Talvikki
Elementalist
- Nov 18, 2021
- 818
This article discusses the dilemma in ambulance care for patients with sodium nitrite poisoning, where the choice between 'stay and play' and 'scoop and run' is influenced by the need for speed in administering the antidote Methylene Blue. It emphasizes the importance of a thoughtful approach, recommending the deployment of two ambulances and a Mobile Medical Team (MMT) as a primary response in known cases of sodium nitrite poisoning. For unknown cases, 'scoop and run' is advised, followed by the secondary deployment of a second ambulance and an MMT if response time justifies arrival at a hospital with Methylene Blue. Training of ambulance professionals and the rapid administration of Methylene Blue are highlighted for improving the quality of care.
Case
At the Ambulance Care Dispatch Center, a report of a resuscitation is received. In response, two ambulances are dispatched. The first ambulance finds a patient in need of resuscitation at a residential address, displaying a distinctive cyanotic color. The ambulance nurse follows the protocol Adult Resuscitation. The second ambulance arrives, and resuscitation continues on-site. After all necessary procedures, the second ambulance nurse inquires with the patient's present partner and discovers the possibility of ingested sodium nitrite. No further details are known. Due to persistent asystole, the crew decides to cease resuscitation after 20 minutes. The family doctor is called to confirm the death. The resuscitation is concluded, and the ambulance personnel departs from the location. The first ambulance nurse documents the care provided.
A few days after the case, it is confirmed that indeed there was a fatal sodium nitrite intoxication.
Several weeks later, a debriefing takes place, raising questions about the decision to continue resuscitation on-site and whether consideration was given to transporting the patient as quickly as possible to a specialized hospital with an available antidote.
Sodium nitrite
In 2017, this substance made headlines through the Last Will Cooperative (organisation for the 'right to die), which describes it as a 'cheap, legal substance leading to a humane death.' Sodium nitrite, NaNO2, is used as a preservative in the meat and fish industry. Nitrite, the active ingredient, transforms into nitric oxide in the body, leading to arterial and venous vasodilation, resulting in severe hypotension. Nitrite also causes hemoglobin in the body to transform into methemoglobin. While hemoglobin binds oxygen to erythrocytes, methemoglobin prevents oxygen binding, resulting in tissue hypoxemia, manifested by significant peripheral and central cyanosis. The substance takes effect within minutes and peaks within 30-60 minutes.
Ambulance Care Protocol
In ambulance care, ambulances are occasionally dispatched for patients with sodium nitrite intoxication. Since there is no protocol for this specific intoxication, every ambulance care professional follows the intoxication protocol and the resuscitation protocol.
The general intoxication protocol outlines the necessity of gathering required information and consulting the National Poison Information Center for advice. The resuscitation protocol states that resuscitation may be discontinued after twenty minutes of persistent asystole. However, the question arises as to whether these protocols are applicable when there is very limited time available to administer the antidote Methylene Blue. This antidote is not available in the ambulance, whereby the patient will not respond to treatment within the current protocols for intoxication and/or resuscitation.
Within ambulance care, there are two choices regarding the approach upon the patient's arrival: applying interventions and then leaving the location, also known as 'stay and play,' or not applying interventions and leaving the location as quickly as possible, referred to as 'scoop and run.' The patient's condition and the treatment options available on-site determine the choice between 'stay and play' or 'scoop and run.'
If the patient requires resuscitation, a Mechanical Thoracic Compression (MTC) device can be applied to ensure Basic Life Support (BLS) during transport.
Mechanical Thoracic Compression (MTC) is a technique where an automated device is used to perform chest compressions during resuscitation. The goal is to maintain blood circulation in patients who have experienced cardiac arrest. The MTC device can provide consistent and powerful compressions, which can be particularly beneficial during the transport of the patient.
Conclusion
Does 'scoop and run' in the prehospital setting lead to a higher chance of survival than following the protocol for intoxication and/or resuscitation in patients with confirmed sodium nitrite intoxication?
