Lots of suspense from last week’s cliffhanger, I know, but basically, the pediatric anaphylaxis protocol plays out largely the same as its adult counterpart, just with peds-relevant dosing, along with a predilection for dexamethasone over methylprednisolone, particularly for kids less than 2 years of age.
Double check your dosages! Need a reference? That’s what www.nycremsco.org and the protocols binder are for!
Dave
Let’s talk about FROSTBITE, BRRRRRRR.
Background
Results from the freezing of tissue that are exposed to temperatures below their freezing point, resulting in direct ice crystal formation and cellular lysis with microvascular occlusion
Most of the damage occurs as a result of a freeze thaw cycle with endothelial damage and cellular death resulting in osmotic gradient changes, initiation of the arachidonic acid cascade, vasoconstriction, and hematologic abnormalities including thrombosis
Risk correlated with temperature and wind speed
Risk is <5% when ambient temperature (includes wind chill) is > –15°C (5°F)
Most often occurs at ambient temperature < –20°C (–4°F)
Wetness and humidity increase the risk (water has 25x thermal conductivity of air)
Can develop within 2-3sec when metal surfaces that are at or below –15°C (5°F) are touched
Most commonly affects distal part of extremities, face, nose, and ears
The severity of irreversible damage is most closely related to ambient temperature and length of time the tissue remains frozen
High-risk groups: outdoor workers, elderly, homeless, drug or alcohol abusers, psychiatric disease, high-altitude or cold-weather athletes, military personnel
"Hunter's response" - prolonged repeated exposure to cold is protective
Classification
Frostbite is classically categorized into four levels of injury.
Management
The initial treatment in the Emergency Department for all degrees of frostbite is the same. Addressing ABC’s, trauma evaluation, removing wet and constrictive clothing, treatment of concomitant hypothermia (must rewarm to a core temperature of at least 35°C), and identification of other injuries should be confirmed in all cold injury cases if warranted.
THAWING: Do NOT attempt until the risk of refreezing is eliminated. Refreezing will cause even more severe damage. Rapid active rewarming is the core of therapy and should be initiated as soon as possible. Best performed in a circulating water bath around 37°C to 39°C. Frostbitten faces can be thawed using warm water compresses, and ears may be thawed with small bowls of warm water. Immersion rewarming can be discontinued when the affected area developed a red or purple appearance and becomes pliable to the touch.
Analgesia: rewarming is very painful, treat your patient's pain!
Local wound care: Gently dry, elevate, and apply bulky dressing to the affected area. Compartment syndrome is a known complication, so maintain a high suspicion.
Update tetanus as needed
Empiric prophylactic antibiotics are not needed and are controversial.
Surgical management may be required if wet gangrene or infection occurs, but this is typically reserved for late frostbite management after the rewarming phase in days to weeks following initial presentation
Dispo Dispo Dispo
Patients with superficial local frostbite may be discharged home if social circumstances allow. Patients unable to care for themselves adequately should never be discharged into subfreezing temperatures.
Significant injuries will require admission.
References:
http://www.emdocs.net/brrr-ed-presentation-evaluation-and-management-of-cold-related-injuries/
http://emedicine.medscape.com/article/926249-treatment#showall
https://wikem.org/wiki/Frostbite
Anaphylaxis is one of the rare protocols where you will actually find medication administration as early as the CFR (FDNY firefighter) level. In this protocol, if CFRs are the first on scene and recognize a patient in anaphylaxis, they will administer epinephrine via auto-injector while awaiting EMS backup.
BLS will also administer IM epi, either by auto-injector or – in some instances – manually drawn up into a premarked syringe. However, EMTs require OLMC approval to give a second dose, regardless if they themselves gave the first epi or the CFRs did. This highlights the importance of checking with crews which meds were given, and by whom. BLS is also equipped to administer albuterol for any wheezing noted.
ALS providers on scene will do all manner of ALS stuff – advanced airway management if needed, IV fluids, steroids, diphenhydramine, ipratropium, and repeat epi if instructed by OLMC. Any further issues with respiratory or hemodynamic status are referred to appropriate protocols for additional management.
That’s it for this week, but I bet you’re all…itching…to find out what happens for pediatric patients in anaphylaxis? Stay tuned, faithful readers!
www.nycremsco.org or the protocol binder for more!
Dave