EMS Protocol of the Week - Drowning/Decompression Illness (Adult and Pediatric)

It’s summertime! Which means it’s hot out! Which means people are going swimming! Which means people are drowning!

Not a ton unexpected out of the protocol for drowning and decompression illness. ABCs again, with a reminder for spinal precautions as needed. The protocol refers out to the previously discussed section on Cold Emergencies for suspected hypothermia and reminds providers to initiate CPR on pulseless hypothermic patients. For suspected decompression illness, EMTs will place the patient left side down in case of air emboli. Most importantly, they are instructed to transport the patient and any companion divers to the nearest appropriate hospital (in this case, one with hyperbarics). The attached appendix is a list of facilities with specialty care capabilities, including hyperbarics.

That’s it! ABCs, protect the spine, know where to look up the closest dive tank, and you’re not dead til you’re warm and dead!

See you all next week! www.nycremsco.org and the protocol binder for more.

 Dave

EMS Protocol of the Week - Cold Emergencies and Heat Emergencies (Adult and Pediatric)

As the weather is (finally…hopefully) getting better, it seems as good a time as any to do a quick review of temperature-related emergencies. Not a ton that should shock you from the cold emergencies protocol - the name of the game is all about removal from the exposure. Also use this opportunity to remember that you’re not dead until you’re warm and dead; keep that in mind should you encounter a cardiac arrest for someone who fell into a pond or, like, a walk-in freezer.

Note that the heat emergencies protocol is designed to have you think about both passive environmental exposures and provoked hyperthermia from things like long-distance running. The latter point becomes more significant as we consider the eventual return of marathons and the like. In these cases, obviously control of environmental exposure is important, but don’t forget about other race-related pathology as well (electrolyte derangement related to hydration status, exercise-induced collapse, arrhythmias, etc.). The Key Points/Considerations section advises OLMC contact prior to oral hydration of patients with possible water intoxication, so just keep that mind if you take a call asking if it’s okay to give someone Gatorade.

That’s all, folks! www.nycremsco.org or the protocol binder for more. Until then, stay cool/warm/temperate!

Dave

Electric Injuries

Electrical Injuries

Starting off, an electrical injury patient is a trauma patient first, make sure to follow primary and secondary survey, EFAST, etc.

May require intubation if obtunded

r/o TBI, spinal cord, blunt thoracic, etc.

Risk Stratification

Low voltage (<600V) – household or office exposures lower risk injuries

High voltage (>600V) – industrial settings, subway rails, power lines are high risk injuries

Alternating Current (AC) – causes prolonged contraction and release of muscle which prevents full release from electrical source which will cause longer contact duration and more tissue damage compared to Direct Current (DC)

Lightning strikes (up to 1 billion V) are DC with brief contact

80% have long term morbidity, 10-30% mortality

Asystole from depolarization of myocardium but sponteous ROSC often achieved

Respiratory arrest from medullary paralysis

For lightning strike mass casualty incident, resuscitate those who appear dead first

Wound Care – saline moistened gauze (ideally sterile) and antibiotic ointment (silver sulfadiazine cream, bacitracin, mupirocin) unless transferring to burn center which mostly prefer just sterile moistened gauze

Cardiac Complications

Bundle branch blocks, AV blocks, QT prolongation, ST changes, Afib – most resolve spontaneously, Vfib (more with AC, asystole more with DC)

STEMI can arise rarely from electrical shocks, can consider trop

Compartment Syndrome – need to monitor, especially burn sites

Rhabdomyolysis/AKI

CK correlates to extent of muscle injury

Can have tea colored urine

Can have hyperK from AKI/Rhabdo but usually resolves with fluids

Treat as normal rhabdo with IVF and consider urine alkalinization with bicarb gtt

Electrical cord bite injury

Children can bite on electrical cords causing damage to oral pharynx, delayed massive bleeding from labial artery can arise – can grip lips with fingers/gauze to decrease bleeding

Cardiac Monitoring

Low voltage exposure w/o chest pain/syncope, no need for ECG monitoring

High voltage exposure – cardiac monitor 6-8hr

Delayed complications – altered mental status, memory loss, limb ischemia from vasospasm, parasthesias, cataract formation, delayed anerusym formation, delayed thrombosis

Disposition

Asymptomatic low voltage can be discharged

High voltage obs for 12 hrs with 6 hrs cardiac monitoring

Admit for dysrhythmia, AMS

Refer to burn center if significant burn injuries