Patients with sodium nitrite intoxication have the greatest chance of survival when administered the antidote Methylene Blue intravenously within 30-60 minutes of ingestion. Treatment according to the intoxication and/or resuscitation protocol on-site results in a delay in effective care. Since the only effective treatment is the intravenous administration of Methylene Blue, and this medication is not available on the ambulance and is unlikely to be available due to the low incidence, additional care is needed from a Mobile Medical Team (MMT) or a hospital with Methylene Blue in stock. Administration by an MMT can only take place after considering whether the response time outweighs 'scoop and run.'
MMT stands for Mobile Medical Team. It typically refers to a specialized medical team that can be dispatched to the scene of an emergency, often by helicopter or other rapid response vehicles. MMTs are equipped to provide advanced medical care and interventions, especially in situations where immediate and specialized medical attention is required.
Advice
In some, especially urban, regions where response times to the patient and to the hospital are short, the use of a Mobile Medical Team (MMT) can add value primarily when deployed for reports indicating clear evidence of sodium nitrite intoxication.
Not every region has short response times to the patient and hospital. During transportation, consideration should be given to the choice of the hospital. Not all hospitals have Methylene Blue in stock. Additionally, not every region has a Mechanical Thoracic Compression (MTC) device available in the back of an ambulance for effective chest compressions; secondary deployment of an MMT and a second ambulance with rendezvous could then be a consideration.
To improve the quality of care, the following advice has been formulated based on this research: if it is already known at the time of the report that it involves sodium nitrite intoxication, deploy two ambulances and a Mobile Medical Team (MMT) as a primary response. If it is only discovered upon arrival that it is a sodium nitrite intoxication: 'scoop and run,' and secondarily dispatch a second ambulance via rendezvous and an MMT via rendezvous if the response time justifies the arrival time to a hospital with Methylene Blue. Be prepared for rapid deterioration of the patient and the need for resuscitation.
Researchers have advised organizations to thoroughly train their ambulance professionals to prioritize adequate recognition, with (hetero)anamnesis being crucial. Key symptoms include rapidly developing cyanosis and the chocolate-colored discoloration of the blood.
It is essential to map out the fastest options for intravenous administration of Methylene Blue for a patient in each region. According to the researchers, the above protocol will be an addition to the current intoxication protocol for a patient with a high suspicion or confirmed sodium nitrite intoxication.
Source: Ambulance Care Netherlands
Case
At the Ambulance Care Dispatch Center, a report of a resuscitation is received. In response, two ambulances are dispatched. The first ambulance finds a patient in need of resuscitation at a residential address, displaying a distinctive cyanotic color. The ambulance nurse follows the protocol Adult Resuscitation. The second ambulance arrives, and resuscitation continues on-site. After all necessary procedures, the second ambulance nurse inquires with the patient's present partner and discovers the possibility of ingested sodium nitrite. No further details are known. Due to persistent asystole, the crew decides to cease resuscitation after 20 minutes. The family doctor is called to confirm the death. The resuscitation is concluded, and the ambulance personnel departs from the location. The first ambulance nurse documents the care provided.
A few days after the case, it is confirmed that indeed there was a fatal sodium nitrite intoxication.
Several weeks later, a debriefing takes place, raising questions about the decision to continue resuscitation on-site and whether consideration was given to transporting the patient as quickly as possible to a specialized hospital with an available antidote.
Sodium nitrite
In 2017, this substance made headlines through the Last Will Cooperative (organisation for the 'right to die), which describes it as a 'cheap, legal substance leading to a humane death.' Sodium nitrite, NaNO2, is used as a preservative in the meat and fish industry. Nitrite, the active ingredient, transforms into nitric oxide in the body, leading to arterial and venous vasodilation, resulting in severe hypotension. Nitrite also causes hemoglobin in the body to transform into methemoglobin. While hemoglobin binds oxygen to erythrocytes, methemoglobin prevents oxygen binding, resulting in tissue hypoxemia, manifested by significant peripheral and central cyanosis. The substance takes effect within minutes and peaks within 30-60 minutes.
