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 Table of Contents  
Year : 2019  |  Volume : 3  |  Issue : 2  |  Page : 85-91

Emergency medical service providers' knowledge and perception of sepsis at Makkah Saudi Red Crescent Authority

Department of Applied Medical Sciences, Umm Al Qurrah University, Makkah, Saudi Arabia

Date of Submission26-Apr-2019
Date of Decision04-Aug-2019
Date of Acceptance06-Aug-2019
Date of Web Publication23-Sep-2019

Correspondence Address:
Bassam Hassan Basaffar
8803 Albuhayrat, Unit Number 45, Makkah Al Mukarramah 24227-4203
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sccj.sccj_14_19

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Background: Sepsis is a life-threatening condition existing worldwide and is frequently known as the “hidden killer” because it is a time-sensitive illness, like myocardial infarction and cardiac arrest; therefore, prehospital providers must have adequate knowledge about it. Aim: The aim was to measure the knowledge and perception of sepsis among emergency medical service (EMS) providers to assure better patient prognosis. Methodology: A cross-sectional paper-based questionnaire survey comprising 15 questions, divided into three sections, was conducted at Makkah Saudi Red Crescent Authority to evaluate their knowledge related to the signs and symptoms of sepsis in particular and management and perception of sepsis in general. The responses received were categorized according to the specialties considering P < 0.05 as statistically significant. Results: The total number of study participants was 102; 26 participants were excluded because they did not meet the inclusion criteria. Among the remaining 76 participants, 64.5% were technicians and 35.5% were specialists. The most common age group was 25 ± 5 years which composed 46.1% of the total participants, and the highest years of experience was between 6 and 10 years which composed 47.4% of the total participants. According to a 5-point Likert scale, there was an adequate level of EMS provider perception on the knowledge of sepsis. Nearly 55.6% of the specialists knew the three stages of sepsis better than technicians (40.8%). Both the technicians and specialists had poor knowledge regarding hypothermia (technicians 20.4% and specialists 25.9%) as a sign of sepsis, in addition to administering intravenous antibiotics (technicians 28.6% and specialists 14.8%) as a management modality. On the other hand, both had enough knowledge regarding the other signs and symptoms with an average of 72.8% and the management of sepsis with an average of 72%. Conclusion: Overall, all participants had a good level of knowledge related to sepsis. However, the participants lack knowledge on administering antibiotics and hypothermia; moreover, their attitude and willingness toward recognizing and managing septic patients is unknown. Hence, it is recommended that further research may be undertaken to measure it at a larger scale and efforts be made to educate the providers certainly on the knowledge they lack of.

Keywords: Emergency medical services, knowledge and perception, sepsis

How to cite this article:
Basaffar BH, Aloitibi NS, Alzahrani RM, Felimban OO, Algethami KS, Alshehri AH. Emergency medical service providers' knowledge and perception of sepsis at Makkah Saudi Red Crescent Authority. Saudi Crit Care J 2019;3:85-91

How to cite this URL:
Basaffar BH, Aloitibi NS, Alzahrani RM, Felimban OO, Algethami KS, Alshehri AH. Emergency medical service providers' knowledge and perception of sepsis at Makkah Saudi Red Crescent Authority. Saudi Crit Care J [serial online] 2019 [cited 2020 Sep 23];3:85-91. Available from: http://www.sccj-sa.org/text.asp?2019/3/2/85/267616

  Introduction Top

Sepsis is a life-threatening condition existing all over the world and is frequently called the “hidden” killer. In the United Kingdom (UK), more than 250,000 episodes of sepsis are encountered annually, with at least 44,000 people dying as a result. Sepsis claims more lives than breast, bowel, and prostate cancer put together, but few have heard of it yet.[1] Furthermore, the overall mortality rate for patients with severe sepsis is 35% – approximately five times higher than that for ST-elevation myocardial infarction (MI) (ECG wave changes) and stroke.[2] Emergency medical service (EMS) providers are the first health-care workers who handle the patient while diagnosing and initiating management based on their provisional diagnosis. In Scotland, a recent study showed that most of the patients diagnosed with severe sepsis or septic shock in emergency departments were transported to hospital by ambulance because sepsis is a time-sensitive illness like MI and cardiac arrest.[3],[4] It is evident that the early recognition and management by the EMS providers will improve not only patient care but also the outcomes.

