Killer. The Silent. CO monitoring adds a new dimension to firefighter rehab & emergency care. october 2010

Transcription

1 october 2010 The Silent Killer CO monitoring adds a new dimension to firefighter rehab & emergency care An exclusive supplement to JEMS sponsored by Masimo and Zoll

2 Vice President/Publisher Jeff Berend Editorial Director A.J. Heightman Managing Editor Jennifer Berry Advertising Director Judi Leidiger Art Director Liliana Estep Cover Photo Chris Swabb The Silent Killer is an editorial supplement sponsored by Masimo & ZOLL Medical Corp., and published by Elsevier Public Safety, 525 B Street, Ste. 1800, San Diego, CA ; 800/ (Fed ID # ). Copyright 2010 Elsevier Inc. material may be reproduced or uploaded on computer network services without the expressed permission of the publisher. Subscription information: To subscribe to an Elsevier publication, visit www. jems.com. Advertising information: Rates are available on request. Contact Elsevier Public Safety, Advertising Department, 525 B Street, Ste. 1800, San Diego, CA ; 800/ contents INTRODUCTION 3 By A.J. Heightman, MPA, EMT-P, Editor-in-Chief, JEMS Sneak Attack: What makes 4 Carbon Monoxide So Insidious By Mike McEvoy, PhD, RN, CCRN, REMT-P Where There's Smoke: There's 10 More than fire to harm firefighters at scenes By Bryan E. Bledsoe, DO, FACEP, FAAEM, EMT-P On the cover Detecting and correcting the effects of CO exposure is a key component of firefighter rehab. Photo Chris Swabb CO close calls: Cases 14 Demonstrate the importance of co monitoring By Teresa McCallion. EMT-B a Standard of Care: early 20 results from fdny point to the benefits of regular co monitoring in patients & firefighters By John Peruggia, BSHuS, EMT-P, & Doug Isaacs, MD Major City Flash Poll 22 Compiled by A.J. Heightman, MPA, EMT-P The new vital sign parameter: 24 co-oximetry should be in the bls toolbag By James J. Augustine, MD Shake the money tree: Finding 29 funding to support your co monitoring goals By Brandon Johnson, FF/NREMT-P 2 JEMS

3 Sensing the Effects of CO Exposure Why is carbon monoxide monitoring so important? By A.J. Heightman, MPA, EMT-P t long ago, the only definitive way for us to know if patients (or potential patients) had carbon monoxide (CO) poisoning was to take them to an emergency department (ED), where blood could be drawn and analyzed, a process that not only delayed diagnosis but also patient care. As a result, many patients were either misdiagnosed as having minor CO exposure or flu-like symptoms. Worse yet, many simply went undetected and untreated. At the scene of major exposures to CO and other products of combustion, we used to hand pick exposed building occupants, firefighters and other obvious patients. We didn t have the benefit of advanced technology and fingertip sensors to assess, triage and treat people with CO exposure early and definitively. Case in point: In 1983, one of my department s crews was dispatched on a man down call. Within seconds of their arrival on scene, the crew reported multiple patients down from CO poisoning and requested a full fire-rescue response and five additional ambulances. When I arrived on scene, six patients were sprawled on the front lawn; three were unconscious including a small child. I learned a 67-year-old man, paralyzed from the waist down as a result of an automobile crash years earlier, came home drunk, drove his specially equipped vehicle into the garage, closed the garage door and fell asleep at the wheel of his car with it still running. His son, daughter-in-law and three grandchildren were asleep in the house. The six-year-old daughter woke her parents, vomiting and complaining of a headache and upset stomach. While on the way to bathroom with the six-year old, the mother found her three-yearold daughter unconscious in the hallway. The father took this child outside to the front lawn and returned to evacuate his seven-year-old son from his bedroom. He found the son unconscious and also carried him outside. His wife called When the father returned to investigate the cause, he heard the car running in the garage and found his disabled father unconscious in the front seat. Unable to extricate his father by himself, he shut off the car, opened the garage door and waited in the garage for the firefighters to arrive. He then collapsed due to his extended CO exposure. The initial fire crews extricated the driver and his adult son from the garage, and two rescue teams entered the house At the scene of major exposures to CO and other products of combustion, we used to 'hand pick' the exposed building occupants, firefighters and other obvious patients. to search for other potential patients. The initial EMS crews began to triage and treat the patients on the front lawn. But because three were unconscious and three others experienced significant respiratory distress, there was no easy way to determine in what order the three conscious patients should be transported. So all six were tagged as Priority 1 patients. safety officer was designated at the scene, and the crews didn t mask up because there was no visible smoke or odor present. (Remember: This incident happened in the early 80s when air packs weren t used often during building searches and overhaul, safety officers weren t frequently deployed and rehabilitation wasn t a standard practice.) The next day, several of our personnel complained of nagging headaches and lethargy. Two of them, while at an ED the next morning following an EMS call, ran into our medical director and told him their symptoms and involvement at a CO incident. He ordered tests that showed both had significantly high CO levels. They were kept at the hospital on oxygen for most of the day. He then called and advised our EMS crews to assess all personnel involved in the CO incident, flush them with oxygen and transport them to the ED if their symptoms persisted. That incident presented a wake-up call for my department about the hidden dangers of CO exposure, the need for vigilant use of air packs at suspicious scenes, use of a safety officer and the need to establish rehab and assess our personnel at incident scenes. This supplement illustrates these lessons and more. It also outlines how CO-oximetry can improve your assessment, triage/screening, and treatment of actual and potential patients, as well as emergency personnel exposed to CO the silent killer that can sneak up on them at many scenes. The Silent Killer: CO Poisoning 3

