EMS Protocol of the Week - Cyanide Poisoning

Hey all,

This week we invite you to drink the EMS Kool-Aid and learn how our pre-hospital colleagues care for patients with suspected cyanide poisoning 💀

Although popularized by mystery novels and mass murder-suicides, the most common and alarming cause of cyanide poisoning we're likely to see is from smoke inhalation. When apartments catch fire, fumes from burning polyurethane, vinyl, and other nitrile-based polymers react to form the deadly compound which is inhaled and rapidly distributed throughout the body. Cyanide then halts ATP production from the electron-transport chain causing a raging lactic acidosis from exclusive anaerobic respiration, and then... well... Cya-never 👋

Initial management consists of ABC's, supplemental O2, and treating burns. Definitive treatment in the field is based on clinical features: cardiac arrest, respiratory arrest, AMS, coma, seizures, and hypotension without an obvious other cause are indications to give the antidote, hydroxocobalamin or sodium thiosulfate via a Cyanokit. Because mortality is high and lab confirmation takes time, treatment should be initiated ASAP, with repeat doses for persistent symptoms. In general, hydroxocobalamin is the first-line agent and can be followed with sodium thiosulfate for continued therapy.

See the contents of the Cyanokit below that NYC paramedics have for use:

Tubes for blood

- pre-hospital lab collection prior to med administration

3-way stopcocks to mix solutions and IV tubing

Hydroxocobalamin 5 g bottle of crystalline powder

-needs to be mixed with 200cc NS or D5W and then IV wide-open over 15 min for adult dosing

-peds dosing 75 mg/kg IV (3 mL/kg of the mixed solution)

20cc syringe to be used to flush crystalloid fluid after hydroxocobalamin administration

Sodium Thiosulfate 12.5 g bottle

-mixed with 100cc NS or D5W and then IV over 10 min for adults

-peds dosing 250 mg/kg IV (3mL/kg of mixed solution)

And keep in mind, although present in smoke inhalation injuries, cyanide poisoning can also be a result of nitroprusside overdose or used as a weapon of mass destruction in an MCI (stay tuned for that protocol...).

See attached protocol and info from FDNY training; check out https://nycremsco.org/ for more!

Best,

Chris Kuhner, MD

PGY-2 Emergency Medicine

EMS Protocol of the Week - Smoke Inhalation

Hello all, 

This week's EMS Protocol is brought to you by my obsession with the HBO smash hit House of the Dragon. 

Picture this -- Two Westerosi men walk into a King's Landing bar. They see Princess Rhaenyra and strike up a heated conversation to delight her. After exhausting all the advances in their arson-al, they realize they're no match. Syrax, fuming at this show of smoke and mirrors, suggests they use Tinder and burns them to the ground. EMS arrives at the scene and then has to deal with the rest of the patrons...

Enter the REMAC protocol for smoke inhalation!

-In general, always start with ABC's -- airway is critical.

-Place patients on NRB for O2.

-EMTs can measure carbon monoxide (SpCO) with a pulse co-oximeter.

              -Keep in mind SpCO measured by an external pulse co-ox is less reliable compared to that calculated from blood co-oximetry.

              -Consider transfer to a facility with hyperbaric capabilities (like Jacobi) if you suspect CO poisoning.

-Medics perform advanced airway management.

              -Have a low threshold to use DL/VL.

              -Intubate early for soot/edema in airway, neck burns, progressive hoarseness, AMS.

-Treat cyanide poisoning early (stay tuned for more info).

Don't forget to check out www.nycremsco.org and the protocol binder for more and reach out for questions!

Remember: Winter is coming. And with winter, comes more electric/gas heating fires and potential for burn/smoke injures.

Best,

Chris Kuhner, MD

PGY-2 Emergency Medicine

EMS Protocol of the Week - Poisoning (Adult and Pediatric)

Previously combined with the protocol for overdoses, the prehospital approach to various types of poisoning is now given its own space to shine in the 2022 edition. First and foremost in terms of importance, as in all prehospital encounters, is for crews to ensure scene safety so as not to put themselves at further risk. From there, special considerations are given regarding decontamination of different potential exposures, from ingestion, to inhalation, to animal envenomation. Read through the attachment for specifics, as it serves as a good refresher of initial steps in management. Otherwise, this protocol contains the other basic tenets that you would expect – support ABCs, and transport to an appropriate facility (including Venomous Bite Centers as needed – check last week’s email to see where they are in the city!). 

www.nycremsco.org and the protocol binder for more!

Dave