Our hypotheses were the belief that the knowledge and perception is scanty among EMS providers in all survey sections. However, it might be higher among the specialists who are bachelorette degree holder, being even higher than the technicians who are diploma degree holder. Hence, we aimed to study the actual level of understanding of the condition to allow the efficient delivery of care to septic victims and to make necessary actions regarding low standards of quality of emergency services being provided. To investigate these hypotheses and achieve our aim, we conducted a paper-based questionnaire survey and distributed it among Makkah Saudi Red Crescent Authority's (SRCA) EMS providers, in particular, to measure their knowledge and perception about sepsis.

Research question

Is the level of knowledge regarding sepsis among the EMS providers acceptable?

Review of literature

There are several similar studies, as an illustration. In 2015, in a study conducted at Seoul, Korea, to find out the knowledge and attitude of the EMS providers, it was found that a substantial portion of EMS personnel lack appropriate level of knowledge on sepsis care. They also found that the intention to engage in sepsis management was associated with appropriate knowledge of sepsis.[5]

In a multi-agency, online survey of emergency medical technicians (EMTs), fire fighter-EMTs (FF-EMTs), and paramedics in a metropolitan, two-tier EMS system, the authors found that EMS personnel demonstrated an overall sound awareness of sepsis. Knowledge of sepsis was less among FF-EMTs and EMTs compared to paramedics. These results suggest that paramedics could be integrated into the strategies of early identification and treatment of sepsis, whereas EMTs may benefit from focused education and training.[6]

However, we did not find any similar study in Saudi Arabia.

Sepsis definition

Sepsis is a life-threatening organ dysfunction caused by a deregulated host response to infection, and septic shock is a “subset” of sepsis in which the underlying circulatory and cellular/metabolic abnormalities are profound enough to substantially increase mortality.[7]

Pathophysiology of sepsis

Understanding the pathophysiology of sepsis is essential to make the EMS provider able to recognize sepsis early. Sepsis does not occur when the body is suffering from a minor infection such as a sore throat; however, if left untreated, a systemic inflammatory response is triggered when pathogens enter the bloodstream. It is started by the release of phagocytes, neutrophils, and macrophages (cells that attack and destroy pathogens) as well as the mast cells (cells that produce vasoactive amines such as histamine), which are thought to be primed by one of the inflammatory mediators called cytokines. Increased levels of cytokines will damage the endothelium and cause a widespread vasodilation, resulting in hypotension and hypoperfusion. The injured endothelium becomes permeable, allowing leakage of fluid into the interstitial space, and loses much of its anticoagulation function, enabling the formation of blood clots in the microvasculature (the body's smallest vessels), which will also increase oxygen demand and fever will follow.[8]

People at risk of sepsis

Sepsis may occur in healthy people; however, people in the age groups stated below are also at higher risk of developing sepsis, the age groups include the very young (<1 year) and older people (>75 years). The other groups might include the very frail patients, patients with impaired immune systems because of illness or drugs, in addition to those who are being treated for cancer with chemotherapy or who have impaired immune functions, and those on long-term steroids. In addition, people taking immunosuppressant drugs to treat nonmalignant disorders such as rheumatoid arthritis are at risk. Patients who have had surgery or other invasive procedures in the past 6 weeks are also at increased risk. This group also involves people with any breach of skin integrity or who misuse drugs intravenously, and, lastly, those with indwelling lines or catheters.[9]

Recognizing sepsis

Sepsis can be recognized by the following signs and symptoms: temperature >38°C or >36°C, tachycardia, tachypnea, hyperglycemia (if no diabetes mellitus), and altered mental status.[10] Red flag signs include systolic blood pressure (BP) <90 mmHg; lactate ≥2 mmol/l (where available); heart rate >130/min; respiratory rate >25/min; oxygen saturation <92%, responding only to voice, pain, or unresponsive; and pubic rash.[11]

Managing septic patients

The “sepsis six” is an initial resuscitation bundle designed to offer basic intervention within the 1st h starting by administering high-flow oxygen, taking blood cultures, administering intravenous antibiotics, giving an intravenous fluid resuscitation, checking the serial lactates, and, lastly, commencing hourly urine output measurement.[11] Each management is briefly discussed below.

