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Fire Ground Carbon Monoxide: EMS Responds

Fire Ground Carbon Monoxide: EMS Responds. Randolph Mantooth and Mike McEvoy, PhD, NRP, RN, CCRN EMS Coordinator – Saratoga County, New York EMS Editor – Fire Engineering Magazine. www.thesilentkiller.net. Or, pick up a copy at the Masimo booth. Disclosures.

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Fire Ground Carbon Monoxide: EMS Responds

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  1. Fire Ground Carbon Monoxide: EMS Responds Randolph Mantooth and Mike McEvoy, PhD, NRP, RN, CCRN EMS Coordinator – Saratoga County, New York EMS Editor – Fire Engineering Magazine

  2. www.thesilentkiller.net Or, pick up a copy at the Masimo booth

  3. Disclosures • I am on the speakers bureaus for Masimo Corporation and Physio-Control Corp. • I am the Fire/EMS technical editor for Fire Engineering magazine. • I do not intend to discuss any unlabeled or unapproved uses of drugs or products. www.mikemcevoy.com

  4. Disclosures www.mikemcevoy.com

  5. Carbon Monoxide (CO) “The Great Imitator” • Invisible • Masquerades

  6. Carbon Monoxide (CO) • Gas: • Colorless • Odorless • Tasteless • Nonirritating • Physical Properties: • Vapor Density = 0.97 • LEL/UEL = 12.5 – 74% • IDLH = 1200 ppm

  7. CO Sources • Exogenous (normal heme catabolism) • Incomplete combustion of any carbon-based material: • Automobiles, trucks, buses, boats • Gas heaters and furnaces • Small gasoline engines • Portable / space heaters • Portable gas-powered generators • Barbecues / fireplaces • Structure / wildland fires • Cigarette smoke • Methylene chloride (paint stripper) - liver converts to CO

  8. Carbon Monoxide Poisoning • Leading cause of poisoning deaths in industrialized countries: • 50,000 emergency room visits in the US annually 1 • At least 3,800 deaths in the US annually 2 • 1,400-3,000 accidental deaths in the US annually 3,4 • Even a single exposure has the potential to induce long-term cardiac and neurocognitive/psychiatric sequelae: • Brain damage at 12 months after exposure is significant 5 • Myocardial Injury is a common consequence of CO poisoning and can identify patients at a higher risk for premature death 6 1 Hampson NB, Weaver LK. Carbon Monoxide poisoning: A new incidence for an old disease. Undersea and Hyperbaric Medicine 2007;34(3):163-168. 2 Mott JA, Wolfe MI, Alverson CJ, MacDonald SC, Bailey CR, Ball LB, Moorman JE, Somers JH, Mannino DM, Redd SC. National Vehicle Emissions policies and practices and declining US carbon monoxide-related mortality. JAMA 2002;288:988-995 3 Hampson NB, Stock AL. Storm-Related Carbon Monoxide Poisoning: Lessons Learned from Recent Epidemics. Undersea Hyperb Med 2006;33(4):257-263 4 Cobb N, Etzel RA, Unintentional Carbon monoxide-related deaths in the United States, 1979 through 1988. JAMA 1991;266(5):659. 5 Weaver LK, et al. N Engl J Med, 2002;347(14):1057-067. 6 Henry CR, et al. JAMA. 2006;295(4):398-402.

  9. Cardiac Effect • 19 year study 8,333 Swedish males ÷ smokers, non-smokers, never smokers. • Never smokers split into quartiles: • 0.13 – 0.49% COHb • 0.50 – 0.57% • 0.58 – 0.66% • 0.67 – 5.47% • Relative risk CV event 3.7, death 2.2 highest to lowest quartiles • Incidence CV disease & death in non-smokers related to COHb% COHb% as a marker of cardiovascular risk in never smokers: Results from a population-based cohort study. Hedblad BO, Engstrom G, Janzon E, Berglund G, Janzon L. Scand J Pub Health. 2006;34:609-615.

  10. Signs and Symptoms Carbon Monoxide Poisoning Presents Like the Flu!

  11. Haunted Houses or CO Poisoning? • Wilmer W. “Mr. and Mrs. H.” Amer J Ophthalmology. 1921 • Purchased new home, c/o headaches & fatigue. Heard bells and footsteps during nights with sightings of mysterious figures. • Investigation revealed prior owners had similar experiences. • Furnace chimney found blocked, venting CO into home.

