Epidemiology of septic shock in prehospital medical services in five Colombian cities

Objetivo: Explorar la asociación entre factores demográficos y clínicos con la presentación de shock séptico en pacientes atendidos en un servicio prehospitalario de emergencias en cinco ciudades colombianas entre los años 2015-2016. Métodos: Estudio de corte transversal con recolección retrospectiv...

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Autores:: López Medina, Diana Carolina
Henao Pérez, Marcela
Arenas Andrade, Jaime
Hinestroza Marín, Emel David
Jaimes Barragan, Fabián Alberto
Quirós Gómez, Oscar Iván

Tipo de recurso:: Article of investigation

Fecha de publicación:: 2020

Institución:: Universidad Cooperativa de Colombia

Repositorio:: Repositorio UCC

Idioma:

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repository_id_str
dc.title.spa.fl_str_mv	Epidemiology of septic shock in prehospital medical services in five Colombian cities
title	Epidemiology of septic shock in prehospital medical services in five Colombian cities
spellingShingle	Epidemiology of septic shock in prehospital medical services in five Colombian cities Choque séptico/ epidemiologia Sepsis Servicios médicos de urgencia Servicios de atención de salud a domicilio Shock Septic/epidemiology Sepsis Emergency medical services Home care services
title_short	Epidemiology of septic shock in prehospital medical services in five Colombian cities
title_full	Epidemiology of septic shock in prehospital medical services in five Colombian cities
title_fullStr	Epidemiology of septic shock in prehospital medical services in five Colombian cities
title_full_unstemmed	Epidemiology of septic shock in prehospital medical services in five Colombian cities
title_sort	Epidemiology of septic shock in prehospital medical services in five Colombian cities
dc.creator.fl_str_mv	López Medina, Diana Carolina Henao Pérez, Marcela Arenas Andrade, Jaime Hinestroza Marín, Emel David Jaimes Barragan, Fabián Alberto Quirós Gómez, Oscar Iván
dc.contributor.advisor.none.fl_str_mv	Cómite evaluador, Revista Brasileira de Terapia Intensiva
dc.contributor.author.none.fl_str_mv	López Medina, Diana Carolina Henao Pérez, Marcela Arenas Andrade, Jaime Hinestroza Marín, Emel David Jaimes Barragan, Fabián Alberto Quirós Gómez, Oscar Iván
dc.subject.spa.fl_str_mv	Choque séptico/ epidemiologia Sepsis Servicios médicos de urgencia Servicios de atención de salud a domicilio
topic	Choque séptico/ epidemiologia Sepsis Servicios médicos de urgencia Servicios de atención de salud a domicilio Shock Septic/epidemiology Sepsis Emergency medical services Home care services
dc.subject.other.spa.fl_str_mv	Shock Septic/epidemiology Sepsis Emergency medical services Home care services
description	Objetivo: Explorar la asociación entre factores demográficos y clínicos con la presentación de shock séptico en pacientes atendidos en un servicio prehospitalario de emergencias en cinco ciudades colombianas entre los años 2015-2016. Métodos: Estudio de corte transversal con recolección retrospectiva de datos. Se recolectó información clínica y demográfica de las historias clínicas de pacientes con diagnóstico de sepsis que recibieron atención prehospitalaria en cinco ciudades colombianas en los años 2015 y 2016. Se realizó una verificación del diagnóstico de shock séptico en el 20% de los casos, dando origen a dos escenarios analizados: observado y verificado. Se analizó la asociación con pruebas de Chi cuadrado, t de Student y finalmente con un modelo de regresión logística ajustado. Se consideró covariables significativas aquellas con p < 0,05. Resultados: Se presentó una mayor frecuencia del evento en mujeres (62,6%) y en mayores de 80 años (64,5%), sin ser factores diferenciadores para shock séptico. El foco infeccioso más común fue urinario. En el escenario observado, los mayores de 60 años (RP: 3,22; IC95%: 1,45 - 35,01) y el antecedente de cáncer fueron las características asociadas con el shock séptico (RP: 1,20; IC95%: 1,2 - 12,87), mientras que en el grupo verificado fueron la enfermedad pulmonar obstructiva crónica (RP: 1,99; IC95%: 1,26 - 7,14), el antecedente de cáncer (RP: 1,15; IC95%: 1,11 - 6,62) y presencia de hipovolemia (RP: 1,41; IC95%: 1,02 - 5,50). Conclusión: Los factores de riesgo más importantes para shock séptico en pacientes de atención prehospitalaria en cinco ciudades colombianas fueron las enfermedades oncológicas, las pulmonares e hipovolemia.
