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 - Procedural Sedation (Adult and Pediatric)

Couple of VERY cool updates to the prehospital sedation protocol this past year:

1. Medications can now be given for procedural (eg, cardioversion, pacing, CPAP) or advanced airway management (eg, endotracheal tube, supraglotic device) sedation as Standing Order (ie, without prior OLMC approval). For advanced airway management, these patients need to meet very strict inclusion criteria; otherwise, crews will have to call OLMC for authorization as before.
2. IV ketamine has finally entered the arena as a possible Standing Order and/or Medical Control Option, rather than the Discretionary Order we had previously made it out to be as some hush-hush, off-label use.

Note that all these doses are weight-based, with a limit on the maximum dose to be given at a time. Be sure to practice good closed-loop communication when confirming doses (and routes, for that matter; notice how these are all written as IV formulations, which I think appropriately implies that anyone about to get electrocuted or have a tube shoved down their throat should have vascular access).

Also bear in mind that for pre-airway sedation, even though the protocol is only written as a pre-intubation dose and a post-intubation dose, many crews will often ask for a third dose as a “standby” in case more meds are needed. You might hear “I’d like to give 40 of etomidate followed by 5 and 5 of diazepam as needed post-intubation” while on the phone. Use your discretion for how much medication you feel comfortable approving at once, and again, clearly state your orders in a closed-loop fashion to avoid medication errors.

ALSO also:

Paramedics
Do
Not
Carry
Paralytics
Do
Not
Ask
Them
To
Give
Rocuronium
You
Will
Sound
Silly


And that’s it! You are now all incredibly well…versed…in the world of prehospital sedation! www.nycremsco.org and the protocol binder to keep the knowledge train rolling!


Dave

EMS Protocol of the Week - Cold Emergencies

Happy COLD Tuesday!

Another guest post for the week where we will be discussing EMS protocol for Cold Emergencies that apply to both adult and pediatric populations.

The prehospital approach to cold emergency shows a nice progression of responsibilities based on level of training. CFRs at the most basic level will move the patient to a warmer environment, remove any wet clothing/jewelry, apply heat packs, and dry the patient with warm blankets. BLS crews will monitor for alter mental status, treat any hypoglycemia and request ALS backup. ALS providers on scene will perform advanced airway management as needed, begin cardiac monitoring and record an EKG for evaluation, and obtain IV access to administer warm crystalloid fluids if available.

Not a lot to do on the OLMC side other than to be aware of this stepwise progression, as well as understand localized cold injury vs generalized hypothermia (with possible loss of central pulses.)

Check out www.nycremsco.org or the protocol binder on North Side for more.

John Su