  12. CO Poisoning: The Great Imitator 30-50 % of CO-exposed patients presenting to Emergency Departments are misdiagnosed Barker MD, et al. J Pediatr. 1988;1:233-43 Barret L, et al. Clin Toxicol. 1985;23:309-13 Grace TW, et al. JAMA. 1981;246:1698-700

  13. CN & CO: Exposure in Fire Deaths Percentage of fire deaths COHb, carboxyhemoglobin; FFS, Foundation for Fire Safety.Adapted from Alarie Y. Crit Rev Toxicol. 2002;32:259-289.

  14. Carbon Monoxide

  15. Carbon Monoxide Firefighter Injuries – 2009 (United States): • Total injuries = 78,150 • Smoke or Gas Inhalation = 3.0% • Burns & Smoke Inhalation = 0.7% - NFPA Survey of Fire Depts for U.S. Fire Experience, 2009.

  16. Exhaled CO Meters • Estimation COHb from alveolar CO concentration first described in 1948 (Sjostrand T. Acta Physiol Scand 16:201-7) • Predominantly used to monitor smoking cessation • Compact, portable, well validated • Requires 20 second breath holding (awake, alert patient) • Disposable mouthpieces, regular gas calibration • Despite widespread availability since 1970’s utilization very low www.micro-direct.com

  17. Noninvasive Pulse CO-Oximetry • FDA approved January 2006 • Compact, portable, well validated • Continuous carboxyhemoglobin measurement • Can be used on any patient (even unconscious) • No disposables, no calibration necessary • Use wider than exhaled devices after shortertime in marketplace • Also measures oxyhemoglobin (SpO2), methemoglobin (SpMet), perfusion index (PI), hemoglobin (SpHb) and Pleth Variability Index (PVI). www.masimo.com

  18. From 2006 until 2011: • SpCO now available on multiple patient monitors, integrated with pulse oximetry • Research, protocols, education have evolved practice • Dec. 2010 survey of 74 major cities: • 82% currently have SpCO monitoring capability • Of those without, 62% intend to add it

  19. Driving Forces: • Called attention to the role of CO on the Fire Ground

  20. Driving Forces: NFPA 1584 • A.6.2.6.4(1)…Any fire fighter exposed to CO or presenting with headache, nausea, shortness of breath, or gastrointestinal symptoms at an incident where CO is present should be assessed for carbon monoxide poisoning.

  21. Driving Forces: Educational Resources • Textbook and classroom resources: Rehabilitation and Medical Monitoring: An Introduction to NFPA 1584 (2008 Standards).

  22. CO Assessment in FF Rehab? • Suggested in NFPA 1584 • CO induces death 2° VF in animal lab • VF initial rhythm in 90% interior FF deaths • Should not leave rehab if > 5% COHb

  23. UL 2034: listings for CO alarms • Revised 1992, 1995, 1998 • Presently: • 30 PPM for 30 days • 70 PPM for 1 – 4 hours • 150 PPM for 10 – 50 minutes • 400 PPM for 4 – 15 minutes (6 min reset > 70 PPM) • Non-alarm status CO2 < 5,000 PPM • Non-alarm limits for methane, butane, heptane, ethyl acetate and isopropyl alcohol

  24. Protocols for CO Assessment & Treatment JEMS supplement – October 2010

  25. Response Protocol for CO Alarms • Atmospheric monitoring (per FD SOGs) • Screen all building occupants for CO symptoms and measure SpCO% • If EMS not on scene, FD should assess occupants • Suspect CO exposure if multiple patients > 3% (non-smokers) or > 8% (smokers) • Occupants closest to CO source will have higher SpCO% (relay this information to interior personnel)

  26. Response Protocol for CO Alarms • Treat any symptomatic patient(s) with high flow oxygen regardless of SpCO% and consider transport • Follow “Routine Assessment” parameters for asymptomatic patients with abnormal SpCO readings

  27. Routine Assessment of SpCO • The vague nature of CO symptoms and lack of correlation to carboxyhemoglobin blood levels suggest routine assessment of SpCO in every patient

  28. CO Assessment • Every patient, every time. • All occupants at CO alarm calls. • Firefighters.

  29. Routine Assessment of SpCO • Caveat:SpCO should not replace clinical judgment. Any symptomatic patient should received further medical evaluation!