publishDate	2020
dc.date.issued.none.fl_str_mv	2020-03-30
dc.date.accessioned.none.fl_str_mv	2021-03-02T15:22:51Z
dc.date.available.none.fl_str_mv	2021-03-02T15:22:51Z
dc.type.none.fl_str_mv	Artículos Científicos
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dc.identifier.isbn.spa.fl_str_mv	0103-507X
dc.identifier.issn.spa.fl_str_mv	1982-4335
dc.identifier.uri.spa.fl_str_mv	10.5935/0103-507X.20200006
dc.identifier.uri.none.fl_str_mv	https://hdl.handle.net/20.500.12494/33515
dc.identifier.bibliographicCitation.spa.fl_str_mv	López Medina, D. C., Henao Perez, M., Arenas Andrade, J., Hinestroza Marín, E. D., Jaimes Barragán, F. A., & Quirós Gómez, O. I. (2020). Epidemiology of septic shock in prehospital medical services in five Colombian cities. Revista Brasileira de terapia intensiva, 32(1), 28-36.
identifier_str_mv	0103-507X 1982-4335 10.5935/0103-507X.20200006 López Medina, D. C., Henao Perez, M., Arenas Andrade, J., Hinestroza Marín, E. D., Jaimes Barragán, F. A., & Quirós Gómez, O. I. (2020). Epidemiology of septic shock in prehospital medical services in five Colombian cities. Revista Brasileira de terapia intensiva, 32(1), 28-36.
url	https://hdl.handle.net/20.500.12494/33515
dc.relation.isversionof.spa.fl_str_mv	https://www.scielo.br/pdf/rbti/v32n1/0103-507X-rbti-32-01-0028.pdf
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dc.relation.references.spa.fl_str_mv	Smyth MA, Brace-McDonnell SJ, Perkins GD. Identification of adults with sepsis in the prehospital environment: a systematic review. BMJ Open. 2016;6(8):e011218 Gorordo Delsol LA. Sepsis: fisiopatología, diagnóstico y tratamiento. Ciudad de México: Intersistemas; 2016. 512 p. Hsiao CY, Yang HY, Chang CH, Lin HL, Wu CY, Hsiao MC, et al. Risk factors for development of septic shock in patients with urinary tract infection. Biomed Res Int. 2015;2015:717094. Seymour CW, Rea TD, Kahn JM, Walkey AJ, Yealy DM, Angus DC. Severe sepsis in pre-hospital emergency care: analysis of incidence, care, and outcome. Am J Respir Crit Care Med. 2012;186(12):1264-71. Rodríguez F, Barrera L, De La Rosa G, Dennis R, Dueñas C, Granados M, et al. The epidemiology of sepsis in Colombia: a prospective multicenter cohort study in ten university hospitals. Crit Care Med. 2011;39(7):1675-82. Schiaffino A, Rodríguez M, Pasarín MI, Regidor E, Borrell C, Fernández E. ¿Odds ratio o razón de proporciones? Su utilización en estudios transversales. Gac Sanit. 2003;17(1):70-4. Singer M, Deutschman CS, Seymour CW, Shankar-Hari M, Annane D, Bauer M, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):801-10. Organización Mundial de la Salud O. Mejora de la prevención, el diagnóstico y la atención clínica de la septicemia [Internet]. 2017 abr. Report No.: A70/13. Disponible en: https://apps.who.int/gb/ebwha/pdf_files/WHA70/A70_13-sp.pdf Grozdanovski K, Milenkovikj Z, Demiri I, Spasovska K, Cvetanovska M, Saveski V, et al. Epidemiology of community-acquired sepsis in adult patients: a six year observational study. Pril (Makedon Akad Nauk Umet Odd Med Nauki). 2018;39(1):59-66 Hunter CL, Silvestri 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;34(5):813-9. Polito CC, Isakov A, Yancey AH 2nd, Wilson DK, Anderson BA, Bloom I, et al. Prehospital recognition of severe sepsis: development and validation of a novel EMS screening tool. Am J Emerg Med. 2015;33(9):1119-25. Cecconi M, Evans L, Levy M, Rhodes A. Sepsis and septic shock. Lancet. 