Chemical Injuries - January 10, 2022

Good morning,

Last week we discussed high acuity low-frequency events that can have a significant impact on a patient’s outcome in which the EMS provider may have little experience. These are serious events that one doesn’t treat every day or have the opportunity to build up a significant amount of experience in managing.

We have all heard the mantra “Time is Muscle” when dealing with STEMI patients. It is clearly a high-acuity and low-frequency patient population. The same holds true for acute stroke patients, where the clock is ticking for obtaining a CAT scan and perhaps providing thrombolytic (clot buster) medications, or clot removal procedures, to dramatically improve the patient’s outcome.

Another group of patients, in which the time to treatment can significantly impact the patient’s outcome, is those with a chemical splashed in their eye. Chemical injuries to the eye can occur at home with cleaning supplies or in the industrial setting whereas part of either a manufacturing or a cleaning process.

The cornea is a very thin, clear, covering overlying the pupil and the colored part of the eye. Chemicals can rapidly destroy the cornea, resulting in permanent damage or blindness. This injury process can occur rapidly. Just like treating the patient of an MI or a stroke where time is critical, EMS can save the patient’s eyesight through rapid treatment.

The emergency treatment for a chemical exposure to the eye is rapid, copious irrigation of the eye with normal saline. Treatment should be performed by EMS as rapidly as possible, and one shouldn’t wait for the care to be initiated within the emergency department. Unfortunately, irrigating a patient’s often painful and burning eye is much easier said than done as patients tend to pinch their eyes closed since opening it hurts.  

The Morgan Lens ® is an excellent device to assist in rapid and effective eye irrigation and helps save corneas and vision. It looks like a soft contact lens with a short IV tubing attached up to the center of it. If the patient doesn’t have any allergy to the medication, one can instill two drops of eye anesthetic into the injured eye. Tetracaine (Pontocaine) or proparacaine (Alcaine)  are often used for this purpose. This reduces the patient’s eye pain and facilitates irrigation of their eye. One then attaches a one-liter bag of normal saline to an IV infusion set and attaches that to the Morgan Lens tubing. Next, start the solution flowing and gently open the patient’s eyelids. Gently place the Morgan Lens on the eye and let the eyelids close over the lens holding it in place with the little Morgan Lens tubing stick out between the patient’s eyelids.

Let the normal saline solution flow, and it will easily and copiously irrigate the patient’s eye. The Morgan Lens floats on a thin layer of normal saline and doesn’t actually touch the patient’s cornea itself. Gently open the patient’s eyelids and lift the Morgan Lens off their eye, with the solution still flowing, before the IV bag is empty.

Thankfully, chemical exposures to the eyes are rather uncommon. Yet the damage they cause to the eye can occur very rapidly and can be devastating, resulting in permanent blindness. Fortunately, EMS can rapidly intervene safely and easily by irrigating the patient’s eye and limiting any long-term injury.

Earning a spot on our list of high acuity, low-frequency events, chemical eye burns can be devastating. With prompt EMS care, using the Morgan Lens, one can truly impact the patient’s outcome in a beneficial manner!  

Jay Carter, MSEE, MD, FACEP, FAEMS

Emergency Medicine and EMS Physician

 Cyanide Poisoning - January 17, 2022

Good morning,

We have been reviewing several High Acuity Low-Frequency events. These are events that can have a significant impact upon a patient’s outcome and yet the EMS provider may have little experience. 

In the case of structure fires, which are relatively common, being handed an unconscious patient from within the structure is, fortunately, a rare event.

Standard EMS care for an unconscious patient in this setting generally entails managing the patient’s airway, and given the risk of carbon monoxide poisoning, it makes sense to place the patient on 100% Oxygen. Oxygen alone, however, won’t treat the cyanide poisoning that is often present along with the carbon monoxide poisoning when treating patients from a fire scene. Cyanide poisoning can also be encountered in accidental industrial chemical exposures, as it is frequently found in the industrial setting.

One doesn’t often casually browse through the HazMat section of the protocol, but there is a specific protocol for treating cyanide poisoning (cyanide exposure). It is one of the relatively few poisonings for which a specific antidote exists but is easily overlooked.

As with all HazMat exposures, the initial steps in care include stopping ongoing exposure and decontaminating the patient of any residual material. There is no field test for cyanide poisoning, so the diagnosis is made clinically from the setting. Given the concern for cyanide poisoning, and a patient with headache, hypotension, tachypnea, weakness, dizziness, or an altered level of consciousness, including seizures or coma, one should proceed with the cyanide antidote.