4 Carbon monoxide can affect firefighters throughout an incident, not just during initial fire operations. Sneak Attack What makes carbon monoxide so insidious? By Mike McEvoy, PhD, RN, CCRN, REMT-P photo michael J. coppola Carbon monoxide (CO) leads poisoning deaths worldwide and masquerades as a variety of medical maladies resulting in frequent misdiagnoses. 1 Whether on scene of a general illness call, providing rehab to firefighters at a major fire or responding to a CO detector alarm, EMS providers need more than a list of signs and symptoms to reliably evaluate, treat and safely transport patients affected by carbon monoxide. This article will review the suspected incidence of CO poisoning and shortand long-term dangers of this invisible poison. It presents a protocol specifically designed for EMS responders using currently available monitoring devices to screen for CO in patients. The true incidence of CO poisoning isn't known. 1 Recent calculations estimate 50,000 emergency department (ED) visits annually in the U.S. result from CO poisoning, although it s widely believed that frequent misdiagnosis results in gross under reporting of the actual incidence. 2,3 CO poisoning is a major public health problem. It accounts for more than half of fatal poisonings in virtually every country worldwide when reported poisoning cases are tabulated. 1 This often surprises health-care providers, who tend to underestimate the prevalence of CO poisoning in their communities. Where It Comes From Sources of CO include endogenous exposure (meaning manufactured within the body) and environmental exposures. At the end of the life of red blood cells, their destruction produces CO. As a consequence, all humans continuously exhibit low levels of CO in the blood, called carboxyhemoglobin (COHb). Individuals with hemolytic anemias, sepsis and critical illness have shorter-than-average red blood cell life spans, resulting in higher-than-normal COHb levels. 1 Environmental carbon monoxide sources encompass any process involving incomplete combustion of a carboncontaining product. These include exhaust from a vehicle, heating appliances, fireplaces, cigarette smoke, barbecue grills, smoke from a fire and a plethora of other combustion-generating devices and processes. 1 Rarely seen but important to prehospital providers, inhaled or absorbed methylene chloride produces significant amounts of CO that can result in poisoning. Methylene chloride is found in paint stripper and can be a component of chemicals used for huffing (deliberate inhalation designed to produce an altered mental state). When broken down in the liver, methylene chloride produces significant amounts of carbon monoxide that can result in CO poisoning. 4 JEMS

5 Figure 1: Routine Assessment of All Patients 1. the vague nature of CO symptoms and lack of correlation to carboxyhemoglobin blood levels suggest routine assessment of SpCO in every patient 2. initial CO assessment parameters: 0 5% Considered normal in non-smokers. When > 3% with symptoms, consider high-flow oxygen and evaluate environment for CO sources. Consider measuring others in same room/office/vehicle as patient. In absence of symptoms, no further medical evaluation of SpCO needed. 5 10% Considered normal in smokers, abnormal in non-smokers. If symptoms are present, consider high flow oxygen and inquire if others are ill. Alert fire department % Abnormal in any patient. Assess for symptoms, consider high-flow oxygen. Evaluate environment for CO sources. > 15% Significantly abnormal in any patient. Administer highflow oxygen, assess for symptoms, consider transport. Evaluate environment for CO sources. > 30% Consider transport to hyperbaric facility (some experts recommend hyperbaric referral for any patient > 25% or with altered mental status or if pregnant). 3. CO reassessment parameters: 0 5% If symptoms persist, recommend transport regardless of SpCO readings. If symptoms resolved, no further medical evaluation of SpCO needed. 5 10% If symptoms persist, recommend transport regardless of SpCO readings. If symptoms resolve and SpCO remains > 5% in any patient, recommend further medical evaluation. n-smokers should be encouraged to have their home/work environment evaluated for CO % If symptoms persist or SpCO remains > 10% in any patient, recommend transport. Encourage patient to have home/work environment evaluated for CO. > 15% Recommend transport regardless of symptoms. Ensure that others in patient s home or workplace are not ill. > 30% Consider transport to hyperbaric facility (some experts recommend hyperbaric referral for any patient > 25% or with altered mental status or if pregnant). Unreliable Indicators It has long been mistakenly believed that classic symptoms of CO exposure, such as headache, nausea, weakness and visual disturbances, were reliable indicators of CO poisoning. In fact, signs and symptoms of carbon monoxide poisoning correlate so poorly with COHb levels that no study conducted to date has been able to reliably detect CO poisoning by symptoms or physical assessment findings alone. 1 The uncanny similarities of CO poisoning to viral illness, gastroenteritis, migraine, acute coronary syndrome or angina, drug abuse and a variety of other medical conditions, coupled with lack of correlation between symptoms and COHb levels, leads to frequent misdiagnosis and has nicknamed CO poisoning as the great imitator. 4 In fact, the high incidence of CO poisoning and the difficulty experienced in detecting poisoned patients when a CO monitoring device isn t available, has prompted many intensive-care unit order sets to include obtaining a COHb level on admission to avoid missing this potential diagnosis. CO is colorless, odorless, invisible and hence, virtually undetectable. It has a vapor density (0.97) very close to ambient air (1.0). This means it will not linger on the ground or rise upward at usual temperatures, but instead spread throughout a room or building when released. 3 The lungs readily absorb inhaled CO into the bloodstream where it binds to hemoglobin with substantially greater affinity than oxygen, forming COHb. 1 Hypoxia results both from decreased oxygen-carrying capacity and an increased affinity of remaining oxygen molecules to the hemoglobin. In the presence of CO, remaining oxygen molecules bind more tightly to hemoglobin, refusing to unload into tissues. This phenomenon, which results in higher-than-normal oxygen levels in venous blood, is responsible for the cherry red skin color sometimes seen in CO-poisoned patients. Hemoglobin delivers CO throughout the body, resulting in a variety of symptoms depending on the concentrations achieved. When CO binds with skeletal muscle, an individual can experience significantly impaired strength that can approach paralysis at high concentrations. Even low levels of CO produce elevated concentrations of the free radical nitric oxide (NO), a highly reactive chemical compound known to cause significant cellular damage in the body. 5 NO causes vasodilation and leads to The Silent Killer: CO Poisoning 5