2018;392(10141):75-87. Mayr FB, Yende S, Angus DC. Epidemiology of severe sepsis. Virulence. 2014;5(1):4-11. Moore LJ, Moore FA, Todd SR, Jones SL, Turner KL, Bass BL. Sepsis in general surgery: the 2005-2007 national surgical quality improvement program perspective. Arch Surg. 2010;145(7):695-700. Guerra WF, Mayfield TR, Meyers MS, Clouatre AE, Riccio JC. Early detection and treatment of patients with severe sepsis by prehospital personnel. J Emerg Med. 2013;44(6):1116-25. Jaimes FA, De La Rosa GD, Valencia ML, Arango CM, Gomez CI, Garcia A, et al. A latent class approach for sepsis diagnosis supports use of procalcitonin in the emergency room for diagnosis of severe sepsis. BMC Anesthesiol. 2013;13(1):23. Staudinger T, Pène F. Current insights into severe sepsis in cancer patients. Rev Bras Ter Intensiva. 2014;26(4):335-8. van der Wekken LC, Alam N, Holleman F, van Exter P, Kramer MH, Nanayakkara PW. Epidemiology of sepsis and its recognition by emergency medical services personnel in the Netherlands. Prehosp Emerg Care. 2016;20(1):90-6. Park DW, Chun BC, Kim JM, Sohn JW, Peck KR, Kim YS, et al. Epidemiological and clinical characteristics of community-acquired severe sepsis and septic shock: a prospective observational study in 12 university hospitals in Korea. J Korean Med Sci. 2012;27(11):1308-14. Cols EM, Reniu AC, Ramos DR, Fontrodona GP, Romero MO. Manejo de la sepsis grave y el shock séptico en un servicio de urgencias de un hospital urbano de tercer nivel. Oportunidades de mejora. Emergencias. 2016;28(4):229-34. García Balmaseda A, Miranda Pérez Y, Breijo Puentes A, Ramos Rodríguez E, Álvarez Dubé E. Marcadores de hipoperfusión tisular y su relación con la mortalidad en pacientes con shock séptico. Rev Cienc Médicas. 2015;19(6):1075-83. Metelmann C, Metelmann B, Scheer C, Gründling M, Henkel B, Hahnenkamp K, et al. Sepsis erkennen im Rettungsdienst: Ergebnisse einer interprofessionellen Befragung zur präklinischen und frühen innerklinischen Sepsiserkennung. Der Anaesthesist. 2018;67(8):584-91. Casu S, Häske D. Severe sepsis and septic shock in pre-hospital emergency medicine: survey results of medical directors of emergency medical services concerning antibiotics, blood cultures and algorithms. Intern Emerg Med. 2016;11(4):571-6. Baez AA, Hanudel P, Wilcox SR. The Prehospital Sepsis Project: out-ofhospital physiologic predictors of sepsis outcomes. Prehosp Disaster Med. 2013;28(6):632-5. Seymour CW, Kahn JM, Cooke CR, Watkins TR, Heckbert SR, Rea TD. Prediction of critical illness during out-of-hospital emergency care. JAMA. 2010;304(7):747-54. Barbara P, Graziano C, Caputo W, Litvak I, Battinelli D, Hahn B. The quick sequential organ failure assessment (qSOFA) identifies septic patients in the out-of-hospital setting. Am J Emerg Med. 2018;36(6):1022-6. Schwarz S, Schwab S, Fabian CW, Schellinger P, Orberk E, Hund E. [Infection: impaired consciousness as the initial symptom. Clinical and pathophysiologic aspects of septic encephalopathy]. Nervenarzt. 1997;68(4):292-7. German. Caraballo C, Ascuntar J, Hincapié C, Restrepo C, Bernal E, Jaimes F. Association between site of infection and in-hospital mortality in patients with sepsis admitted to emergency departments of tertiary hospitals in Medellin, Colombia. Rev Bras Ter Intensiva. 