The cyanide poisoning antidote is the Cyanokit (hydroxocobalamin). The hydroxocobalamin binds with the cyanide forming cyanocobalamin, which is harmless and excreted in the patient’s urine. The usual adult dose is hydroxocobalamin 5 g IV administered over 15 minutes. The drug comes packaged in a 250 ml glass bottle(vial)along with its own infusion set, Add 200 ml of normal saline to the glass bottle to mix the powdered medication into a solution. Repeatedly inverting the bottle for at least one-minute aids in the mixing, and the solution will be a dark red color. Don’t shake the bottle as this fills the solution with small air bubbles. Although a second 5 g dose can be administered, it would likely be given in the emergency department if needed. Pediatric doses are provided within the HazMat Cyanokit (hydroxocobalamin) administration protocol. 

Lastly, while reviewing the presentation of an unconscious patient extricated from a fire scene, remember that basic pulse oximeters don’t measure carboxyhemoglobin or HbCO for carbon monoxide poisoning. A patient could have a 50% carboxyhemoglobin level, and the pulse oximeter could still read in the upper 90’s %. The Rad-57® pulse oximeters, either the stand=alone units or those incorporated into some cardiac monitors, can measure the patient’s carboxyhemoglobin level. A typical normal level is ≤ 5% HbCO.

In summary, remember that the confused, seizing, or unconscious patient pulled from a fire scene (or an industrial chemical exposure patient with concern for cyanide poisoning) warrants both 100% oxygen and prompt treatment with the Cyanokit.

Jay Carter, MSEE, MD, FACEP, FAEMS

Emergency Medicine and EMS Physician

Frostbite - January 24, 2022

Good morning,

January is a great time for a refresher regarding frostbite!

Frostbite is most easily defined as frozen tissue. The face (cheeks, nose, ears, etc.), hands, and feet are the most commonly involved areas. Frostbite occurs when there is exposure to very cold weather, i.e., when the temperature is well below freezing. The incidence of frostbite injury patients increases significantly when the temperature is ≤ 10 °F, (-23°C). With these very cold temperatures, the tissue cools down faster than the circulation and metabolism can warm it up, and the tissue temperature drops below its own freezing point. When this happens, ice crystals form within the tissue, and the local circulation decreases or stops, further exacerbating the freezing of the tissue. Clinically one recognizes this as cold, pale, waxy tissue that is firm and not soft and pliable. As the frostbite occurs, the patient might experience numbness, burning, and pain, but often these systems don’t manifest themselves until the tissue starts to warm up and thaw out.

If the weather is windy, such as during a blizzard, the risk of an individual sustaining frostbite is even greater. This is due to the wind increasing convective heat losses (the wind blowing across the tissue increasing its heat loss) and the wind decreasing the thermal insulating capability of one’s clothing. 

Although one might expect to see frostbite in homeless individuals who cannot escape the cold, those working outdoors (shoveling a driveway), walking to a bus or subway station, or those stuck in a broken-down car, etc., EMS personnel are also at risk. When the weather is really cold, salt and other road deicers lose their effectiveness. Icy roads can lead to MVAs, and this can lead to sustained cold exposure during patient extrication activities. As the EMS personnel might well be focused on on-scene management, extrication, and patient care, they are even less likely to recognize frostbite happening to themselves. If you see your co-worker’s ears or the tip of their nose turning white, it would be good for them to take a break and warm up in the back of the squad (winter weather scene rehab).

A day or two after the initial freezing event, a patient with a frostbite injury may have tissue that is swollen (edematous)and erythematous(reddened). There can also be fluid-filled blisters overlying the involved area. Severe frostbite can lead to irreversible tissue death and black, necrotic tissue, but this typically happens over a period of days to weeks.

Frostbite treatment is easy. Stop the cold exposure and get the individual into a warm environment. Gently remove any wet clothing. Assess the patient for any other conditions and transport. It is generally recommended to leave rewarming the frostbitten tissue to the Emergency Department. Rewarming is usually performed rather quickly and can be quite painful. It is also critical that the frozen, frostbitten, tissue isn’t partially thawed and re-frozen, as this is known to significantly worsen the outcome. Also, treat the frostbitten tissue very gently and carefully. Do not rub the area to “help warm it up”. The pressure and motion of the tissue cause increased tissue injury when the tissue is frozen.

