Advanced Medical Emergencies

Sepsis and Septic Shock

Sepsis is life-threatening organ dysfunction caused by a dysregulated host response to infection. It's not just an infection that's bad — it's the immune system causing collateral damage to the body. Septic shock is sepsis with persistent hypotension despite fluids, requiring vasopressors.

Recognition

• qSOFA (quick screen): 2 of 3 = high risk for sepsis: Altered mental status, RR ≥22, SBP ≤100 mmHg
• Fever (or hypothermia in severe sepsis), tachycardia, WBC abnormalities
• Warm, flushed skin early (vasodilation) → cool, clammy later (decompensation)
• Source: pneumonia (most common), UTI, skin/wound, abdominal

Prehospital Management

• IV fluid bolus: 30 mL/kg of LR or NS — give within first hour
• Oxygen to maintain SpO₂ ≥94%
• Blood glucose check — septic patients often have hypoglycemia or hyperglycemia
• If hypotension persists after fluids: Norepinephrine infusion 0.1–0.5 mcg/kg/min IV, titrate to MAP ≥65
• Rapid transport — definitive treatment (antibiotics, source control) is in the hospital
• Pre-notify receiving hospital — sepsis alert activates the sepsis bundle

Diabetic Ketoacidosis (DKA)

DKA occurs in type 1 diabetics (and sometimes type 2) when insulin deficiency causes cells to use fat for fuel → ketones → acidosis. Triad: hyperglycemia + ketosis + metabolic acidosis.

• Signs: gradual onset over hours-days, fruity (acetone) breath, Kussmaul respirations (deep rapid breathing to blow off CO₂), nausea/vomiting, abdominal pain, polyuria/polydipsia, altered mental status
• Blood glucose typically >250 mg/dL, often >400
• Prehospital treatment: IV fluid resuscitation (NS 1–2 L bolus), oxygen, glucose check, transport
• Do NOT give insulin prehospital — fluid resuscitation is the priority and insulin without potassium monitoring is dangerous
• If hypoglycemic (rare in DKA but possible): dextrose as appropriate

Status Epilepticus

Continuous seizure activity lasting ≥5 minutes, or two or more seizures without return to baseline consciousness between them. Without treatment, causes permanent neurological injury and death from hypoxia, hyperthermia, and metabolic exhaustion.

ALS Treatment

• Airway, breathing, oxygenation — first priority. Suction, O₂, consider intubation if prolonged.
• First-line: Benzodiazepines
• Midazolam 5–10 mg IM (preferred prehospital — no IV needed) or 2–4 mg IV/IO
• Diazepam 5–10 mg IV/IO or rectal if no IV access
• Lorazepam 2–4 mg IV/IO (if available)
• If benzodiazepines fail (refractory status): levetiracetam, phenytoin, or propofol — hospital-level agents
• Check glucose — hypoglycemia causes seizures and is immediately treatable
• Monitor temperature — hyperthermia worsens neurological injury

Refractory Anaphylaxis

When anaphylaxis fails to respond to IM epinephrine, IV epinephrine infusion is required. This is an ALS intervention — the cardiovascular compromise of anaphylaxis can be profound and rapidly fatal.

• IV Epinephrine infusion: 1 mg in 1000 mL NS (1 mcg/mL), start at 2–10 mcg/min, titrate to BP response
• Diphenhydramine (Benadryl) 25–50 mg IV — H1 blocker, adjunct only
• Ranitidine or famotidine — H2 blocker, additive benefit
• Methylprednisolone 125 mg IV — corticosteroid, prevents late-phase reaction. Not immediate.
• Fluid bolus for hypotension: 1–2 L NS
• Glucagon 1 mg IV for patients on beta-blockers who aren't responding to epinephrine — beta-blockers block the epinephrine response

Post-ROSC Care

Return of spontaneous circulation (ROSC) after cardiac arrest is the beginning, not the end. Post-cardiac arrest syndrome causes brain injury, myocardial dysfunction, and systemic inflammation. Goal-directed post-ROSC care improves neurological outcomes.

Targets After ROSC

• SpO₂: 94–99% — avoid hyperoxia. Titrate O₂ down from 100% once SpO₂ is stable.
• ETCO₂: 35–40 mmHg — avoid hyperventilation. Each extra breath drops ETCO₂ and causes cerebral vasoconstriction.
• SBP: ≥90 mmHg — hypotension after ROSC causes secondary brain injury. IV fluids or norepinephrine.
• Blood glucose: 144–180 mg/dL — both hypoglycemia and severe hyperglycemia worsen neurological outcomes
• 12-lead ECG immediately — identify STEMI. If present, transport directly to PCI center.
• Prevent fever — temperature >37.5°C worsens outcomes post-arrest
• Targeted temperature management (TTM) — 32–36°C for 24 hours — initiated in hospital, not prehospital