Delivering high-flow oxygen

All severe sepsis or septic shock patients should initially be given high-flow oxygen. Once the patient is stable, the oxygen should be titrated to maintain the oxygen saturation at 94% or more.[11]

Blood cultures

Blood culture remains one of the most important investigations in the management of sepsis. It allows identification of the responsible organism(s) for sepsis and appropriate choice of empirical and specific antibiotic(s) and points toward further investigations required to identify the focus of infection.[12]

However, taking blood cultures is not a routinely performed procedure in the prehospital phase by EMS providers.

Intravenous antibiotics

In a large prospective study of ED septic shock patients who received standardized early recognition and aggressive resuscitation at three experienced institutions, they failed to demonstrate an association between the timing of antibiotic administration from ED triage and hospital mortality. A delay in administering antibiotics until after shock recognition, as compared to before, was associated with increased mortality; however, if antibiotics are administered after shock recognition, there is no increase in mortality with hourly delays.[13] Thus, using antibiotics in the prehospital setting will not give sufficient results with the timing of administration prehospitaly. However, antibiotic is not used currently in prehospital settings in SRCA.

Starting intravenous fluid resuscitation

One of the most critical problems in severe sepsis is multiple organ dysfunction syndrome, which is primarily caused by a deficiency of blood supply to various organs. This deficiency is often caused by hypovolemia.

The primary reason to start fluid therapy is to correct the hypovolemia, which should normalize the BP and heart rate. Patients with severe sepsis should be given 30 mL/kg of normal saline rapidly.[11]

Serum lactate

Patients with septic shock can be identified clinically, with persisting hypotension requiring vasopressors to maintain mean arterial pressure ≥65 mmHg and having a serum lactate level >2 mmol/L (18 mg/dL) despite adequate volume resuscitation. With these criteria, hospital mortality is in excess of 40%.[7] However, it is not routinely measured in the prehospital phase by EMS providers.

Urine output

Measurement of urine output is crucial to determine the level of kidney function, which is an essential indicator for tissue perfusion and is more reliable than BP.

Catheterization in the prehospital phase is not performed routinely; however, it is essential to ask patients about their urinary habits while considering dry pads in people with incontinence and asking about volume in catheterized patients, which will help in the determination of the severity of sepsis.[11]

  Methodology Top

Study design

A prospective descriptive comparative study design was used to compare EMS providers, specialists, and technicians at SRCA and describe the results obtained.

The setting of the questionnaire

The paper-based survey questionnaire was developed by the authors based on literature and had been validated by the supervisors and tested statistically. The questionnaire has been translated into Arabic because English is not a local language, and some of the providers have poor command over the language. The survey was divided into three sections as follows.

Section one

Section one measures the level of sepsis perception by EMS providers about their knowledge by using Likert scale questions from 1 to 12 [Table 4], and multiple-choice question in 13.
Table 4: The 5-point Likert questions that are used

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Section two

Section two measures the level of knowledge related to the signs and symptoms of the condition, in a single question, i.e., question 14, as a yes or no question.

Section three

Section three measures the level of knowledge regarding the management of sepsis, in a single question, i.e., question 15, as a yes or no question.

Inclusion and exclusion criteria

EMS participants in this study must have at least a 1-year experience; should be still working in SRCA centers, particularly in field practice; should have direct contact with the patients, either technicians or specialists (paramedic); and should have completed at least 60% of the survey. Doctors were not included. Participants not meeting the above-stated criteria were excluded from the study.


The participants were randomly selected; 102 out of 318 SRCA providers in Makkah city (this number has been taken from Makkah SRCA administration). According to their graduate degree programs, technicians are diploma holders who have studied for at least 2 years in well-recognized EMS programs and specialists (paramedics) are baccalaureate holders who have studied for at least 4 years in EMS programs. They were chosen randomly to measure their knowledge and perception of sepsis; all of them were males, 26 participants were excluded because they did not meet the inclusion criteria.


A paper-based questionnaire was distributed during 7 consecutive days from March 12–18, 2018, at Makkah SRCA centers. The investigators were divided into three groups; each group included two investigators and went to 19 out of 25 SRCA centers in Makkah city.

Ethical consideration

Each author explained the study purpose and rights and confidentiality to the providers, after which informed consent was received, and distribution of questionnaire was initiated. Numbers of all the providers were taken from Makkah SRCA administration after gaining their approval.

