Sepsis alerts in EMS and the results of pre-hospital ETCO2

Published:November 08, 2018DOI:



      Field sepsis alerts have the ability to expedite initial ED sepsis treatment. Our hypothesis is that in patients that meet EMS sepsis alert criteria there is a strong relationship between prehospital end-tidal carbon dioxide (ETCO2) readings and the outcome of diagnosed infection.


      In 2014, our EMS service initiated a protocol requiring hospitals to receive notification of a “sepsis alert” on all suspected sepsis patients. The EMS service transports 70,000 patients/year to a number of urban centers. All patients transported to our major urban teaching hospital by our EMS service in one year in which a sepsis alert was announced were included in this study. The primary outcome variable was diagnosed infection and secondary outcomes were hospital admission, ICU admission and mortality. Positive lactate was defined as >4.0 mmol/L. ROC curve analysis was used to define the best cutoff for ETCO2.


      351 patients were announced as EMS sepsis alert patients and transported to our center over a one year period. Positive outcomes were as follows: diagnosed infection in 28% of patients, hospital admission in 63% and ICU admission in 11%. The correlation between lactate and ETCO2 was −0.45. A ROC curve analysis of ETCO2 vs. lactate >4 found that the best cutoff to predict a high lactate was an ETCO2 of 25 or less, which was considered a positive ETCO2 (AUC = 0.73). 27% of patients had a positive ETCO2 and 24% had a positive lactate. A positive ETCO2 predicted a positive lactate with 76% accuracy, 63% sensitivity and 80% specificity. 27% of those with a positive ETCO2 and 44% of those with a positive lactate had a diagnosed infection. 59% of those with a positive ETCO2 and 89% of those with a positive lactate had admission to the hospital. 15% of those with a positive ETCO2 and 18% of those with a positive lactate had admission to the ICU. Neither lactate nor ETCO2 were predictive of an increased risk for diagnosed infection, hospital admission or ICU admission in this patient population.


