June 2020

KCEMS RoundUp

Closing the Loop

Pre-Hospital Use of CyanoKit

Nicholas Cozzi, MD MBA

Chief Resident/ PGY-2, Emergency Medicine

Spectrum Health / Michigan State University

What is cyanide?

Cyanide (CN) is a rapid acting, highly toxic compound that is

life threatening. When carbon and nitrogen ignite at ex-

tremely hot temperatures, this can result.

Where is cyanide found?

Cyanide is found in the combustion of plastics, synthetics,

wool, and most commonly enclosed house fires via smoke

inhalation.

What is the mechanism of action of CN?

Cyanide interrupts cellular respiration and subsequent ATP production leading to buildup of lactic acidosis

What are the symptoms of CN?

The symptoms of CN can be nausea, vomiting, all the way to profound AMS, lactic acidosis, and shock.

What is cyanokit and how does it work?

Cyanokit, or hydroxocobalamin, is a compound administered to treat cyanide poisoning. A single dose Cyanokit acts

to form cyanocobalamin, a non-toxic and renally excreted compound. It causes the urine to become red.

Cyanokit is a known compound used to treat cyanide poison-

ing and is very efficacious. The question of whether Cyanokit

is appropriate to be used in the pre-hospital environment re-

mains. It has been used since 1980 since Europe and became

FDA approved in 2006. A 2017 study to EMS providers indicated that 46% of all pre-hospital EMS respondents used

FYI : The KCEMS protocol that allows for Cyanokit usage is 10.5 - Cyanide Exposure.

Cyanokit and only 20% had formal protocols regarding this ([1]). But, what is the evidence regarding Cyanokit use

for cyanide poisoning? A retrospective study out of Vanderbilt University described decreased ventiltor depend-

ence times (4 days vs. 7 days), decreased pneumonia rates, and decreased length of stay in the ICU (6 days vs. ten

days)([2]) With this data in hand, should EMS providers be routinely administering Cyanokit for suspected cyanide

poisonings? The answer may seem obvious but other considerations must be accounted. For example, does a local

municipality or EMS service line have enough volume to warrant having Cyanokit on their rigs? Per Annals of

Emergency Medicine, the maximum shelf life is 36 months and one of the most pressing issues with Cyanokit was

lack of full understanding of safety profiles and lack of repeatable randomized controlled trials for EMS use of Cy-

anokit. Furthermore, one article finds it reasonable to administer to comatose patients, those in cardiac arrest, or

have clear signs of shock. Finally, if given, it should be given as rapidly as possible – perhaps in the field[3]. One po-

tential reason to carry the Cyanokit pre-hospital is the lack of a rapid test assay available in the field to rapidly

identify cyanide poisoning – it’s a clinical diagnosis and treated empirically. Many fire departments across the na-

tion are starting to carry this antidote or perhaps carrying a few doses in a battalion chief or EMS supervisor’s ve-

hicle. Cost is an issue as well, with one vial of 5 grams costing near $1,000. As we review this medication and the

issues surrounding it being carried, cost and rate of utilization are significant issues. This issue is worth continued

discussion Thank you for what you do every day. We appreciate it. It matters. -Nicholas Cozzi

[1] Prehospital hydroxocobalamin for inhalation injury and cyanide toxicity in the

United States – analysis of a database and survey of EMS Providers. Purvis et al.

Annals of Burns Fire Disasters. June 30, 2017. 30(2): 126–128.

[2] Utility and Outcomes of Hydroxocobalamin Use in Smoke Inhalation Patients.

Nguyen et al. Burns. February, 2017. 43(1).

[3] Is Hydroxocobalamin Safe and Effective for Smoke Inhalation? Searching for

Guidance in the Haze. Annals of Emergency Medicine. Erdman et al. June 2007.

Volume 49, 6 (814-816)

We are seeking membership for the KCEMS Education Committee

This committee will study information and data provided by agencies and develop education plans based

on those needs. Education Committee Meetings will be held on the second Thursday of odd months

at 1pm, starting this July.

If you’re interested in joining, a short committee application can be found here:

https://www.surveygizmo.com/s3/5345531/Kent-County-EMS-Committee-Application

KCEMS Education Committee

Cyanokit Locations - Kent County:

• Wyoming FD

Ottawa County:

• Wright-Tallmadge FD • Grand Haven Twp. FD • Holland FD • Georgetown e-unit

Febrile Seizure for EMS Review

Dr. Peter Nguyen, 4th Year Resident

Overview

• Most common between age groups 6 months to 6 years of age

• 2%-5% of all children will have febrile seizures

• There does seem to be a hereditary component to febrile seizures i.e.

family history

• Febrile seizures are divided into 2 categories:

Simple: generalized tonic-clonic seizures that last < 15 mins,

do not recur within 24 hours, do not localize to any specific body part.