2019;31(1):47-56. Vincent JL, Rello J, Marshall J, Silva E, Anzueto A, Martin CD, Moreno R, Lipman J, Gomersall C, Sakr Y, Reinhart K; EPIC II Group of Investigators. International study of the prevalence and outcomes of infection in intensive care units. JAMA. 2009;302(21):2323-9. Macdonald SP, Arendts G, Fatovich DM, Brown SG. Comparison of PIRO, SOFA, and MEDS scores for predicting mortality in emergency department patients with severe sepsis and septic shock. Merchant RC, editor. Acad Emerg Med. 2014;21(11):1257-63. Walchok JG, Pirrallo RG, Furmanek D, Lutz M, Shope C, Giles B, et al. Paramedic-Initiated CMS Sepsis Core Measure Bundle Prior to Hospital Arrival: A Stepwise Approach. Prehosp Emerg Care. 2017;21(3):291-300. Matthaeus-Kraemer CT, Thomas-Rueddel DO, Schwarzkopf D, Rueddel H, Poidinger B, Reinhart K, et al. Crossing the handover chasm: Clinicians’ perceptions of barriers to the early detection and timely management of severe sepsis and septic shock. J Crit Care. 2016;36:85-91. Rello J, Leblebicioglu H; members of ESGGCIP. Sepsis and septic shock in low-income and middle-income countries: need for a different paradigm. Int J Infect Dis. 2016;48:120-2. Peltan ID, Mitchell KH, Rudd KE, Mann BA, Carlbom DJ, Hough CL, et al. Physician variation in time to antimicrobial treatment for septic patients presenting to the emergency department.Crit Care Med. 2017;45(6):1011-8. Westphal GA, Lino AS. Systematic screening is essential for early diagnosis of severe sepsis and septic shock. Rev Bras Ter Intensiva. 2015;27(2):96-101
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dc.publisher.spa.fl_str_mv	Universidad Cooperativa de Colombia, Facultad de Ciencias de la Salud, Medicina, Medellín y Envigado Gilberto Friedman
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spelling	Cómite evaluador, Revista Brasileira de Terapia IntensivaLópez Medina, Diana CarolinaHenao Pérez, MarcelaArenas Andrade, JaimeHinestroza Marín, Emel DavidJaimes Barragan, Fabián AlbertoQuirós Gómez, Oscar Iván322021-03-02T15:22:51Z2021-03-02T15:22:51Z2020-03-300103-507X1982-433510.5935/0103-507X.20200006https://hdl.handle.net/20.500.12494/33515López Medina, D. C., Henao Perez, M., Arenas Andrade, J., Hinestroza Marín, E. D., Jaimes Barragán, F. A., & Quirós Gómez, O. I. (2020). Epidemiology of septic shock in prehospital medical services in five Colombian cities. Revista Brasileira de terapia intensiva, 32(1), 28-36.Objetivo: Explorar la asociación entre factores demográficos y clínicos con la presentación de shock séptico en pacientes atendidos en un servicio prehospitalario de emergencias en cinco ciudades colombianas entre los años 2015-2016. Métodos: Estudio de corte transversal con recolección retrospectiva de datos. Se recolectó información clínica y demográfica de las historias clínicas de pacientes con diagnóstico de sepsis que recibieron atención prehospitalaria en cinco ciudades colombianas en los años 2015 y 2016. Se realizó una verificación del diagnóstico de shock séptico en el 20% de los casos, dando origen a dos escenarios analizados: observado y verificado. Se analizó la asociación con pruebas de Chi cuadrado, t de Student y finalmente con un modelo de regresión logística ajustado. Se consideró covariables significativas aquellas con p < 0,05. Resultados: Se presentó una mayor frecuencia del evento en mujeres (62,6%) y en mayores de 80 años (64,5%), sin ser factores diferenciadores para shock séptico. El foco infeccioso más común fue urinario. En el escenario observado, los mayores de 60 años (RP: 3,22; IC95%: 1,45 - 35,01) y el antecedente de cáncer fueron las características asociadas con el shock séptico (RP: 1,20; IC95%: 1,2 - 12,87), mientras que en el grupo verificado fueron la enfermedad pulmonar obstructiva crónica (RP: 1,99; IC95%: 1,26 - 7,14), el antecedente de cáncer (RP: 1,15; IC95%: 1,11 - 6,62) y presencia de hipovolemia (RP: 1,41; IC95%: 1,02 - 5,50). Conclusión: Los factores de riesgo más importantes para shock séptico en pacientes de atención prehospitalaria en cinco ciudades colombianas fueron las enfermedades oncológicas, las pulmonares e hipovolemia.Objective: To explore the association between demographic and clinical factors and the presentation of septic shock in patients treated by prehospital emergency services in five Colombian cities between 2015 and 2016. Methods: This was a cross-sectional study with retrospective data collection. Clinical and demographic data were collected from the medical records of patients diagnosed with sepsis who received prehospital care in five Colombian cities in 2015 and 2016. The diagnosis of septic shock was checked in 20% of the cases, generating two analyzed scenarios: observed and verified. Data were analyzed using the chi-square test, Student’s t test and an adjusted logistic regression model. Covariates with p < 0.05 were considered significant. Results: There was a higher frequency of septic shock in women (62.6%) and in individuals older than 80 years (64.5%), but these were not differentiating factors for septic shock. The most common source of infection was the urinary tract. In the observed scenario, age over 60 (prevalence ratio (PR): 3.22; 95% confidence interval (CI): 1.45 - 35.01) and history of cancer (PR: 1.20; 95%CI: 1.2 - 12.87) were the characteristics associated with septic shock, whereas in the verified scenario, chronic obstructive pulmonary disease (PR: 1.99; 95%CI: 1.26 - 7.14), history of cancer (PR: 1.15; 95%CI: 1.11 - 6.62) and presence of hypovolemia (PR: 1.41; 95%CI: 1.02 - 5.50) were observed. Conclusion: The most important risk factors for septic shock in prehospital care patients in five Colombian cities were oncological and pulmonary diseases and hypovolemia1.Introducción--. 2. Método--.3.Resultados--. 4. Discusión--. 5. Conclusiones.https://scienti.minciencias.gov.co/cvlac/visualizador/generarCurriculoCv.do?cod_rh=0001598004https://orcid.org/0000-0003-2098-7319https://scienti.minciencias.gov.co/gruplac/jsp/visualiza/visualizagr.jsp?nro=00000000011355diana.lopezme@campusucc.edu.comarcela.henaop@campusucc.edu.cojaime.arenasandrade17@gmail.comdavidhinestroz1@hotmail.comfabian.jaimes@udea.edu.cooquiros@ces.edu.cohttps://scholar.google.com/citations?view_op=list_works&hl=es&user=cVNjWXQAAAAJ28-36Universidad Cooperativa de Colombia, Facultad de Ciencias de la Salud, Medicina, Medellín y EnvigadoGilberto FriedmanMedicinaMedellínhttps://www.scielo.br/pdf/rbti/v32n1/0103-507X-rbti-32-01-0028.pdfRevista Brasileira de Terapia IntensivaSmyth MA, Brace-McDonnell SJ, Perkins GD. Identification of adults with sepsis in the prehospital environment: a systematic review. BMJ Open. 2016;6(8):e011218Gorordo Delsol LA. Sepsis: fisiopatología, diagnóstico y tratamiento. Ciudad de México: Intersistemas; 2016. 