Fire Ground Carbon Monoxide: EMS Responds

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Fire Ground Carbon Monoxide EMS Responds

• Randolph Mantooth
• and
• Mike McEvoy, PhD, NRP, RN, CCRN
• Professor Emeritus Albany Medical College, New
  York
• EMS Coordinator Saratoga County, New York
• EMS Editor Fire Engineering Magazine

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

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Disclosures

• www.mikemcevoy.com

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Carbon Monoxide (CO)

• The Great Imitator
• Invisible
• Masquerades

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Carbon Monoxide (CO)

• Gas
• Colorless
• Odorless
• Tasteless
• Nonirritating
• Physical Properties
• Vapor Density 0.97
• LEL/UEL 12.5 74
• IDLH 1200 ppm

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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

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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/psychi
  atric 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
200734(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
2002288988-995 3 Hampson NB, Stock AL.
Storm-Related Carbon Monoxide Poisoning Lessons
Learned from Recent Epidemics. Undersea Hyperb
Med 200633(4)257-263 4 Cobb N, Etzel RA,
Unintentional Carbon monoxide-related deaths in
the United States, 1979 through 1988. JAMA
1991266(5)659. 5 Weaver LK, et al. N Engl J
Med, 2002347(14)1057-067. 6 Henry CR, et al.
JAMA. 2006295(4)398-402.
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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.
200634609-615.
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Signs and Symptoms
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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.

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CO Poisoning The Great Imitator

• 30-50 of CO-exposed patients presenting to
  Emergency Departments are misdiagnosed

Barker MD, et al. J Pediatr. 19881233-43 Barret
L, et al. Clin Toxicol. 198523309-13 Grace TW,
et al. JAMA. 19812461698-700
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CN CO Exposure in Fire Deaths
Percentage of fire deaths
COHb, carboxyhemoglobin FFS, Foundation for Fire
Safety.Adapted from Alarie Y. Crit Rev Toxicol.
200232259-289.
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Carbon Monoxide
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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.

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Exhaled CO Meters

• Estimation COHb from alveolar CO concentration
  first described in 1948 (Sjostrand T. Acta
  Physiol Scand 16201-7)
• 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 1970s
  utilization very low

www.micro-direct.com
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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
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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

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Driving Forces

• Called attention to the role of CO on the Fire
  Ground

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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.

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Driving Forces Educational Resources

• Textbook and classroom resources Rehabilitation
  and Medical Monitoring An Introduction to NFPA
  1584 (2008 Standards).

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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 gt 5 COHb

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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 gt 70 PPM)
• Non-alarm status CO2 lt 5,000 PPM
• Non-alarm limits for methane, butane, heptane,
  ethyl acetate and isopropyl alcohol

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Protocols for CO Assessment Treatment

• JEMS supplement October 2010

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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 gt 3
  (non-smokers) or gt 8 (smokers)
• Occupants closest to CO source will have higher
  SpCO (relay this information to interior
  personnel)

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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

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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

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CO Assessment

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

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Routine Assessment of SpCO

• Caveat SpCO should not replace clinical
  judgment. Any symptomatic patient should
  received further medical evaluation!

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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.

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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

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CO Research
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Smoke Characterization Study
www.ul.com
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Firefighter Health the Obvious
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Smoke Characterization Study

• Carbon Monoxide

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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.
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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 201056382-388
• Study included 120 emergency dept patients at
  Jacobi Medical Center in the Bronx, NY 23
  patients gt15 CO
• Limits of agreement of measurement differences
  between SpCO and COHb were -11.6 to 14.4
• Lab CO lt15, RAD-57 identified 96/97 Reported
  specificity 99
• Lab CO gt15, 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

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This was Only ONE Study
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Eagles XIII - Dallas
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Roth et alJuly 2011

• Study included 1,578 emergency dept patients at
  AKH Vienna, one of the largest hospitals in
  Europe 17 patients poisoned (Ann Emerg Med.
  20115874-79)
• 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

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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 lt 90
• Will not report CO when Met gt 2

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Atmospheric Monitoring
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Wildland Firefighting Xcaper
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Xcaper.com the future?
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firefightercoexposure.com
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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

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Thank You
mcevoymike_at_aol.com