6 Sneak Attack: continued photos Michael J. Coppola profound hypotension in patients with major CO poisoning. Neurologic & Cardiac Concerns In addition to the hypoxia and tissuedamaging effects already mentioned, CO also causes inflammation through multiple pathways independent of those associated with hypoxia, leading to direct neurologic and cardiac injury, both with long-term consequences. 4 Therefore, disabling cardiac injury often occurs even with low-level CO exposures, a cause of concern for firefighters who frequently work in smoky conditions and persons who live or work with cigarette smokers. In a Swedish study monitoring the incidence of cardiovascular disease in 8,333 men over a 19-year period, those who never smoked but had COHb levels consistent with exposure to second-hand smoke were 3.7 times more likely to have a cardiac event (stroke or myocardial infarction) and 2.2 times more likely to die than those who had not been exposed to CO. 6 A particularly disconcerting takeaway from these data is that the COHb levels of men in the higher risk group were very similar to those normally observed in firefighters who, despite proper use of personal protective equipment (PPE), have a certain degree of unavoidable occupational CO exposure. 5 Numerous studies have documented increased incidences of cardiovascular events and higher mortality in longterm follow up of patients who have been CO poisoned. 7 Therefore, COpoisoned patients should always receive a thorough cardiac workup. Troubling neurologic impairment also occurs with CO exposure, leaving up to one-third of CO-poisoned patients with profound neurological disabilities that may include substantial drop in intelligence, memory loss, difficulty concentrating, seizures, Parkinson-like tremors, psychosis, dementia, and cognitive or personality changes. 8 Catching the Killer Given the very real and significant incidence of carbon monoxide poisoning in every part of the world, our total inability to detect this very sneaky, colorless, odorless and invisible gas, and the complete lack of relationship between signs or symptoms and COHb levels, the challenge has been how to improve our ability to detect and treat COpoisoned patients. With signs and symptoms that range from none to mild headache, tiredness, nausea, vomiting, tachycardia, confusion, seizures and unconsciousness, it would seem that virtually any patient could be poisoned with carbon monoxide. Therefore, to avoid missing this important diagnosis, I believe we need to screen every patient we encounter for carbon monoxide poisoning. Exhaled breath assessment of CO, used extensively in the UK to monitor compliance with smoking cessation, has been used to assess CO exposure in U.S. firefighters since ,10 There is close correlation between exhaled breath CO and COHb, but the technology has The goal of rehab is to protect our most valuable asset our personnel. A formal, environmentally controlled area and assessment process ensures dangerous CO levels and cardiovascular abnormalities aren't missed. 6 JEMS

7 Figure 2: Firefighter Rehab 1. measure any firefighter exposed to smoke (including pump operators and command staff) 2. Initial CO assessment parameters: 0 5% rmal 5 10% rmal in a smoker > 10% Abnormal in any person. Consider high-flow oxygen. > 15% Significantly abnormal in any person. Treatment mandated. 3. CO reassessment parameters: 0 5% Acceptable for return to firefighting activities if medically cleared 5 10% Consider high-flow oxygen until less than 5% regardless of symptoms. > 10% Abnormal. Assess for symptoms. Consider high-flow oxygen. > 15% Significantly abnormal. Treatment mandated. Consider transport. never been widely adopted. 11 Pulse CO-oximetry technology that can non-invasively measure COHb has been available in the U.S. since Many EMS services and fire departments now carry portable CO-oximeter units. More recently, CO-oximetry has become available in several monitor-defibrillator models. Conventional pulse oximeters transmit two wavelengths of light (red and infrared) through body tissue, measuring the absorption of each wavelength and calculating the oxygen saturation of hemoglobin (SpO 2 %). However, because oxygen and CO have similar absorption characteristics, conventional pulse oximetry sees them as identical, reporting an SpO 2 falsely elevated by CO. On the other hand, pulse COoximetry uses at least eight wavelengths of both visible and invisible spectrum light to accurately measure COHb, displayed as SpCO%. Its accuracy is reported at plus or minus 3% SpCO at levels up to 40%. 12 Shielding from extraneous light sources and meticulous attention to proper probe placement improves accuracy. Read more about SpCO in "The New Vital Sign Parameter" on p. 24. In a study to determine what would happen if every patient encountered in the field was screened with pulse CO-oximetry, researchers at Brown University Hospital in Rhode Island found previously unsuspected elevated carbon monoxide levels in four of every 10,000 patients during winter (heating) months and in one of every 10,000 patients during summer months. 13 Although other researchers have questioned these data, the fact remains that CO poisoning is a significant public health problem, and one that frequently eludes detection. 14,15 Good patient-care decisions flow from good understanding of technology and the knowledge to interpret data obtained from a medical device. Pulse CO-oximetry should never replace clinical judgment; any symptomatic patient should receive further medical evaluation regardless of measured SpCO%. Based on published recommendations and the author s decade of experience with non-invasive CO assessment technologies, Figure 1 (see p. 5) is a recommended guideline for routine assessment and reassessment of the patient's carboxyhemoglobin levels. 1,12,13,16 Fire Scene Rehab An additional and critically important niche for pulse CO-oximetry is firefighter rehabilitation. The National Fire Protection Association (NFPA) 1584 Standard on the Rehabilitation Process for Members During Emergency Operations and Training Exercises suggests that EMS personnel assess any firefighter for CO poisoning who has been exposed to carbon monoxide or presents with symptoms at an incident where CO is present. 17 When engaged in firefighting, firefighters use selfcontained breathing apparatus (SCBA) to protect themselves from respiratory exposure to CO and other toxins known to be present in fire smoke. Yet it's readily apparent that firefighters fail to use SCBA during overhaul and when operating in smoky environments outside or nearby the fire location. These circumstances unnecessarily expose firefighters to CO. 5 The usual terminal event in CO poisoning is cardiac arrest, most often heralded by ventricular fibrillation. 6,7 You have a clear opportunity to protect firefighters by screening for CO. Screen potentially exposed firefighters for CO, Figure 3: Carbon Monoxide Alarms (CO Detector Alarm Activation) 1. conduct atmospheric monitoring, following fire department (FD) standard operating guidelines. 2. screen all building occupants for CO symptoms and measure SpCO%. a. if EMS isn't on scene, FD should assess occupants and measure SpCO. b. suspect CO exposure if multiple patients > 3% (non-smokers) or > 8% (smokers). c. occupants closest to CO source will have higher SpCO% (relay this information to fire department interior personnel) 3. treat any symptomatic patient(s) with high-flow oxygen regardless of SpCO reading and consider transport. 4. Follow Routine Assessment parameters for asymptomatic patients with abnormal SpCO readings. The Silent Killer: CO Poisoning 7