Pilot testing

We tested this survey on a pilot sample of five SRCA EMS providers (three technicians and two specialists) who have experience in working out of the hospitals (in SRCA centers). Additionally, they were asked to examine the questionnaire to assure that it was acceptable and easy to be understood. Their responses were not included in the study.

Data analysis method

Data were collected by entering the data in Microsoft Excel and analyzed by Statistical Package for Social Sciences version 22 (IBM Corp., Armonk, NY). Cronbach's alpha test was used for evaluating the reliability of the three sections. Descriptive analysis was performed; percentage and frequencies were calculated to see the responses of the participants, and any percentage above 60 was considered acceptable. The mean percentage was calculated for all the sections; for Likert scale, we used [Table 1] to see the mean general trend. Chi-square and independent-samples t-test were performed to measure the difference between the EMS providers (technicians and specialists). P(significance) < 0.05 was treated as statistically significant. Demographic data such as age and years of experience were manually sorted into four groups after the data collection.
Table 1: An estimated scale according to 5-point Likert scale

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  Results Top

The reliability test was conducted by Cronbach's alpha on all the three sections of the “level of sepsis knowledge and perception questionnaire from Q1 to 13.” It was found that section one's alpha level was 0.70, and for “level of sepsis signs and symptoms' knowledge and perception (Q14),” the score was 0.85. Lastly, for the “level of sepsis management knowledge and perception (Q15),” the score was found to be 0.78, which indicates that the subscale has an adequate level of inter-item reliability [Table 2].
Table 2: Alpha Cronbach's reliability for the three sections

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The age range of the technicians, 51% (n = 25), was from 21 to 30 years and that of the specialists, 59.3% (n = 16), was from 31 to 40 years. In general, 47.9% (n = 23) of the technicians had a working experience from 6 to 10 years and 51.9% (n = 14) of the specialists had a working experience from 6 to 10 years [Table 3].
Table 3: Age and years of experience of the providers in percentages and numbers

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The first section: The emergency medical service perception about their knowledge of sepsis from questions 1–13

The mean general trend was 3.37, which indicates that EMS providers' perception of their knowledge regarding sepsis was adequate [Figure 1]. Moreover, there was a statistically significant difference between the EMS providers in Q1, Q2, and Q6; in Q1, 77.8% of the specialists strongly agreed about hearing of the term sepsis, but 49% of the technicians strongly agreed about hearing of the term sepsis (P = 0.03).
Figure 1: The mean and general trend of each question in the first section

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In Q2, 48.1% of the specialists strongly agreed about the correct definition of sepsis, whereas 44.9% of technicians agreed about the correct definition of sepsis (P = 0.009).

In Q6, 48.1% of the specialists agreed that they are familiar with the pathophysiology of sepsis, whereas only 28.5 were aware of it (P = 0.013).

[Figure 2] shows the total responses of technicians and specialists.
Figure 2: Emergency medical service providers' responses to the first section

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Q13: Which of the following is considered the three distinct categories of sepsis (in correct arrangement)?

The number of EMS specialists that answered correctly, 55.6% (n = 15), was higher than those who answered incorrectly, 44.4 (n = 12). A higher number of technicians answered incorrectly, 59.2 (n = 29), compared to the number that answered correctly, 40.8 (n = 20).

The second section: Level of sepsis signs and symptoms' knowledge and perception; only question 14

Q14: In your opinion, which of the following are the signs and symptoms that can occur in sepsis?

Specialists ranked fever and tachycardia (92.6%) in the first place followed by altered mental status and tachypnea (88.9%), hypotension (70.4%), and finally hypothermia (25.9%) as the most common signs and symptoms of sepsis.

Technicians, on the other hand, ranked fever (94.9%) in the first place followed by tachycardia (89.8%), tachypnea (83.7%), altered mental status (65.3%), and finally hypothermia (20.4%). The mean percentage was 72.8%, which is acceptable [Figure 3].
Figure 3: Emergency medical service providers' responses to the second section

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The third section: Level of knowledge regarding the management of sepsis; only question 15

Q15: In your opinion, which of the following is an appropriate management by emergency medical service providers toward sepsis?

Specialists prioritized fluid resuscitation, 100%, as the first step toward the management of suspected septic patients. Followed by transporting and notifying the receiving hospital (96.3%). Administration of high-flow oxygen 92.6%, asking for decrease urinary habit 70.4% and finally administering intravenous antibiotics 14.8% were considered no less important.

