Conflict of Interest Declaration
The ILCOR Continuous Evidence Evaluation process is guided by a rigorous ILCOR Conflict of Interest policy. The following Task Force members and other authors were recused from the discussion as they declared a conflict of interest: None.
Task Force Synthesis Citation
Kule A, Bradley R, Flores-Bauer G, Stassen W, and Djarv T on behalf of the International Liaison Committee on Resuscitation First Aid Task Force.
Recognition of Sepsis in First Aid. First Aid Task Force Synthesis of a Scoping Review Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) First Aid Task Force, 2023 x x. Available from: http://ilcor.org
Methodological Preamble and Link to Published Scoping Review
The continuous evidence evaluation process started with a scoping review of the Recognition of Sepsis in the First Aid Setting, conducted by the ILCOR First Aid Task Force Scoping Review team. Evidence from the peer-reviewed and gray literature was sought and considered by the First Aid Task Force
PICOST
The PICOST (Population, Intervention, Comparator, Outcome, Study Designs and Timeframe)
Population: Among adults who are being evaluated by a first aid provider for an acute illness
Intervention: The presence of any specific signs or symptoms (i.e., pale, blue or mottled skin, lips or tongue, gums, nails; non-blanching rash; difficulty breathing or rapid respiratory rates; rigors/shivering; lack of urination in a day; muscle pain; confusion or slurred speech)
Comparators: Fever (≥38 C) with signs of infection
Outcomes:
1. Recognition of a seriously ill person requiring hospitalization or evaluation by a physician for sepsis
2. Increased awareness of sepsis
Study Designs: Randomized controlled trials (RCTs) and non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies) are eligible for inclusion. Gray literature and social media and non-peer reviewed studies, unpublished studies, conference abstracts and trial protocols are eligible for inclusion.
All relevant publications in any language are included as long as there is an English abstract.
Timeframe: Default is all years.
Literature search updated to December 2, 2023.
Search Strategies: FA 7180 Recognition of Sepsis Sc R Search Strategy
Database Search:
Summary of the databases that were searched and important search terms.
With the assistance of a medical librarian, a search strategy was developed and executed in Embase (1974 to 2023 January 17); MEDLINE(R) and Epub Ahead of Print, In-Process, In-Data-Review & Other Non-Indexed Citations and Daily (1946 to January 17, 2023) (multi-database search via Ovid); Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Trials (Cochrane Library via Wiley Online). Final database searches were conducted on January 18, 2023. A total of 5495 results were retrieved, and after removing duplicates, 3774 unique results remained for the initial title and abstract screening in a web-based tool called Rayyan (www.rayyan.ai).
Records from database searches were downloaded and imported into an EndNote database to facilitate removal of duplicates and screening. Databases searched were Embase 1974 to 2023 January 17; MEDLINE(R) and Epub Ahead of Print, In-Process, In-Data-Review & Other Non-Indexed Citations and Daily 1946 to January 17, 2023 (multi-database search via Ovid); Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Trials (Cochrane Library via Wiley Online).
Updated search November 21, 2023: Records from database searches were downloaded and imported into Covidence for de-duplication. Databases searched were Embase 1974 to 2023 November 22 via Embase.com; MEDLINE(R) and Epub Ahead of Print, In-Process, In-Data-Review & Other Non-Indexed Citations and Daily 1946 to November 22, 2023 via Ovid; Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Trials (Cochrane Library via Wiley Online). Total retrieval after deduplication was 274 citations.
Updated search through December 2, 2023: Ovid Medline (strategy below) n=6, Embase (strategy below) n=27, Cochrane Library n=0 reviews, n=1 trial. After de-duplication, n=30
Grey Literature Search: FA 7180 Recognition of Sepsis Sc R Grey Lit Search Results
In order to supplement the database search, a grey literature search was performed on August 29, 2023 through Google.com using key terms “Sepsis” and “First Aid” (747,000 results); “Sepsis Recognition” and “Public” (15,900 results); and “Sepsis Recognition” and “Signs and Symptoms” (38,300,000 results). The first 100 titles for each search were screened for relevance, and after removal for redundancy, a total of 31 were selected for inclusion.