8 Sneak Attack: continued immediately treat any abnormal levels and never release emergency personnel from rehab with an SpCO level greater than 5%. 1 Given NFPA 1584 and the ready availability of a non-invasive screening tool for detecting CO poisoning, it seems reasonable that EMS providers operating in the rehab area should have this capability available. A sample protocol developed by the author for firefighter rehab is presented in Figure 2 (see p. 7). Top photo michael J. coppola/bottom photo chris swabb Public Screenings Lastly, public health initiatives to reduce the incidence of CO poisoning in the community have enhanced building codes, leading to increasing use of CO detectors in homes and businesses. Responses to CO alarm activations constitute a significant number of fire department runs each year. Considering the wide variety of conditions that can activate a typical household CO detector, ranging from 30 parts per million (PPM) for 30 days to 400 PPM for 15 minutes, and including other gases such as CO 2, methane, and isopropyl alcohol, it's no wonder why firefighters are often unable to determine what tripped the CO alarm. 1 The goal when responding to a carbon monoxide alarm is to determine whether the environment is poisonous. However, atmospheric monitoring using appropriate gas meters often won't detect low levels of CO, especially when homeowners have exited the building prior to fire department arrival, ventilating CO in the process. CO-oximetry can play an important role in detecting CO-exposed individuals regardless of atmospheric reading levels obtained on scene, since COHb has a four-hour half life in individuals breathing room air. 16 Because prolonged exposure to very low levels of CO can be just as lethal as short-term exposure to high CO concentrations, firefighters who screen building occupants with CO-oximetry in addition to monitoring the home or Oxygen therapy should be started as early as possible on firefighters and others exposed to carbon monoxide. The use of rehabilitation tags ensures that each firefighter is assessed, hydrated and monitored appropriately. 8 JEMS

9 Mike McEvoy, PhD, RN other structure with a four-gas meter, can now more definitively rule out CO poisoning and feel much more confident allowing a family to return to their home. In fact, many fire departments have incorporated protocols, such as the one in Figure 3 (see p. 7), to more confidently respond to CO alarms. Conclusion CO is an invisible and insidious poison that often eludes detection by appearing like general illness. We often miss dangerous CO levels because we fail to look for them, chalking up symptoms (when present) to general weakness or flu-like illness. Pulse CO-oximetry now offers us the ability to non-invasively detect CO poisoning during regular and focused patient exams. To be part of the solution, in my opinion, we need to screen every patient we see, potentially exposed firefighters managed during rehab operations and every building occupant at the scene of a CO detector alarm activation. Using the sample protocols outlined in this article, EMS providers and firefighters have a new opportunity to detect this elusive poison early in prehospital patient encounters and during the performance of rehab operations. Mike McEvoy, PhD, RN, CCRN, REMT-P, is the EMS coordinator for Saratoga County, N.Y., and teaches critical care medicine at Albany Medical College. He s a nurse clinician in the cardiothoracic surgical intensive care units at Albany Med, a paramedic with Clifton Park-Halfmoon Ambulance, a firefighter and chief medical officer for West Crescent Fire Department and EMS director on the Board of the New York State Association of Fire Chiefs. Disclosure: The author has reported receiving honoraria and/or research support, either directly or indirectly, from Masimo. References 1. Raub JA, Mathieu-lf M, Hampson NB, et al. Carbon monoxide poisoning: A public health perspective. Toxicology. 2000;145: Hampson NB, Weaver LK. Carbon monoxide poisoning: A new incidence for an old disease. Undersea Hyperb Med. 2007;34: Kele A, Demircan A, Kurto lu G. Carbon Monoxide poisoning: How many patients do we miss? Eur J Emerg Med. 2008;15: Never release emergency personnel from rehab with an SpCO level greater than 5% Weaver LK. Clinical practice. Carbon monoxide poisoning. N Engl J Med. 2009;360: Bledsoe BE. The heart dangers of CO. Understanding cardiovascular risks to responders from CO exposure. JEMS. 2007;32: Hedblad B, Engström G, Janzon E, et al. COHb% as a marker of cardiovascular risk in never smokers: Results of a population-based cohort study. Scand J Pub Health. 2006;34: Hampson NB, Rudd RA, Hauff NM. Increased long-term mortality among survivors of acute carbon monoxide poisoning. Crit Care Med. 2009;37: Amitai Y, Zlotogorski Z, Golan-Katzav V, et al. Neuropsychological impairment from acute low-level exposure to carbon monoxide. 1998;55: Deveci SE, Deveci F, Acik Y, et al. The measurement of exhaled carbon monoxide in healthy smokers and non-smokers. Respir Med. 2004;98: Stewart RD, Stewart, RS, Stamm W, et al. Rapid estimation of carboxyhemoglobin level in firefighters. JAMA. 1976;235: Cone DC, MacMillan DS, Van Gelder C, et al. ninvasive fireground assessment of carboxyhemoglobin levels in firefighters. Prehosp Emerg Care. 2005;9: Hampson NB. ninvasive Measurement of Blood Carboxyhemoglobin with Pulse CO-Oximetry. In Penney DG: Carbon Monoxide Poisoning. CRC Press: Boca Raton, La, 2008, pp Suner S, Partridge R, Sucov A, et al. n-invasive pulse CO-oximetry screening in the emergency department identifies occult carbon monoxide toxicity. J Emerg Med. 2008;34: O Malley GF. Letter to the Editor: n-invasive carbon monoxide measurement is not accurate. Ann Emerg Med. 2006;48: Centers for Disease Control and Prevention. Carbon Monoxide Poisoning. April Crawford DM, Hampson NB. Fire and ice: Diagnosis of carbon monoxide poisoning in a remote environment. Emerg Med J. 2008;25: NFPA Standard in the Rehabilitation Process for Members during Emergency Operations and Training Exercises. NFPA: Quincy, Mass., The Silent Killer: CO Poisoning 9