Ambulance Care Protocol
In ambulance care, ambulances are occasionally dispatched for patients with sodium nitrite intoxication. Since there is no protocol for this specific intoxication, every ambulance care professional follows the intoxication protocol and the resuscitation protocol.
The general intoxication protocol outlines the necessity of gathering required information and consulting the National Poison Information Center for advice. The resuscitation protocol states that resuscitation may be discontinued after twenty minutes of persistent asystole. However, the question arises as to whether these protocols are applicable when there is very limited time available to administer the antidote Methylene Blue. This antidote is not available in the ambulance, whereby the patient will not respond to treatment within the current protocols for intoxication and/or resuscitation.
Within ambulance care, there are two choices regarding the approach upon the patient's arrival: applying interventions and then leaving the location, also known as 'stay and play,' or not applying interventions and leaving the location as quickly as possible, referred to as 'scoop and run.' The patient's condition and the treatment options available on-site determine the choice between 'stay and play' or 'scoop and run.'
If the patient requires resuscitation, a Mechanical Thoracic Compression (MTC) device can be applied to ensure Basic Life Support (BLS) during transport.
Mechanical Thoracic Compression (MTC) is a technique where an automated device is used to perform chest compressions during resuscitation. The goal is to maintain blood circulation in patients who have experienced cardiac arrest. The MTC device can provide consistent and powerful compressions, which can be particularly beneficial during the transport of the patient.
Conclusion
Does 'scoop and run' in the prehospital setting lead to a higher chance of survival than following the protocol for intoxication and/or resuscitation in patients with confirmed sodium nitrite intoxication?
Patients with sodium nitrite intoxication have the greatest chance of survival when administered the antidote Methylene Blue intravenously within 30-60 minutes of ingestion. Treatment according to the intoxication and/or resuscitation protocol on-site results in a delay in effective care. Since the only effective treatment is the intravenous administration of Methylene Blue, and this medication is not available on the ambulance and is unlikely to be available due to the low incidence, additional care is needed from a Mobile Medical Team (MMT) or a hospital with Methylene Blue in stock. Administration by an MMT can only take place after considering whether the response time outweighs 'scoop and run.'
MMT stands for Mobile Medical Team. It typically refers to a specialized medical team that can be dispatched to the scene of an emergency, often by helicopter or other rapid response vehicles. MMTs are equipped to provide advanced medical care and interventions, especially in situations where immediate and specialized medical attention is required.
Advice
In some, especially urban, regions where response times to the patient and to the hospital are short, the use of a Mobile Medical Team (MMT) can add value primarily when deployed for reports indicating clear evidence of sodium nitrite intoxication.
Not every region has short response times to the patient and hospital. During transportation, consideration should be given to the choice of the hospital. Not all hospitals have Methylene Blue in stock. Additionally, not every region has a Mechanical Thoracic Compression (MTC) device available in the back of an ambulance for effective chest compressions; secondary deployment of an MMT and a second ambulance with rendezvous could then be a consideration.
To improve the quality of care, the following advice has been formulated based on this research: if it is already known at the time of the report that it involves sodium nitrite intoxication, deploy two ambulances and a Mobile Medical Team (MMT) as a primary response. If it is only discovered upon arrival that it is a sodium nitrite intoxication: 'scoop and run,' and secondarily dispatch a second ambulance via rendezvous and an MMT via rendezvous if the response time justifies the arrival time to a hospital with Methylene Blue. Be prepared for rapid deterioration of the patient and the need for resuscitation.
Researchers have advised organizations to thoroughly train their ambulance professionals to prioritize adequate recognition, with (hetero)anamnesis being crucial. Key symptoms include rapidly developing cyanosis and the chocolate-colored discoloration of the blood.
It is essential to map out the fastest options for intravenous administration of Methylene Blue for a patient in each region. According to the researchers, the above protocol will be an addition to the current intoxication protocol for a patient with a high suspicion or confirmed sodium nitrite intoxication.
Source: Ambulance Care Netherlands