512 p.Hsiao CY, Yang HY, Chang CH, Lin HL, Wu CY, Hsiao MC, et al. Risk factors for development of septic shock in patients with urinary tract infection. Biomed Res Int. 2015;2015:717094.Seymour CW, Rea TD, Kahn JM, Walkey AJ, Yealy DM, Angus DC. Severe sepsis in pre-hospital emergency care: analysis of incidence, care, and outcome. Am J Respir Crit Care Med. 2012;186(12):1264-71.Rodríguez F, Barrera L, De La Rosa G, Dennis R, Dueñas C, Granados M, et al. The epidemiology of sepsis in Colombia: a prospective multicenter cohort study in ten university hospitals. Crit Care Med. 2011;39(7):1675-82.Schiaffino A, Rodríguez M, Pasarín MI, Regidor E, Borrell C, Fernández E. ¿Odds ratio o razón de proporciones? Su utilización en estudios transversales. Gac Sanit. 2003;17(1):70-4.Singer M, Deutschman CS, Seymour CW, Shankar-Hari M, Annane D, Bauer M, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):801-10.Organización Mundial de la Salud O. Mejora de la prevención, el diagnóstico y la atención clínica de la septicemia [Internet]. 2017 abr. Report No.: A70/13. Disponible en: https://apps.who.int/gb/ebwha/pdf_files/WHA70/A70_13-sp.pdfGrozdanovski K, Milenkovikj Z, Demiri I, Spasovska K, Cvetanovska M, Saveski V, et al. Epidemiology of community-acquired sepsis in adult patients: a six year observational study. Pril (Makedon Akad Nauk Umet Odd Med Nauki). 2018;39(1):59-66Hunter CL, Silvestri 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;34(5):813-9.Polito CC, Isakov A, Yancey AH 2nd, Wilson DK, Anderson BA, Bloom I, et al. Prehospital recognition of severe sepsis: development and validation of a novel EMS screening tool. Am J Emerg Med. 2015;33(9):1119-25.Cecconi M, Evans L, Levy M, Rhodes A. Sepsis and septic shock. Lancet. 2018;392(10141):75-87.Mayr FB, Yende S, Angus DC. Epidemiology of severe sepsis. Virulence. 2014;5(1):4-11.Moore LJ, Moore FA, Todd SR, Jones SL, Turner KL, Bass BL. Sepsis in general surgery: the 2005-2007 national surgical quality improvement program perspective. Arch Surg. 2010;145(7):695-700.Guerra WF, Mayfield TR, Meyers MS, Clouatre AE, Riccio JC. Early detection and treatment of patients with severe sepsis by prehospital personnel. J Emerg Med. 2013;44(6):1116-25.Jaimes FA, De La Rosa GD, Valencia ML, Arango CM, Gomez CI, Garcia A, et al. A latent class approach for sepsis diagnosis supports use of procalcitonin in the emergency room for diagnosis of severe sepsis. BMC Anesthesiol. 2013;13(1):23.Staudinger T, Pène F. Current insights into severe sepsis in cancer patients. Rev Bras Ter Intensiva. 2014;26(4):335-8.van der Wekken LC, Alam N, Holleman F, van Exter P, Kramer MH, Nanayakkara PW. Epidemiology of sepsis and its recognition by emergency medical services personnel in the Netherlands. Prehosp Emerg Care. 2016;20(1):90-6.Park DW, Chun BC, Kim JM, Sohn JW, Peck KR, Kim YS, et al. Epidemiological and clinical characteristics of community-acquired severe sepsis and septic shock: a prospective observational study in 12 university hospitals in Korea. J Korean Med Sci. 2012;27(11):1308-14.Cols EM, Reniu AC, Ramos DR, Fontrodona GP, Romero MO. Manejo de la sepsis grave y el shock séptico en un servicio de urgencias de un hospital urbano de tercer nivel. Oportunidades de mejora. Emergencias. 