10 Personnel exposed to smoke conditions should be monitored and assessed for CO poisoning. Where There's Smoke There's more than fire to harm firefighters at scenes By Bryan E. Bledsoe, DO, FACEP, FAAEM, EMT-P photo A.J. Heightman This past year, there were 90 onduty firefighter deaths in the U.S., fewer than the 114 on-duty deaths that occurred in Regardless, even one firefighter death is one too many. Although the total number of firefighter deaths has been steadily declining over the past decade, the number of firefighter deaths per 100,000 fire incidents has remained relatively unchanged. This would seem to indicate that the reduction in firefighter deaths is primarily related to a decreased number of fires being fought a result of effective fire prevention strategies and enhanced building codes and not a result of improved firefighting tactics. 2 The Problem Most firefighter line-of-duty deaths are due to cardiovascular disease and occur during the active phase of fire suppression. 3 Although most firefighter studies and statistics have looked almost exclusively at on-duty deaths, few studies have looked at the long-term effects of career firefighting on health and longevity. Unfortunately, little information is available on the ill effects of exposure to fireground toxins on firefighters and exposed occupants. 4 5 A limited but evolving body of literature is starting to link toxic smoke exposure and longterm morbidity and mortality, such as one Florida study that identified an increased incidence of bladder cancers in male firefighters. 6 A Canadian study indicated that firefighters with 30 years of employment or more had a significantly increased mortality risk of colon cancer, kidney cancer, brain cancer and leukemia. In addition, firefighters with 40 years of employment or more had a significantly increased risk of bladder cancer in addition to the risks previously described. 5 Similar findings were noted in a study of Massachusetts firefighters. 6 The prevailing theory is that repeated exposures to toxins on the fireground may result in the development of selected types of cancers. It has long been known that there are numerous toxic substances on the fireground and in smoke. 7 However, until the past decade, we haven t had any reliable way of detecting these toxins and providing effective treatment just oxygen in most cases. Certainly environmental gas meters and other atmospheric monitors have been an important step in improving fireground safety by identifying certain toxins on scene. However, two fairly recent developments have dramatically changed the way we look at fireground and smoke hazards. The first of these is the ability to measure biological exposure to carbon monoxide (CO) with either an exhaled CO monitor or pulse CO-oximetry. The other is the ability to treat cyanide poisoning with the antidote hydroxocobalamin (Cyanokit). w, we can both detect and treat exposures earlier and hopefully improve outcomes of those exposed. Also, we can now mitigate many risks to firefighters and other emergency responders through use of formalized and evidencebased on-scene rehabilitation programs. Chemistry of CO During a fire, the materials that burn are largely organic and subsequently release carbon dioxide and water during 10 JEMS

11 the process of combustion. CO almost always also develops because combustion is rarely complete. CO competes with oxygen for oxygen-binding sites on hemoglobin and has a much greater affinity ( times) for these binding sites than oxygen, displacing previously bound oxygen. The binding of CO to hemoglobin results in the formation of carboxyhemoglobin (COHb), which doesn t transport oxygen. In addition to hemoglobin, CO also binds to other iron-containing proteins in the body, including the enzyme cytochrome oxidase. This is the same enzyme system to which the toxin cyanide binds, explaining why the signs and symptoms of CO and cyanide poisoning are similar. It s now known that many of the toxic effects of CO are more due to the effects on cytochrome oxidase (and other iron-containing proteins) rather than the binding to hemoglobin. Typically, a phase of decreased oxygen content in the blood (hypoxemia) follows CO exposure. The effects of COmediated hypoxemia are dependent on any underlying disease that might be present, such as emphysema or heart disease. 8 These periods of hypoxemia and re-oxygenation often result in the formation of dangerous chemicals called free radicals, which causes oxidative stress, as well as cell and tissue damage. 9,10 Oxidative stress has been associated with the development of many diseases, including atherosclerosis, Parkinson s disease and Alzheimer s disease. 11 Thus, exposure to CO (either acute or chronic) may be a risk factor for the development of cardiovascular and neurological diseases. Patients with moderate to severe CO poisoning are at increased risk of developing cardiovascular complications. 12 These complications occur in all age groups regardless of the patient s underlying health status. In a 2005 study, researchers in Minneapolis evaluated 230 victims of CO poisoning and found that myocardial injury was common in moderate to severe CO poisoning. These same 230 patients were followed for an average of 7.6 years after their exposure. Initially, 85 (37%) patients had an associated myocardial injury, such as ECG changes A key component of firefighter rehab is medical monitoring of all personnel. and elevated cardiac biomarkers, associated with the poisoning. Interestingly, of the 85 who had myocardial injury, 32 (38%) eventually died during the study. In contrast, only 22 (15%) of the 145 patients who did not sustain myocardial injury eventually died. 13 Although most of the studies to date have addressed immediate deaths from CO poisoning, other research is starting to demonstrate that long-term mortality may be related to both acute and chronic CO exposure. In a Swedish study, researchers concluded that the incidence of cardiovascular disease and death in nonsmokers was related to COHb levels and Safety for All By Gary Ludwig One theme is consistent among the members of the International Association of Fire Chiefs (IAFC ). The safety of all firefighters and emergency response personnel is imperative. Chief fire officers, whether suggested that measurement of COHb levels should be a part of risk screening for cardiovascular disease. 14 CO poisoning can interrupt oxygen delivery to the brain, causing brain hypoxia. This is later followed by oxidative stress that can damage sensitive brain tissue. The detrimental effects of hypoxia and oxidative stress can be either temporary or permanent. Acute and chronic neurological problems have been documented following CO poisoning. These occur regardless of whether the CO exposure was acute or chronic. It's believed that the mechanism of brain injuries is related to the it's in the fire station, responding to the scene or on the scene, are responsible for the safety, health and well-being of their firefighters and other emergency response personnel. In 2009, 90 firefighters lost their lives in the line-of-duty. This was the lowest number of firefighters killed in the line-of-duty since 1993, when it was 81. But this is still 90 too many. Of those, more than half were related to heart attacks and strokes, which tend to occur either during or immediately after incidents that require heavy exertion. Science is now uncovering that these heart attacks and strokes occur after firefighters have also been exposed to high concentrations or levels of carbon monoxide (CO). The IAFC fully supports rehabilitation and medical monitoring of firefighters during fireground operations. The National Fire Protection Association 1584 addresses this important issue. The rehabilitation of firefighters should occur whenever on-scene activities pose the risk of members exceeding a safe level of physical or mental endurance. These types of incidents will vary from structural and wildland fires to hazmat and long-term EMS incidents. We've all felt the fatigue and exhaustion that comes from intense work. That s why it s important we properly rehabilitate and monitor the CO levels of those engaged in on-scene activities that can push their stamina past safe levels of physical and mental endurance. The Silent Killer: CO Poisoning 11