Complex: Any febrile seizure that; lasts > 15 mins, OR recurs within 24 hours, OR localizes to a specific

body part

Signs and Symptoms

Out of hospital management

• ABCs and supportive care

• KCEMS protocol (use MI-MEDIC cards)

Perform a Medication Cross check prior to any medication administration

IM versed 0.1 mg (max 10mg)1

Establish IV/IO access if needed

If IV access established and no IM versed given → versed IV 0.05mg/kg

(max 5mg)

• Blood glucose (use MI-MEDIC card when available)

If <40mg/dL in a patient <1yo or <60mg/dL >1yo, administer dextrose

0.5g/kg

<2mo: dextrose 12.5%

>2mo <6yo: dextrose 25%

>6yo: dextrose 50%

Unable to start IV → proceed to glucagon

< 4 yo: glucagon 0.5mg IM

> 4 yo: glucagon 1mg IM

“Simple” febrile seizures

Majority of febrile seizures are

simple

< 15 mins and do not recur

Will be generalized tonic-clonic

With or without post-ictal

“Complex” febrile seizures

>15 mins and will recur

Focal findings

Disposition

• Patients with simple febrile seizures who have returned to neurologic baseline will likely be discharged home.

• Patients with simple febrile seizures rarely are started on antiepileptic medication even for recurrent febrile sei-

zures.

• Complex febrile seizures may require more investigative work including lab work and possible head imaging.

Other Pearls

• Kids who have one febrile seizure are at higher risk for more febrile seizures (30% recurrence risk)

• The overall risk of epilepsy in the general population is 1%. In kids who have febrile seizures, the risk increases by

1% to 2% overall.

• Although fevers can lead to seizures. Antipyretics do not prevent febrile seizure recurrence2

1. Silbergleit R, et al. "Intramuscular versus Intravenous Therapy for Prehospital Status Epilepticus". The New England Journal of Medicine. 2012. 366(7):591-600

2. Rosenbloom E, et al. Do antipyretics prevent the recurrence of febrile seizures in children? A systematic review of randomized controlled trials and meta-analysis. Eur J

Paediatr Neurol. 2013;17(6):585‐588. doi:10.1016/j.ejpn.2013.04.008

QI Topic Review

We wanted to take a moment to help discuss a couple of topics that have come into the office through

case reviews.

Charlie Trauma Patients – Over the last several months, mul-

tiple hospitals in our region have reported that several Charlie

level trauma patients have been transported to hospitals and

have not received both EMTrack and MedCom Radio/phone

reports. This requirement was changed with the July 2019

protocol revisions due to the wide variety of hospital criteria

used to determined activation levels. So, to not have all of

the EMS providers to remember all of the individual hospital

criteria radio reports for Charlie level trauma and higher pa-

tients need to have both reports submitted. If you would like

to review the protocol that covers this change is Regional Sys-

tem Protocol 8.42 Communications Policy.

High Priority Interfacility Transfers – Normally interfacility transfers going to Emergency Departments do

not require EMTrack or MedCom Radio/Phone Report, however, we have been asked to encourage EMS

Providers to call MedCom reports for types of calls that would receive a hospital alert if the call was coming

from a scene. Types of calls this request was made for are STEMI, CVA, Trauma.

More Support from our Community

American Legion Post 179

Bier Distillery

Brewery Vivant

Collen Vorel, Executive Chef for Catholic Charities of

West Michigan

Downtown Market Education Foundation

Family of Lindsay Chandler

Family of Michael Miller

Festida Foods

Fresh Coast Kitchens

Go Java Coffee

GR Fire

GR Police

Jason and Elsbeth Heyboer

Kent ISD

Mayan Buzz Café

Metro Health

New Life Church/Mrs. Jaffas

Sam’s Club Holland

Sarah Mitchell/Mary Kay

School Emergency Response Coalition (SERC) - Kevin &

Vickie McGraw

Sears Architects

Spartan Nash/Family Fare (Leonard St.) Bakery

Spectrum Health Donor Network

Susan Samples/Chef Jenna—Amore Trattoria Italiana

The Oven Mitt

The Salvation Army

Tri Tech Tooling

Many organizations and individuals continue to donate supplies, food and other items to our agencies. We

are grateful for their thoughtfulness and generosity.

If there’s a business that has provided help for your department, please email Caitlin at

cmoulds@kcems.org, so that we can acknowledge them in a future newsletter.

Medical Educator (I/C)

Program Course dates: Meets Fridays & Saturdays 8a-5p

September 11th & 12th, 25th & 26th

October 2nd & 3rd, 16th & 17th, 30th &

31st

November 6th & 7th, 20th & 21st

December 4th & 5th, 11th & 12th

Course Location:

Plainfield Township Fire Department

4343 Plainfield Ave NE, Grand Rapids

Cost:

$1800.00

(Includes Textbook: Foundations of Educa-

tion: An EMS Approach - 3rd Edition)

Payment Plans available by request

Instructors:

Doug Smith

Kim Schrader

Course Description

This program is designed to assist the professional EMS provider in developing the skills and techniques required to efficiently and effectively manage and co-ordinate the classroom.

In addition to the teaching component of the program, students are also pre-pared to coordinate education programs, including proper documentation and management of an EMS education program. The entry-level EMS educator en-gages in learner-centered, outcome-based best-practices articulated by the specified curriculum. Successful completion of the program provides the oppor-tunity for building and developing teaching skills on a solid foundation that can lead to higher levels of instructional and administrative expertise.

In addition, a minimum of thirty (30) hours of mentored Student Teaching are required. Student Teaching must occur outside of the program and under the direction and supervision of a licensed I/C.

Students who successfully complete this program will be eligible to take the MDHHS-BETP Emergency Medical Services Instructor-Coordinator exam.

For more information or to register, visit:

www.bdi-training.com/medical-educator

“Advancing the art and science of providing good medicine in bad situations”

*This program is pending MDHHS approval