Everything BURNS!

Good Monday Morning all!

This one took me all weekend - but I think it will be particularly helpful! I am always looking up how to dress burn wounds and who to give followup to and who to transfer etc, so I think this will be a nice easy reference.

There is just too much info around burns (from cyanide poising which we just reviewed w/Dr. Harmouche to awake nasotracheal intubation) and there are just so many learning points and I could only include so many - so I apologize for having the leave some things out. its already a dense one!

Prepare to zoom in/magnify, and happy learning (:

A couple key take home points that I wasnt able to fit into the graphic:

Burns are dynamic wounds. Burns can deepen over the next few days, and so it is difficult to know the true depth of the wound for at least 48-72 hours. Even burn specialists are only correct about 60% of the time at accurately identifying the depth of the burn on initial assessment. Burns can deepen after the first few hours to days of assessment. This is particularly important when setting expectations with patients and families at the initial visit.

Initial approach to any patient in a fire:

Don’t get distracted by the burns. Perform your primary and secondary survey as you normally would with a trauma patient and address the burns later.

Carbon monoxide (CO) and cyanide poisoning are also associated with burn injuries. Apply 100% O2 to reduce the half-life of carboxyhemoglobin to all patients with a history of exposure to fire in an enclosed space. Assume the pt is both trauma AND tox until proven otherwise.

Many of these pictures and pearls came from this amazing website:

https://emergencymedicinecases.com/burn-inhalation-injuries/

EMS Protocol of the Week - Smoke Inhalation and Cyanide Exposure

“What’s with all the doubling up on protocols, Dave?”

It’s called Being Efficient, get off my back! Plus, seeing as the subject was just thoroughly reviewed at conference, Protocol 500-A – Smoke Inhalation and Protocol 500-B – Cyanide Exposure are both timely and topical! Let’s get our spaced repetition on!

The real meat of both of these protocols concerns possible cyanide toxicity, although 500-A addresses it in the context of smoke and fire exposure (incidental, potentially secondary), while 500-B deals with cyanide as the potential primary pathogen. As such, both protocols lead with evaluating and managing ABCs, and 500-A includes a reminder to refer to the appropriate protocol for burns, if indicated (stay tuned, dear readers!). Both protocols then describe the scenarios in which cyanide antidotes may be indicated and should be administered – unexplained hypotension, AMS, coma, seizures, respiratory or cardiac arrest, all in the setting of presumed exposure to smoke and/or cyanide. The cyanide toxicity kits (previously only carried by FDNY EMS supervisors but as of 12/1/2020 are mandatory on all 911-system ALS units) contain hydroxocobalamin, sodium thiosulfate, and three blood tubes. Crews are instructed to draw blood samples into the tubes prior to administering the meds to provide reliable samples to receiving hospitals for running labs (this is currently the one instance where providers are drawing blood in the field!). Crews will generally look to administer hydroxocobalamin and sodium thiosulfate through two separate lines, although if only one vascular access site is available, they are instructed to administer the hydroxocobalamin first, followed by a 20 mL flush, in order to prevent its inactivation by sodium thiosulfate. For continued hypotension after administration of the cyanide toxicity kit, crews are allowed by SO to start vasopressors, either in the form of push-dose epinephrine, norepinephrine drip, or dopamine drip (as previously discussed in the Cardiogenic Shock protocol).

The last thing to note for this week is the introduction to Protocol 500-B. If a crew arrives on the scene of a suspected cyanide exposure where there are 5 or more patients, the scenario has pushed into MCI territory, and crews are instructed to approach it as a potential WMD attack. As such, the protocol calls for a FDNY Medical Director to give a Class Order, which generally kicks off disaster policies and procedures enacted through FDNY’s city-wide infrastructure. If the time ever comes where a crew calls our OLMC reporting an MCI scenario with cyanide, you should refer them to FDNY OLMC or FDNY Emergency Medical Dispatch, as these are the places that can operationally mobilize the appropriate wide-scale resources needed for the situation.

See? Two protocol birds, one email stone, and you’re all stronger for it. See you all next week for another protocol (or five)! Until then, keep checking www.nycremsco.org or the protocols binder!

Dave

EMS Protocol of the Week - Obstructed Airway, Pediatric Obstructed Airway, Pediatric Croup/Epiglottitis

Another 3-fer! He’s a madman! 

Yeah, mad like a fox!

There’s plenty of overlap between Protocol 502 – Obstructed Airway, its kid-friendly counterpart Protocol 551 – Pediatric Obstructed Airway, and its adjunct Protocol 552 – Pediatric Croup, and they’re all short and sweet, so let’s knock them all out at once, shall we?

502 deals initially with identifying a foreign body under direct laryngoscopy. Paramedics are directed to attempt removal with Magill forceps, but if this is unsuccessful and there is any issue with patient ventilation, the next steps guide paramedics through advanced airway management (namely, endotracheal intubation), and from there, an intentional right mainstem maneuver to push the obstruction out of the trachea. 551 for peds is the same but includes language to specify cuffed versus uncuffed ET tubes. And 552 adds the consideration for patients whose obstruction is related to potential croup or epiglottitis, in which case crews are instructed to avoid intubation and to stick with BVM if needed during transport.

That’s it! Knew you could do it! Stay tuned for another protocol next week! Until then, you always have www.nycremsco.org and the protocol binder to keep you company.

Dave