12 Where There's Smoke: continued TABLE 1: Toxic Substances on the Fireground Acetaldehyde Asbestos Benzene Carbon dioxide (CO 2 ) Carbon monoxide (CO) Formaldehyde Hydrogen chloride (HCl) Hydrogen cyanide (HCN) Nitrogen dioxide (NO 2 ) polynuclear aromatic hydrocarbons (PNA) Sulfur dioxide (SO 2 ) Toluene production of free radicals primarily nitric oxide (NO). rmally found in the body, NO causes vasodilatation and can injure or kill cells through oxidative stress. NO levels are increased with CO exposure. In fact, most of the signs and symptoms associated with CO poisoning are primarily due to the vasodilatory effects of NO. Numerous neurological findings reported following CO exposure are primarily affective and cognitive. In a study of 127 CO-poisoned patients, researchers found depression and anxiety were common, and they were often permanent. 15 Delayed neurologic syndrome (DNS) has been identified as a complication of acute and chronic CO poisoning. 16 In DNS, recovery from the initial CO poisoning is seemingly apparent, only to have the patient develop behavioral and neurological deterioration, often permanent, anywhere from two to 40 days later. Other neurologic complications, such as Parkinsonism (findings that mimic Parkinson s disease), have been reported with DNS. 17 Cyanide Cyanide (CN) is a highly toxic substance that results from the combustion of materials often found on fire scenes, including plastics, rubber and silk. CN affects an enzyme in cells that uses oxygen for energy production. The signs and symptoms of CN poisoning can be similar to those of CO poisoning, and we now know the mechanisms of action are similar. However, unlike CO, the effects of CN occur rapidly and are more pronounced. Other Toxins Smoke is a complex mixture of airborne solid and liquid particulates and gases that develop when materials undergo vaporization or thermal decomposition. 18 This vaporization and decomposition can liberate various toxins, many of which are detailed in Table 1. Although the effect of these agents is unclear, exposure to some (e.g., aromatic hydrocarbons) has been linked to cancer development. Prevention as a Solution The solution to mitigating the toxic effects of smoke and fireground risks, and thus many of the occupational risks of firefighting, is through prevention and treatment. This can be achieved through several efforts, including use of safe firefighting tactics (including safe overhaul) that mitigate unnecessary risks and exposures, and use of proper protective equipment (PPE) and clothing. Use of PPE is very important because many fire departments don t require their members to be on SCBA during interior overhaul and data shows they get significant CO exposure in this phase of operations without SCBA. This is an important intervention to reduce firefighter exposure to CO so all the chronic downstream health risks can be attenuated. 19 Other preventive practices inlude: Ensured adequate nutrition and hydration. Attainment of a satisfactory level of physical fitness. Organized firefighter rehabilitation practices. Considerable research over the past two decades has been devoted to strategies to improve the health and safety of firefighters. The National Fire Protection Association (NFPA) recognized this and published the NFPA 1584 Standard on the Rehabilitation Process for Members During Emergency Operations and Training Exercises, which established guidelines and recommendations for formalized firefighter rehabilitation programs. 20 Rehabilitation is an organized intervention designed to mitigate the effects of physical, physiological and emotional stress of firefighting in order to sustain a member s ability to work, improve performance and decrease the likelihood of on-scene injury or death. Because many firefighter injuries and deaths are preventable, rehab should be an integral part of the incident management system for the fireground and training exercises. Rehabilitation should commence any time emergency or training operations pose a risk of department members exceeding a safe level of mental or physical endurance. A key component of firefighter rehab is medical monitoring of all personnel. EMS providers promptly evaluate firefighters for worrisome signs and symptoms as they enter the rehab area, placing particular emphasis on evaluating hydration status and the effects of heat or cold stress. In some situations, various vital signs are taken as well as pulse oximetry readings. Medical personnel should be alert for signs and symptoms that may indicate exposure to toxic gases. Screening for CO with either exhaled CO detectors or pulse CO-oximetry is recommended. Those with elevated COHb levels shouldn t be allowed to return to the fire until the levels have returned to normal. Early treatment of CO poisoning may mitigate some of the untoward longterm effects detailed above. Following rest and medical assessment, personnel who have returned to their baseline physical status can be allowed to return to active firefighting. Those who don't must remain in the rehab area. Even after being released from rehab, firefight- 12 JEMS

13 Bryan E. Bledsoe, DO ers should be continually monitored for potential problems. The role of EMS providers in firefighter rehab is different than standard EMS practices. Often, medical monitoring will simply be an evaluation of the firefighter and no further care provided. In other instances, firefighters maybe kept in the rehab area longer than normal while hydration status is restored and vital signs return to normal. If an affected firefighter doesn t respond as expected, they should be moved from the medical monitoring area to the emergency treatment area. In some cases, transport to the emergency department may be necessary. Conclusion The health and safety of firefighters is a paramount concern. The time to reevaluate and change firefighting tactics and practices to minimize dangers and mitigate risks is now. This is best achieved through prevention strategies, including formalized rehab practices. Also, evaluation for exposure to treatable toxins, especially CO and CN, can save lives both immediately and in the future. The fire and EMS professions must come together to achieve these goals. Bryan E. Bledsoe, DO, FACEP, FAAEM, EMT-P, is clinical professor of emergency medicine at the University of Nevada School of Medicine in Las Vegas and director of the EMS Fellowship. Disclosure: The author has reported receiving honoraria and/or research support, either directly or indirectly, from Masimo. References 1. United States Fire Administration. A Provisional Report: On-duty firefighter fatalities in the United States. pdf/09_fatality_summary.pdf 2. United States Fire Administration. Firefighter Fatality Retrospective Study. publications/fa-220.pdf 3. Alarie Y. Toxicity of fire smoke. Crit Rev Toxicol. 2002;32: Cohen MA, Guzzardi LJ. Inhalation of products of combustion. Ann Emerg Med. 1983;12: Kales SN, Soteriades ES, Christophi CA, et al. Emergency Duties and Deaths from Heart Disease among Firefighters in the United States. NEJM. 2007;356: Ma F, Fleming LE, Lee DJ, et al. Mortality in Florida Professional Firefighters, 1972 to Am J Ind Med. 2005;47: Youakim S. Risk of cancer among firefighters: a qualitative review of Tissues with the highest oxygen demands, primarily the nervous and cardiovascular systems, are most vulnerable to the effects of CO. selected malignancies. Arch Environ Occup Health. 2006;61: Mannatoni PF, Masini VE. Carbon monoxide: the bad and the good side of the coin, from neuronal death to anti-inflammatory activity. Inflammatory Research. 2006;55: Zang J, Piantadosi CA. Mitochondrial oxidative stress after carbon monoxide hypoxia in the rat brain. Journal of Clinical Investigations. 1992;90: Van der Vaart H, Psotma DS, Timens W, et al. Acute effects of cigarette smoke on inflammation and oxidative stress: a review. Thorax. 2004;59: Rice-Evans CA, Gopinathan V. Oxygen toxicity, free radicals and antioxidants in human disease: biochemical implications in atherosclerosis and the problems of premature neonates. Biochemical Essays. 1995;29: Kang D, Davis LK, Hunt P, et al. Cancer incidence among male Massachusetts firefighters, Am J Ind Med. 2008;51: Henry CR, Satran D, Lindgren B, et al. Myocardial injury and long-term mortality following moderate to severe carbon monoxide poisoning. JAMA. 2006;295: Hedblad B, Engström, Janzon E, et al. COHb% as a marker for cardiovascular risk in never smokers: Results from a population-based cohort study. Scandinavian Journal of Public Health. 2006;34: Jasper BW, Hopkins RO, Van Duker H, et al. Affective outcome following carbon monoxide poisoning. Cog Behav Neurol. 2005;18: Raj RS, Abdurahiman P, Jose J. Delayed neurologic syndrome in carbon monoxide poisoning. J Assoc Physicians India. 2006;54: Lassinger BK, Kwak C, Walford RL, et al. Atypical Parkinsonism and motor neuron syndrome in a Biosphere 2 participant: a possible complication of chronic hypoxia and carbon monoxide toxicity. Movement Disorders. 2004;19: Stefanidou M, Athanaselis S, Spillopoulou C. Health impacts of fire smoke inhalation. Inhal Toxicol. 2008;20: Dickinson ET, Mechem, CC, Thom, SR, et al. The non-invasive carboxyhemoglobin monitoring of firefighters engaged in fire suppression and overhaul operations. International Fire Service Journal of Leadership and Management 2008;2: NFPA Standard on the Rehabilitation Process for Members During Emergency Operations and Training Exercises. Quincy, Mass.: NFPA, The Silent Killer: CO Poisoning 13

