EMS Protocol of the Week - Smoke Inhalation (Adult and Pediatric) and Cyanide Exposure (Adult and Pediatric)

The NYC prehospital approaches to smoke inhalation and cyanide exposure are nearly identical, so it’s worth knocking them both out at once. Both protocols start with ABCs and burn management, and both then focus on the administration of cyanide toxicity kits for post-exposure patients who are symptomatic. You can refer to the PDFs directly for advice on dosing and administration considerations (remember: hydroxocobalaminBEFORE sodium thiosulfate to avoid medication inactivation!). Otherwise, note that prior to administering the cyanide toxicity kit is the ONLY instance in these protocols where paramedics are trained and ordered to draw blood (for pre-medication cyanide levels). 

The key difference in the protocol for cyanide exposure is the early recognition of a possible MCI scenario, which would require a Class Order for widespread medication orders that would then be dispatched through our OLMC line. We touched on this months ago with the WMD protocol and the use of nerve agent antidotes.

Scary stuff, but always better to be aware ahead of time! Want to get even MORE ahead? Check out www.nycremsco.org or the protocol binder to stay on top of it all!

Dave

EMS Protocol of the Week - Carbon Monoxide (Adult and Pediatric)

Anyone else start getting that dusty, musty smell from the heater in your apartment running for the first time since spring? Anyone get headaches with that must? Nausea, confusion? Syncope?

The prehospital protocol for carbon monoxide poisoning is primarily about recognition. Some services may carry CO monitors that can measure a patient’s SpCO, much like a pulse oximeter, but the more important thing is to have a healthy clinical suspicion for it the same way you would in the ED. Often, these crews will be responding to the scene of a fire, or where a CO detector has gone off, so ensuring scene safety is obviously the other crucial part of this approach.

Speaking of fires, what other considerations do we have for EMS when flames are involved? Stay tuned to find out! www.nycremsco.org or the protocol binder until then.

Dave

POTD: Winter is Coming.

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

https://www.emrap.org/episode/environmentalem/hypothermia

https://www.emrap.org/episode/environmentalem/frostbite