Inclusion and Exclusion Criteria
Inclusion criteria
- Adults
- Signs and symptoms of sepsis
- Public awareness of sepsis
Exclusion criteria
- Assessment tools with no variables able to be obtained in the first aid setting
- Consensus
- Opinion
Data tables: FA 7180 Recognition of Sepsis Sc R Data Table
Task Force Insights
1. Why this topic was reviewed.
This topic was prioritized by the First Aid Task Force because of the significant proportion of preventable deaths caused by sepsis worldwide and the benefit of early detection and treatment. No prior review has been undertaken, and in 2022, the Task Force elected by consensus to undertake a scoping review on the recognition and awareness of sepsis by first aid providers evaluating adults with an acute illness.
2. Narrative summary of evidence identified
There were insufficient studies identified to support a more specific systematic review. Studies that were selected for inclusion evaluated physiologic variables that a lay provider could obtain in a first aid setting, such as temperature, heart rate and respiratory rate, either in isolation or when assessing using clinical scoring tools. Pre-hospital signs and symptoms that were identified in patients with sepsis included: respiratory difficulties, muscle weakness, GI symptoms, altered mental status, and unspecified pain. One retrospective, cross-sectional descriptive study found that rapid respiratory rate had high predictability for ICU admission. {Baez 2013 632}. One cross-sectional survey evaluating public awareness and knowledge of sepsis in Canada found the most recognized sign or symptom of sepsis was “fever” (55.7%) and others being “infection” (52.9%), “feeling extremely ill (like you are going to die)” (39.3%), “extreme shivering or muscle pain” (27.6%), “fast heart rate” (26.4%), “fast breathing/severe breathlessness” (21.2%), “skin blotchy or discolored” (20.7), “slurred speech or confusion” (12.5%), and “passing no urine all day” (8.0%). {Parsons 2022 337}
- Sepsis Awareness Campaigns: It was noted that online resources that focused on educating the public on sepsis recognition listed presenting signs and symptoms of sepsis under nine general categories: Temperature (fever or hypothermia), neurologic (i.e. change in mental state, dizziness, slurred speech), musculoskeletal (i.e. severe muscle pain, extreme shivering), urologic (poor urine output), respiratory (rapid breathing or breathlessness), skin (clammy/sweaty, new rash, mottled or discolored), cardiac (elevated heart rate), GI (nausea, vomiting, diarrhea), and subjective (feeling very unwell or impending sense of doom). However, it was variable as to which signs or symptoms were highlighted by each campaign or organization. For instance, only five of the 31 websites included from the gray literature search mentioned “infection” when describing presenting signs and symptoms of sepsis.
3. Narrative Reporting of the task force discussions
No published studies evaluated the presence of a specific sign or symptoms in a seriously ill person and a first aid provider’s recognition of the need to seek further medical attention for sepsis. Given the lack of any direct studies, the task force agreed to include studies that were performed in either the pre-hospital, by Emergency Medical Service providers, or in-hospital settings and extrapolated data to suggest relevance to the first aid setting. Despite the utilization of early warning scoring tools to assist in the detection of sepsis, sepsis recognition in the healthcare setting by trained clinicians remains challenging. Additionally, the definition of sepsis and the criteria defining sepsis continues to change. Therefore, it was felt by the task force that it was beyond the scope of a first aider to recognize, and subsequently diagnose an acute illness as sepsis. As sepsis cannot occur without an infection, a more reasonable expectation of a lay provider is to suspect an infection in a person presenting with an acute illness. Based on the evidence extrapolated from the EMS and in-hospital settings, a septic patient will typically present with frequently associated signs and symptoms. These have the potential to be recognized by a first aid provider as suggested by online resources educating the public on the signs and symptoms of sepsis. Interestingly, the presence of a fever (>/=38°C) was noted to be inconsistently listed as a sign of sepsis. While a person with an infection with any correlating signs or symptoms may not meet, at that present time or anytime in the future, the definition of sepsis, they are likely to still benefit from additional screening and evaluation by a medical professional. Increasing sensitivity for the detection of sepsis can be achieved by screening people with an infection who may fall along the spectrum of a less severe presentation.
Therefore, a first aid provider should consider an infection in a person who presents with an acute illness, and if associated with any abnormal signs or symptoms, should seek further medical evaluation.
Knowledge Gaps
- Retrospective diagnostic studies are needed to evaluate the accuracy of criteria used in specific sepsis awareness campaigns for lay responders.
- The effectiveness of sepsis awareness campaigns in helping lay responders to consider or identify sepsis should be studied to determine if any one campaign is more helpful than another.
Prisma: FA 7180 Recognition of Sepsis Sc R PRISMA
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