14 Rehab assists in not only refreshing and rehydrating your personnel, but also in detecting CO poisoning and other medical abnormalities. CO Close Calls Cases demonstrate the importance of CO monitoring By Teresa McCallion, EMT-B photo A.J. Heightman Until just a few years ago, patients who complained of vague, flu-like symptoms typical of carbon monoxide (CO) poisoning may not have been transported to a hospital. Instead, wellmeaning EMTs and paramedics may have had these patients sign a release after advising them to contact their primary physician if they continued to feel ill. Without knowing that their home or hotel room was filled with toxic gas, some patients were later found dead due to lethal levels of CO. The difference today is a non-invasive assessment tool that allows prehospital providers to monitor blood CO levels. Those found with elevated levels can be treated with oxygen or, if the levels are particularly high, hyperbaric oxygen therapy. An increasing number of emergency service agencies are using this tool as a regular part of their assessment of patients and during rehab operations on the fire ground. Firefighters are particularly at risk of exposure to CO when fighting fires, but so are civilians who are unwittingly exposed to high CO levels. Perhaps the best evidence of the significant impact CO monitoring can have on the detection and correction of potentially lethal CO exposure comes from actual case reports. What follows are first-hand accounts of patients with CO poisoning who might not have been detected and treated if prehospital CO monitoring was not available and utilized. Surprising CO Source Firefighter Dan Steaves Durango (Colo.) Fire & Rescue Authority When Durango (Colo.) Fire & Rescue Authority firefighters arrived on scene at a local ski resort, smoke and flames were visible in several units of a condominium complex. By the time the fire was extinguished, three of the condo units were completely destroyed. Firefighter Dan Steaves was part of the attack team that knocked down the fire and helped to overhaul the damaged units. In accordance with the fire department s protocols, he and his crew went to rehab after they had consumed two tanks of air. While they sipped water to rehydrate, their vital signs were taken and CO levels monitored. Although he felt fine, Steaves was surprised to learn that his CO level was elevated. I didn t have any signs or symptoms [of CO poisoning] and no reason to think anything was wrong, Steaves says. A quick check of the other two members of his crew showed that Steaves was the only firefighter with elevated levels. Curiously, no other firefighter on scene was affected. Steaves was still concerned a few days later and checked his reading while on duty. He was stunned to see that his 14 JEMS

15 Teresa McCallion, EMT-B carboxyhemoglobin (COHb) reading remained above normal. Durango s EMS captain suggested Steaves check his home, so the firefighters went to his apartment and learned that the source of his high CO level was his gas stove. As soon as we turned the oven on, we were getting 100 parts per million readings right away, he says. If these CO levels were present at a fire scene, the firefighters would be required to wear breathing apparatus, yet Steaves was breathing toxic air every time he entered his home. Steaves wonders what would have happened had noninvasive CO monitoring not been available to alert him and his colleagues to his CO exposure. Vague Signs & Symptoms Fire Chief Richard Shakerley West NCrescent (N.Y.) Fire Department ew CO-monitoring devices proved their value soon after the West Crescent (N.Y.) Fire Department placed them in service. Firefighters responded to the home of a 46-year-old man who had been to the emergency department (ED) twice in the past couple of days, seeking treatment for a constant, throbbing headache. He wasn t experiencing dizziness, fever or visual disturbances; the only symptoms were a headache the patient rated as a 10 on a 1 10 scale and nausea without vomiting. The patient s vital signs were within the normal range, and a cursory physical and neurological exam was unremarkable. The transporting ambulance was delayed, so one of the firefighters decided to try the CO monitoring device while completing a second set of vitals. Shockingly, the patient s SpCO reading was 40%. They evacuated the patient from the porch, placed him on oxygen by non-rebreather mask and, to protect themselves from the toxic gas, donned self-contained breathing apparatus before entering the patient s home. Inside, they got readings of nearly 2,000 parts per million near a propane-fired gas water heater. Fire Chief Richard Shakerley says these masked calls are common. By the time the firefighters arrive, the family has often ventilated their home, so atmospheric CO readings in the home are within the normal range. The COoximetry device now allows firefighters who suspect CO poisoning to check The best evidence of the significant impact of CO monitoring on potentially lethal CO exposure comes from actual case reports. the family in addition to the residence. If they find a problem, they can mitigate the source. It s one of the tools we use to test a patient. It s a quicker assessment of what s really going on, Shakerly says. The department has since purchased an additional device and incorporated CO monitoring into the department s rehab protocol. MCI Averted Chief Skip Kirkwood Wake County (N.C.) EMS Division Wake County (N.C.) Department of Emergency Services A crew was dispatched to a 3 a.m. call for a 10-year old with a headache. They were told the patient would be in a car parked along one of the area s highways. However, when they arrived, they found a family of five in a sportutility vehicle (SUV), all suffering from headaches, nausea, vomiting, confusion and tingling skin. To complicate matters, no one in the family spoke English. Fortunately, one of the paramedics is a native of Chile and was able to determine that the family had been living in a local motel. They woke up in the middle of the night feeling ill and left in the SUV to go for help. On the way to the hospital, they became so confused that they called Once the on-scene crew realized they had a family with CO poisoning, they requested the Raleigh Fire Department be dispatched to the residential motel where the family had been staying. There, firefighters found dangerously high CO levels and multiple guests with elevated CO readings who required treatment. More than 50 guests were subsequently evacuated. Each patient was assessed and triaged with the assistance of the CO-oximetry device. Firefighters determined that a malfunctioning central HVAC unit had been circulating CO throughout the motel. You can t predict what would have happened, Kirkwood says. But there could have been 50 dead people by morning. He credits the first-arriving crew for their quick thinking in requesting a CO-monitoring device to assess the patients for CO exposure. The device was relatively new to his department at the time and only carried on a supervisor s vehicle. Since then, they have added another unit to their specialized major incident rehabilitation truck. Kirkwood is quick to point out that just having a tool isn t enough; you have to know when to apply it. This crew thought about the larger implications and probably saved a number of lives, he says. The Silent Killer: CO Poisoning 15