Prevention is always the best medicine! If you, your crew, or your family and friends find themselves outdoors in the very cold weather, be sure to dress appropriately and prevent skin from being directly exposed to the cold air (wear a hat, scarf, quality gloves, and dry, waterproof, insulated boots). Limit one’s cold exposure and watch for the early onset of frostbite in yourself and those around you. 

Winter recreational activities, such as skiing, snowboarding, skating, and ice fishing, can all be great fun. Just make sure to dress appropriately, warm-up often, and stay healthy!

Jay Carter, MSEE, MD, FACEP, FAEMS

Emergency Medicine and EMS Physician

Scene Safety - January 31, 2022

Good morning,

Today’s Monday Morning Message is the most important one we are covering this month, and yet it isn’t to be found within the 2022 EMS Protocol! Today’s topic is Rule #1 in EMS: Scene Safety.

Scene safety is everyone’s responsibility. It is especially important for the seasoned crew members to keep their eyes on the EMS student or newcomer in the department. They might be focused on their patient and less focused on the dangers around them. Such tunnel vision can affect everyone, solidifying the need to have a list of potential dangers that one can run through in their mind as they first evaluate a scene. This is part of maintaining one’s situational awareness.

When responding to an MVA, our goal is to take care of the injured patients, not to become one ourselves. Unfortunately, law enforcement officers and FF/EMS personnel are killed every year by passing motorists, and far too many are injured.   It is likely due to the law enforcement officers often being the first on the scene, before the scene traffic has been controlled, and due to FF/EMS personnel having a higher rate of compliance with wearing hyperfluorescent reflective vests on the scene. A highly visible individual is more likely to attract the attention of a distracted driver than is an individual in a dark navy-blue uniform, especially at dusk, dawn, or throughout the night, when they are essentially invisible.

Upon evaluating an MVA scene, it is important to look for wires, fires, and traffic. Wires can be a silent killer. They can be easily overlooked. Looking UP as well as around the scene is a must. The number of wires on a residential pole can be staggering, with power, telephone, cable, fiberoptic, and ground wires also come into play. In addition, remember that even if a power line appears to be dead (un-energized), the goal of the power company is to minimize service interruption to their customers. Many power lines can be energized from either direction, and the power company might re-energize a line several times to restore power to a region. This works well for a simple tree branch disrupting service, but it can prove fatal to first responders on a scene.

Scene traffic flow can sometimes be a point of contention between law enforcement and Fire/EMS. Law enforcement often wants to minimize disruption of the traffic flow.  Keeping even one lane open is a huge help in this regard. Yet traffic flowing past a scene puts the rescuers at an increased risk of being injured. Having a safe zone to conduct patient extrications and patient care is key. Airbags that haven’t ) deployed and electric & hybrid vehicle wiring can pose additional risks at the scene of an accident.

When responding to a residence, it is important to include the presence of “hostiles” and animals, (dogs) in one’s scene assessment. An openly hostile family member, patient’s friend, or even a passer-by can put the provider at risk for injury and impede the ability to care for their patients. There is no shame in retreating to a safe location and awaiting law enforcement backup. Remember, you can’t care for your patient if you or your partner are injured on the scene.

Can you breathe on your scene? Astronauts wear spacesuits. Firefighters wear SCBAs. What do you have? Being aware of the atmosphere is second nature to those with HazMat training and hopefully comes to mind when entering a “confined space” environment. The presence of toxic gases and the lack of oxygen in the surrounding atmosphere can occur in residential dwellings, fast food restaurants, industrial facilities, computer rooms, on fire scenes, and elsewhere. Having a small, handheld four gas meter clipped to one’s belt or EMS gear bag is considered a best practice.

Finally, there are over twenty-one million concealed firearm permit holders in the USA. That number doesn’t include law enforcement personnel, those who carry a gun without a permit, and those in states where data reporting is not required. Assuming the individual with the gun isn’t intentionally trying to harm you (see “hostiles” above), what is the individual’s mental status? Having a policy in place helps prepare.

Other scene safety items include wearing seatbelts in the back of the squad, provider fatigue, and the more familiar PPE (gloves, masks, needle stick precautions, etc.) topics. Although many training sessions briefly mention Rule #1, scene safety, it can be worthwhile to review what it entails! Remember, the goal is to go home intact and healthy at the end of one’s shift! Keep your eyes open and maintain your situational awareness for both you and your partner’s sake!

Jay Carter, MSEE, MD, FACEP, FAEMS

Emergency Medicine and EMS Physician