Technicians considered transporting and notifying the receiving hospital of sepsis (98%) in the first place followed by administering high-flow oxygen (91.8%), administering intravenous fluid resuscitation (89.8%), asking for a decrease in urinary habit (49%), and administering intravenous antibiotics (28.6%). The mean was 72% which is acceptable [Figure 4].
Figure 4: Emergency medical service providers' responses to the third section

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By using independent-samples t-test, we observed that there was a significant difference in scores in the first section (Q1–13) for technicians (M = 3.26, standard deviation [SD] = 0.60) and specialists (M = 3.57, SD = 0.43); t (74) = 2.34, P= 0.022. In the second section (Q14), there was a significant deference in the scores between technicians (M = 1.70, SD = 0.16) and specialists (M = 1.79, SD = 0.13); t (74) = 2.35, P= 0.021. Furthermore, there was no statistically significant difference in the third section.

  Discussion Top

EMS personnel have already made substantial contributions to improving care for patients with time-dependent illnesses, such as trauma and MI. Patients with sepsis could also benefit from timely prehospital care.[14] Sepsis is similar to MI and requires immediate intervention.[15]

The overall mortality rate for patients with severe sepsis is 35% – approximately five times higher than for ST-elevation MI and stroke. Sepsis is responsible for at least 37,000 deaths and 100,000 hospital admissions in the UK/year.[2] Therefore, the EMS providers' knowledge and perception about sepsis is crucial. This study has investigated the knowledge and perception of EMS providers of SRCA in Makkah by conducting a paper-based questionnaire survey, consisting of 15 questions, to test our hypotheses. The survey was distributed randomly among a total of 102 Makkah SRCA's EMS providers out of a total of 318 EMS providers employed at SRCA Makkah. A total of 75 providers were technicians and 27 were specialists. The questionnaire was handed out in 19 out of 25 Makkah SRCA stations during 7 consecutive days. Twenty-six technicians were dropped out because they did not meet the inclusion criteria. The analysis showed that the providers have a poor level of sepsis knowledge and perception. After reviewing the survey results, we safely concluded that they had acceptable knowledge regarding the signs and symptoms and management, which is contrary to our hypotheses and we accept it. Furthermore, as per hypothesized, the specialists' knowledge and perception were higher than that of technicians concerning the condition in general. However, they were the same when the signs and symptoms and management of the condition were taken into consideration.

Early recognition of sepsis by prehospital personnel leads to transport of patients to proper hospitals and behavioral changes in hospital staff.[16] Most of the providers agreed that early recognition and management would positively increase the patient's prognosis.

Emergency department arrivals by EMS triggered the in-hospital sepsis care, resulting in a shorter time to initiate early therapy in patients with severe sepsis. For both EMS groups, hypothermia (technicians 20.4% and specialists 25.9%) was least known as a sign of sepsis. Septic patients who develop hypothermia have a significantly worse outcome than those who develop fever or maintain a normal body temperature.[17] Thus, it is a critical sign for sepsis.

Administering antibiotics, as a treatment modality by providers, was remarkably low, which might strongly be due to institutional protocols, which prohibit providing antibiotics to patients prior to emergency department arrival through SRCA (the technicians' scores were 28.6% compared to specialists' scores of 14.8%). Fever as a sign of sepsis, on the other hand, scored almost the same response between the two providers; technicians' scores were 94.9% and specialists' scores were 92.6%. This might have been emphasized in both providers' study curricula. With regard to tachycardia as a sign of sepsis, technicians' scores were convincingly high (89.8%) and specialists' scores were 92.6%, which showed only a slight difference among the participants. When reviewing knowledge scores among the providers with regard to the management of sepsis, the specialists were most focused on administrating intravenous fluid (100%), followed by transporting the patient while notifying the hospital, which was the most common response and the foremost action taken by the technicians (98%). Our study suggested that, in general, the providers do have knowledge about the condition. However, the research has several limitations; the first one which is the use of Likert scale, which might lead to experimental bias effect for the study because it does not quantify the agreement or disagreement responses. Next is the fact that all those participants who were excluded from the analysis were technicians, and this might influence and limit the generalizability of the results obtained for the technicians. The strength of the study lies in the fact that this study is one of the first-ever studies undertaken under this subject and specialty in Saudi Arabia, and EMS knowledge can dramatically impact in prehospital patient prognosis levels. In addition, the conduction of a pilot test makes this beneficial and reliable.

