Good morning everyone:

Some of you may not have been able to attend the meeting this morning but there are IMPORTANT changes that you need to be aware of regarding the new STATEWIDE PROTOCOLS that are in effect as of June 2013.

–> REMEMBER – There is a copy of the Tri-County Protocols at the EMS Desk in a large black binder. 

Also, there are (2) documents in PDF form for you to review that are the executive summaries of all the differences between the new and older protocol guidelines that you should be familiar with.

“CODE SMOKE” – If there is a suspected smoke inhalation victim from a house or car fire, we need to standardize the tests that we order between our providers. I am working to get this added as an order set in EPIC, but in the mean time, please make sure to order:

If there is an EMS radio report of:
  • unconscious victim, Downed Firefighter or,
  • atmospheric confirmation of HCN Smoke Inhalation/Toxic gas exposure with chest pain or,
  • >3 EMS transported patients from a single scene with hx of smoke exposure
“Code Smoke” departmental page overhead
 –> Triage, cardiac monitor, EKG, pulse oximetry, 100% NRB, saline lock (IV present), seizure precautions; contact Critical Care Ground Transport RN; Contact the Charge RN and goal to group patients together; Contact Respiratory Therapy (RT) if >3 patients and group oxygen therapy is needed
 –> Obtain immediate SpCO level with CO-oximeter
–> Obtain immediate glucose via bedside accucheck
SEVERITY ASSESSMENT
Use the following table to idenity the risk group for this patient
  • HIGH RISK (requires only (1) feature to classify as HIGH RISK)
    • Loss of consciousness (either upon arrival or by history)
    • syncope (witnessed)
    • Chest pain (either upon arrival or by history)
    • Acute EKG changes (ST-Twave changes, arrhythmias, new LBBB)
    • Hypotension and/or shock
    • Urinary and/or fecal incontinence
    • Bradypnea (based on age)
    • Blindness (ex cortical blindness)
    • Reported or apparent pregnancy (at any gestational age)
    • Confirmed presence of cyanide products (confirmed by FD gas monitoring)
    • Rapid lactate assay > 10mmol/L
    • SpCO or COHb >40%
  • INTERMEDIATE RISK (any of the following features and DO NOT meet the HIGH RISK features)
    • Elderly
    • Comorbid conditions (ex heard disease, COPD, blood dycrasisas)
    • Confined space situation (ex structure fire, entrapment)
    • Chemical attack/terroristic act
    • Altered mental status/confusion
    • Red/Grey skin discoloration
    • Reported death in same building
    • Confirmed presence of cyanide products on scene
    • Nausea and/or vomiting/diarrhea (acute onset)
    • SpCO or COHb >20% and <40%
    • Rapid blood lactate assay >2mmol/L but <10mmol/L
  • LOW RISK (No HIGH or INTERMEDIATE RISK feature)
    • Possible CO exposure without complaints (SpCO or COHb <20%)
TESTING (* – physician discretion)
  • LAB STUDIES
    • CBC
    • basic metabolic (renal) panel
    • CPK
    • Troponin
    • Lactate
    • Carboxyhemoglobin
    • Cyanide
    • Ethanol*
    • Urine Drug Screen*
    • Liver functions*
    • Coagulation panel*
    • BNP*
    • ABGs*
    • Methemoglobin*
  • IMAGING STUDIES
    • CXR*
    • CT Brain (w/o contrast)*
    • MRI Brain*
  • OTHER STUDIES
    • EKG
    • repeat EKG*
  • MEDICATIONS
    • high flow oxygen at 15Lpm by NRB
    • Cyanocobalmin (Cyanokit) 5grams (2 x 2.3gram vials in NS) IV over 15 mins*
    • Repeat cyanococalamin (Cyanokit) 2.5 grams IV over 15 mins*
    • Sodium thiosulfate 12.5 grams (50mL) IV at 3-5 mL/min*
    • Diphenhydramine 25mg IV push*
  • MONITORING
    • cardiac monitoring
    • pulse oximetry
    • end-tidal CO2*
    • SpCO monitor (LifePack 15 model)*
  • CONSULTS
    • Cardiology*
    • Intensivist/Critical Care
    • Hospitalist*
    • CDU/Clincal Decision Unit*
    • Hyperbaric therapy/Chamber*

CyanoKit – is going to be given by the Delta and East Lansing Fire Dept PRIOR to contacting the ED physician if there is a high clinical suspicion for a severe smoke inhalation injury. This is a very useful medication with a very low risk side effect profile (they will have a darker red colored urine similar to pyridium for a few days)

Do you want more information? Here is the ACEP discussion (click here) or the Cyanide Coalition (click here)