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