  Conclusion Top

Overall, EMS providers at SRCA had an adequate level of knowledge and perception, including the signs, symptoms, and management of sepsis, which indicates that they can safely recognize and manage septic patients. However, there were a couple of conditions which limit the study, i.e., providers had poor knowledge of administering the appropriate antibiotics and hypothermia; moreover, their attitude is unknown until know.


We recommend further research to consider the following: replication of the study at a larger scale especially in Saudi Arabia because there are no similar researches. Furthermore, measure the EMS provider's attitude and willingness toward septic patient's treatment. To add to the list, at an institutional level, SRCA may consider holding courses to educate providers regarding the standardized recognition and management of sepsis, especially updating their knowledge about hypothermia and the administration of intravenous antibiotics.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Daniels R, Nutbeam T. The Sepsis Manual. 4th ed. Bennetts HillBirmingham: United Kingdom Sepsis Trust; 2018.  Back to cited text no. 1
Daniels R. Surviving the first hours in sepsis: Getting the basics right (an intensivist's perspective). J Antimicrob Chemother 2011;66 Suppl 2:ii11-23.  Back to cited text no. 2
Gray A, Ward K, Lees F, Dewar C, Dickie S, McGuffie C, et al. The epidemiology of adults with severe sepsis and septic shock in Scottish emergency departments. Emerg Med J 2013;30:397-401.  Back to cited text no. 3
Levy MM, Evans LE, Rhodes A. The surviving sepsis campaign bundle: 2018 update. Intensive Care Med 2018;44:925-8.  Back to cited text no. 4
Park J, Hwang SY, Shin TG, Jo IJ, Yoon H, Lee TR, et al. Emergency medical service personnel need to improve knowledge and attitude regarding prehospital sepsis care. Clin Exp Emerg Med 2017;4:48-55.  Back to cited text no. 5
Seymour CW, Carlbom D, Engelberg RA, Larsen J, Bulger EM, Copass MK, et al. Understanding of sepsis among emergency medical services: A survey study. J Emerg Med 2012;42:666-77.  Back to cited text no. 6
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;315:801-10.  Back to cited text no. 7
Bledsoe BE, Cherry RA, Porter RS. Essentials of Paramedic Care-Update. 2nd ed. New Jersy: Pearson Education, Inc., Upper Saddle River, Robert J. Brady Co.; 2011.  Back to cited text no. 8
National Guideline Centre Sepsis: Recognition, Assessment and Early Management. London, UK: National Guideline Centre; 2016.  Back to cited text no. 9
Gotts JE, Matthay MA. Sepsis: Pathophysiology and clinical management. BMJ 2016;353:i1585.  Back to cited text no. 10
Nutbeam T, Daniels R, Keep J. Toolkit: Emergency Department Management of Sepsis in Adults and Young People Over 12 Years-2016; 2016.  Back to cited text no. 11
Patel M. Utility of blood culture in sepsis diagnostics. J Acad Clin Microbiol 2016;18:74.  Back to cited text no. 12
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Puskarich MA, Trzeciak S, Shapiro NI, Arnold RC, Horton JM, Studnek JR, et al. Association between timing of antibiotic administration and mortality from septic shock in patients treated with a quantitative resuscitation protocol. Crit Care Med 2011;39:2066-71.  Back to cited text no. 13
Alam N, Oskam E, Stassen PM, Exter PV, van de Ven PM, Haak HR, et al. Prehospital antibiotics in the ambulance for sepsis: A multicentre, open label, randomised trial. Lancet Respir Med 2018;6:40-50.  Back to cited text no. 14
Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, Osborn TM. Surviving sepsis campaign: International guidelines for management of severe sepsis and septic shock: 2012. Intensive Care Med 2013;39:165-228.  Back to cited text no. 15
Band RA, Gaieski DF, Hylton JH, Shofer FS, Goyal M, Meisel ZF. Arriving by emergency medical services improves time to treatment endpoints for patients with severe sepsis or septic shock. Acad Emerg Med 2011;18:934-40.  Back to cited text no. 16
Remick DG, Xioa H. Hypothermia and sepsis. Front Biosci 2006;11:1006-13.  Back to cited text no. 17


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

  [Table 1], [Table 2], [Table 3], [Table 4]


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