      While ETCO2 predicted the initial ED lactate levels it did not predict diagnosed infection, admission to the hospital or ICU admission in our patient population but did predict mortality.
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        • Rivers E.P.
        • Katranji M.
        • Jaehne K.A.
        • Brown S.
        • Abou Dagher G.
        • Cannon C.
        • et al.
        Early interventions in severe sepsis and septic shock: a review of the evidence one decade later.
        Minerva Anestesiol. 2012 Jun; 78: 712-724
        • Perman S.M.
        • Goyal M.
        • Gaieski D.F.
        Initial emergency department diagnosis and management of adult patients with severe sepsis and septic shock.
        Scand J Trauma Resusc Emerg Med. 2012; 20: 41
        • Kethireddy S.
        • Kumar A.
        Mortality due to septic shock following early, appropriate antibiotic therapy: can we do better?*.
        Crit Care Med. 2012 Jul; 40: 2228-2229
        • Nguyen H.B.
        • Lynch E.L.
        • Mou J.A.
        • Lyon K.
        • Wittlake W.A.
        • Corbett S.W.
        The utility of a quality improvement bundle in bridging the gap between research and standard care in the management of severe sepsis and septic shock in the emergency department.
        Acad Emerg Med. 2007 Nov; 14: 1079-1086
        • Puskarich M.A.
        • Trzeciak S.
        • Shapiro N.I.
        • Arnold R.C.
        • Heffner A.C.
        • Kline J.A.
        • et al.
        Prognostic value and agreement of achieving lactate clearance or central venous oxygen saturation goals during early sepsis resuscitation.
        Acad Emerg Med. 2012 Mar; 19: 252-258
        • Jones A.E.
        • Shapiro N.I.
        • Trzeciak S.
        • Arnold R.C.
        • Claremont H.A.
        • Kline J.A.
        Lactate clearance vs central venous oxygen saturation as goals of early sepsis therapy: a randomized clinical trial.
        JAMA. 2010 Feb; 303: 739-746
        • Goyal M.
        • Pines J.M.
        • Drumheller B.C.
        • Gaieski D.F.
        Point-of-care testing at triage decreases time to lactate level in septic patients.
        J Emerg Med. 2010 Jun; 38: 578-581
        • Puskarich M.A.
        • Kline J.A.
        • Summers R.L.
        • Jones A.E.
        Prognostic value of incremental lactate elevations in emergency department patients with suspected infection.
        Acad Emerg Med. 2012 Aug; 19: 983-985
        • Band R.A.
        • Gaieski D.F.
        • Hylton J.H.
        • Shofer F.S.
        • Goyal M.
        • Meisel Z.F.
        Arriving by emergency medical services improves time to treatment endpoints for patients with severe sepsis or septic shock.
        Acad Emerg Med. 2011 Sep; 18: 934-940
        • Studnek J.R.
        • Artho M.R.
        • Garner Jr., C.L.
        • Jones A.E.
        The impact of emergency medical services on the ED care of severe sepsis.
        Am J Emerg Med. 2012 Jan; 30: 51-56
        • Seymour C.W.
        • Band R.A.
        • Cooke C.R.
        • Mikkelsen M.E.
        • Hylton J.
        • Rea T.D.
        • et al.
        Out-of-hospital characteristics and care of patients with severe sepsis: a cohort study.
        J Crit Care. 2010 Dec; 25: 553-562
        • Seymour C.W.
        • Cooke C.R.
        • Mikkelsen M.E.
        • Hylton J.
        • Rea T.D.
        • Goss C.H.
        • et al.
        Out-of-hospital fluid in severe sepsis: effect on early resuscitation in the emergency department.
        Prehosp Emerg Care. 2010; 14 ([Apr-2010 Jun]): 145-152
        • Wang H.E.
        • Weaver M.D.
        • Shapiro N.I.
        • Yealy D.M.
        Opportunities for emergency medical services care of sepsis.
        Resuscitation. 2010 Feb; 81: 193-197
        • Guerra W.F.
        • Mayfield T.R.
        • Meyers M.S.
        • Clouatre A.E.
        • Riccio J.C.
        Early detection and treatment of patients with severe sepsis by prehospital personnel.
        J Emerg Med. 2013 Jun; 44: 1116-1125
        • Seymour C.W.
        • Rea T.D.
        • Kahn J.M.
        • Walkey A.J.
        • Yealy D.M.
        • Angus D.C.
        Severe sepsis in pre-hospital emergency care: analysis of incidence, care, and outcome.
        Am J Respir Crit Care Med. 2012 Dec; 186: 1264-1271
        • Herlitz J.
        • Bang A.
        • Wireklint-Sundstrom B.
        • Axelsson C.
        • Bremer A.
        • Hagiwara M.
        • et al.
        Suspicion and treatment of severe sepsis. An overview of the prehospital chain of care.
        Scand J Trauma Resusc Emerg Med. 2012; 20: 42
        • Brown J.P.
        • Mahmud E.
        • Dunford J.V.
        • Ben-Yehuda O.
        Effect of prehospital 12-lead electrocardiogram on activation of the cardiac catheterization laboratory and door-to-balloon time in ST-segment elevation acute myocardial infarction.
        Am J Cardiol. 2008 Jan; 101: 158-161
        • Mosley I.
        • Nicol M.
        • Donnan G.
        • Patrick I.
        • Kerr F.
        • Dewey H.
        The impact of ambulance practice on acute stroke care.
        Stroke. 2007 Oct; 38: 2765-2770
        • Hartl R.
        • Gerber L.M.
        • Iacono L.
        • Ni Q.
        • Lyons K.
        • Ghajar J.
        Direct transport within an organized state trauma system reduces mortality in patients with severe traumatic brain injury.
        J Trauma. 2006 Jun; 60 ([discussion 1256]): 1250-1256
        • Institute for Healthcare improvement
        ([Available at]) ([Accessed 2013 Feb 16])
        • Nguyen H.B.
        • Van Ginkel C.
        • Batech M.
        • Banta J.
        • Corbett S.W.
        Comparison of predisposition, insult/infection, response, and organ dysfunction, acute physiology and chronic health evaluation II, and mortality in emergency department sepsis in patients meeting criteria for early goal-directed therapy and the severe sepsis resuscitation bundle.
        J Crit Care. 2012 Aug; 27: 362-369
        • Jones A.E.
        • Trzeciak S.
        • Kline J.A.
        The Sequential Organ Failure Assessment score for predicting outcome in patients with severe sepsis and evidence of hypoperfusion at the time of emergency department presentation.
        Crit Care Med. 2009 May; 37: 1649-1654
        • Rivers E.
        • Nguyen B.
        • Havstad S.
        • Ressler J.
        • Muzzin A.
        • Knoblich B.
        • et al.
        Early goal-directed therapy in the treatment of severe sepsis and septic shock.
        N Engl J Med. 2001 Nov; 345: 1368-1377
        • Nguyen H.B.
        • Banta J.E.
        • Cho T.W.
        • Van Ginkel C.
        • Burroughs K.
        • Wittlake W.A.
        • et al.
        Mortality predictions using current physiologic scoring systems in patients meeting criteria for early goal-directed therapy and the severe sepsis resuscitation bundle.
        Shock. 2008 Jul; 30: 23-28
        • Vincent J.L.
        • de Mendonca A.
        • Cantraine F.
        • Moreno R.
        • Takala J.
        • Suter P.M.
        • et al.
        Use of the SOFA score to assess the incidence of organ dysfunction/failure in intensive care units: results of a multicenter, prospective study. Working group on “sepsis-related problems” of the European Society of Intensive Care Medicine.
        Crit Care Med. 1998 Nov; 26: 1793-1800
        • Hunter C.L.
        • Silvestri S.
        • Ralls G.
        • Bright S.
        • Papa L.
        The sixth vital sign: prehospital end-tidal carbon dioxide predicts in-hospital mortality and metabolic disturbances.
        Am J Emerg Med. 2014; V32: 160-165
        • Hunter C.L.
        • Salvatore S.
        • Ralls G.
        • Stone A.
        • Walker A.
        • Papa L.
        A prehospital screening tool utilizing end-tidal carbon dioxide predicts sepsis and severe sepsis.
        Am J Emerg Med. 2016; V34: 813-819
        • Williams J.
        • Cabanas J.
        Sepsis early recognition and treatment in prehsopital setting vital for patient outcome. JEMS [September].
        . 2016; 41 ([Accessed on Internet 10/22/2018 at])
        • Smyth M.A.
        • Brace-McDonnell S.J.
        • Perkins G.D.
        Impact of prehospital care on outcomes in Sepsis: a systematic review.
        West J Emerg Med. 2017; 19: 427-437