your other patients to one suffering from sepsis.
4. Monitor vital signs for change in status. Any deviation in vital signs should be reported immediately and assessed for impact on the efficacy of current treatment. Further, health care professionals must remember to check for a pulse during assessments, looking beyond the monitor, remembering the PALS algorithm guidelines to recognize pulseless electrical activity as any heart rate below 60 beats per minute.
Stop Septic Shock With Quality Life-Saving Skills
Sepsis and its more severe form, septic shock, represent one of the biggest threats to those most at risk, children. Failure to recognize sepsis will inevitably increase risk of poor outcomes and may cause long-term, if not permanent injury. Health care professionals can know more about sepsis can take the initial steps to recognize sepsis and force it into retreat.
Have you cared for someone that suffered sepsis, or have you worked for a facility that follows sepsis-recognition protocols? Share your thoughts and experiences, as well as this article, to social media now. Also remember to enroll in your life-saving skills course to ensure you know when to look for sepsis in following the PALS algorithm today.