  30. Fire Service CO Cases • Elevated rehab CO levels in a Colorado FF led todiscovery of a defective gas stove in his apartment. • A Colorado FD discovered CO poisoning while assessing a seizure patient, averting additional harm to her boyfriend who also had CO poisoning. • A Washington Fire Captain traveled 3 hours to an EMS meeting in a department SUV. There, a product demo led to discovery of a CO leak in his vehicle. • An Upstate New York FD discovered near fatal CO poisoning in a patient who had been seen in two different Emergency Departments over a three day period for headaches.

  31. Fire Service CO Cases • High CO levels in multiple FF at a multiple alarm fire in the Midwest were traced to an engine exhaust leak into the rehab area. • FF in Upstate New York used CO-Oximetry to evaluate 200 nursing home patients, pinpointing the location of a CO leak and averting transport of 182 patients for evaluation. • FF in California transporting a dental patient with excessive bleeding after a tooth extraction were alerted to high SpCO and found her entire family unconscious at her residence. • Your story here…

  32. CO Research

  33. Smoke Characterization Study www.ul.com

  34. Firefighter Health: the Obvious

  35. Smoke Characterization Study Carbon Monoxide

  36. 14,438 Patient Brown University Study • Partridge and Jay (Rhode Island Hospital, Brown University Medical School), assessed carbon monoxide (CO) levels of 10,856 ED patients • 11 unsuspected cases of CO Toxicity (COT) were discovered.Overall mean SpCO was 3.60% • Occult COT was 4 in 10,000 during cold, 1 in 10,000 during warm months • They concluded “unsuspected COT may be identified using noninvasive COHb screening and the prevalence of COT may be higher than previously recognized” Non-Invasive Pulse CO-Oximetry Screening in the Emergency Department Identifies Occult Carbon Monoxide Toxicity. Suner S, Partridge R, Sucov A, Valente J, Chee K, Hughes A, Jay G. J Emerg Med 2008 Department of Emergency Medicine, Rhode Island Hospital, Brown Medical School, Providence, RI.

  37. RAD-57 Accuracy • Touger, et al study published Oct 2010: “Performance of the RAD-57 Pulse Co-Oximeter Compared to Standard Laboratory CO Measurement” Ann Emerg Med 2010;56:382-388 • Study included 120 emergency dept patients at Jacobi Medical Center in the Bronx, NY – 23 patients >15% CO • Limits of agreement of measurement differences between SpCO and COHb were -11.6% to +14.4% • Lab CO <15%, RAD-57 identified 96/97 – Reported specificity 99% • Lab CO >15%, RAD-57 identified only 11 of 23 patients – Reported sensitivity of 48% suggests that the RAD-57 cannot reliably exclude CO poisoning in any potentially poisoned patient

  38. This was Only ONE Study

  39. Eagles XIII - Dallas

  40. Roth et al…July 2011 • Study included 1,578 emergency dept patients at AKH Vienna, one of the largest hospitals in Europe – 17 patients poisoned (Ann Emerg Med. 2011;58:74-79) • Limits of agreement of measurement differences between SpCO and COHb were -3.55% to +9.53%; lab CO compared to RAD-57 had specificity 77% • Lab CO compared to RAD-57 all patients – Reported sensitivity of 94% suggests that the RAD-57 can be used to reliably screen large numbers of patients for CO poisoning

  41. Masimo Response • Assigned top engineers to work on SpCO sensor for 6 months • Released new version May 2011 • Dramatically improved CO accuracyin low sats (range 90 – 95%) • Will not report CO when sat < 90% • Will not report CO when Met > 2%

  42. Atmospheric Monitoring

  43. Wildland Firefighting: Xcaper

  44. Xcaper.com: the future?

  45. firefightercoexposure.com

  46. Fire Ground Exposure Issues Carbon Monoxide • Leading cause of poisoning deaths worldwide • Commonly misdiagnosed (medical and fire personnel) • Clear evidence of harm from low level exposures • Likely role in FF cardiovascular events and deaths

  47. Thank You mcevoymike@aol.com

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