2016;28(4):229-34.García Balmaseda A, Miranda Pérez Y, Breijo Puentes A, Ramos Rodríguez E, Álvarez Dubé E. Marcadores de hipoperfusión tisular y su relación con la mortalidad en pacientes con shock séptico. Rev Cienc Médicas. 2015;19(6):1075-83.Metelmann C, Metelmann B, Scheer C, Gründling M, Henkel B, Hahnenkamp K, et al. Sepsis erkennen im Rettungsdienst: Ergebnisse einer interprofessionellen Befragung zur präklinischen und frühen innerklinischen Sepsiserkennung. Der Anaesthesist. 2018;67(8):584-91.Casu S, Häske D. Severe sepsis and septic shock in pre-hospital emergency medicine: survey results of medical directors of emergency medical services concerning antibiotics, blood cultures and algorithms. Intern Emerg Med. 2016;11(4):571-6.Baez AA, Hanudel P, Wilcox SR. The Prehospital Sepsis Project: out-ofhospital physiologic predictors of sepsis outcomes. Prehosp Disaster Med. 2013;28(6):632-5.Seymour CW, Kahn JM, Cooke CR, Watkins TR, Heckbert SR, Rea TD. Prediction of critical illness during out-of-hospital emergency care. JAMA. 2010;304(7):747-54.Barbara P, Graziano C, Caputo W, Litvak I, Battinelli D, Hahn B. The quick sequential organ failure assessment (qSOFA) identifies septic patients in the out-of-hospital setting. Am J Emerg Med. 2018;36(6):1022-6.Schwarz S, Schwab S, Fabian CW, Schellinger P, Orberk E, Hund E. [Infection: impaired consciousness as the initial symptom. Clinical and pathophysiologic aspects of septic encephalopathy]. Nervenarzt. 1997;68(4):292-7. German.Caraballo C, Ascuntar J, Hincapié C, Restrepo C, Bernal E, Jaimes F. Association between site of infection and in-hospital mortality in patients with sepsis admitted to emergency departments of tertiary hospitals in Medellin, Colombia. Rev Bras Ter Intensiva. 2019;31(1):47-56.Vincent JL, Rello J, Marshall J, Silva E, Anzueto A, Martin CD, Moreno R, Lipman J, Gomersall C, Sakr Y, Reinhart K; EPIC II Group of Investigators. International study of the prevalence and outcomes of infection in intensive care units. JAMA. 2009;302(21):2323-9.Macdonald SP, Arendts G, Fatovich DM, Brown SG. Comparison of PIRO, SOFA, and MEDS scores for predicting mortality in emergency department patients with severe sepsis and septic shock. Merchant RC, editor. Acad Emerg Med. 2014;21(11):1257-63.Walchok JG, Pirrallo RG, Furmanek D, Lutz M, Shope C, Giles B, et al. Paramedic-Initiated CMS Sepsis Core Measure Bundle Prior to Hospital Arrival: A Stepwise Approach. Prehosp Emerg Care. 2017;21(3):291-300.Matthaeus-Kraemer CT, Thomas-Rueddel DO, Schwarzkopf D, Rueddel H, Poidinger B, Reinhart K, et al. Crossing the handover chasm: Clinicians’ perceptions of barriers to the early detection and timely management of severe sepsis and septic shock. J Crit Care. 2016;36:85-91.Rello J, Leblebicioglu H; members of ESGGCIP. Sepsis and septic shock in low-income and middle-income countries: need for a different paradigm. Int J Infect Dis. 2016;48:120-2.Peltan ID, Mitchell KH, Rudd KE, Mann BA, Carlbom DJ, Hough CL, et al. Physician variation in time to antimicrobial treatment for septic patients presenting to the emergency department.Crit Care Med. 2017;45(6):1011-8.Westphal GA, Lino AS. Systematic screening is essential for early diagnosis of severe sepsis and septic shock. 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Epidemiology of septic shock in prehospital medical services in five Colombian cities

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