16 CO Close Calls: continued Uncovering CO Sources Firefighter/Paramedic Dwayne Love Aurora T (Colo.) Fire Department he Aurora (Colo.) Fire Department had been using a CO monitoring devices for less than a year when firefighter/paramedics Dwayne Love and Jim Rufer responded to a seizure call. On arrival, they found a postictal 29-year-old woman sitting in her kitchen. She says she had been watching a movie in a basement room with her boyfriend when she suffered the seizure. She also stated that she didn t feel well earlier in the week and that her two dogs had been vomiting in the house recently. This information was enough to cause Love and Rufer to check the patient and her boyfriend for CO poisoning. The woman s SpCO was 26%. A quick check of the boyfriend revealed a reading of 30%. The levels were so high Love noted that, in the past, this could have been one of those calls where the patient was merely advised to see their family physician. These dramatic saves prompted Aurora FD members to begin monitoring CO levels more frequently. It s another tool in our arsenal to give people the best care we can provide, Love says. Toxic SUV Capt. Stan Plyler (retired) BBremerton (Wash.) Fire Department remerton Fire Department (BFD) Captain Stan Plyler had a positive experience with CO monitoring before the department even purchased a unit. His experience started with a threehour road trip in his department utility rig to a regional EMS meeting. This was the first time he d had the opportunity to take his new sport-utility vehicle on an extended drive. He went directly from his meeting to another one with a Masimo representative at a neighboring fire district, where he watched a demonstration of the company s CO monitoring device. The representative placed the probe on each person at the meeting. Everyone else had normal readings, but Plyler s registered a moderate 7%. After some questioning, the group identified a defect in the department vehicle as the source of CO. The department ordered a CO monitoring device soon after this incident and, while Plyler was training a few of the firefighters how to use the device, a call came in for an unconscious man on a small pleasure boat. The patient, an older man who had been working on his boat engine, was overcome by the exhaust engine fumes. His wife found him unconscious on the boat, woke him and helped him onto the dock. When BFD crews arrived, the man was vomiting and confused. Plyler immediately monitored the patient s CO levels, which registered 45%. The patient was placed on high-flow oxygen and began to feel better. Initially, he didn't want to go to the hospital but agreed to go after the significance of the high CO level. [The SpCO reading] was explained to him, Plyler says. It was nice to have that. The patient was transported to a specialty facility and placed in a hyperbaric chamber to recover from the effects of a near-fatal CO poisoning. photo Durango (Colo.) Fire & Rsecue From left is Dan Steaves, Sean Schmida, Leo Lloyd, John Brennan and Beau Mattison. firefighters thought the unit might not be working properly. After confirming it was functioning normally, they treated and transported both patients and sent the dogs to a local veterinary hospital. Firefighters conducted a CO inspection of the house, and identified a faulty boiler as the culprit. 16 JEMS A Convincing Story Fire Chief Mark Niemeyer Meridian M (Idaho) Fire Department eridian (Idaho) Fire Department (MFD) Chief Mark Niemeyer says his department was the first in his state to purchase a CO-oximeter. We had done a bunch of research before we bought [it], he says, adding that he used that research to convince elected officials to authorize the purchase of one unit. Just one week after receiving the device, Meridian firefighters and an ambulance crew from Ada County were called to the scene of a possible suicide. They found a deceased woman seated upright in her car, which was parked in the garage of a two-story duplex. The garage door had been sealed with tape and the woman had left a suicide note.

17 While the firefighters searched the woman s home for other potential patients, paramedics interviewed the man living in the other half of the duplex. He says he worked nights and slept during the day. He reported awakening earlier to the smell of gas and contacted the gas company. A gas company employee responded and found elevated CO levels in the man s apartment. The upstairs bedroom, where the man had been sleeping, registered 750 parts per million on his monitor. He was ventilating the apartment and investigating the source of the CO when he heard the car running in the garage. After finding the woman s body, he called It was estimated that the car had been running for six hours, spewing deadly CO gasses into the man s apartment through a shared attic space and the HVAC system. Because of his obvious exposure, the patient s CO levels were tested. His first SpCO reading was 24%. However, he reported feeling better and refused to be transported to a hospital. After explaining the risk of a reading that high, the man finally agreed to treatment. He spent two days in a hyperbaric chamber until his CO levels returned to normal. In my 17 years in the fire service, I can t imagine [how] many patients like him we left at home. w we have a quantifiable number on a screen, Niemeyer says. MFD also uses the device for firefighter rehab. In conjunction with Ada and Canyon counties, Niemeyer is developing a standardized rehab policy for the Treasure Valley, an area that includes Idaho s largest city, Boise. CO monitoring and oximetry is part of that [program], Niemeyer says. Niemeyer felt so strongly about the effectiveness of the device that he requested the Idaho State board s approval of CO-oximetry as a standard of care. After a year-long study on its use, the board signed off on his additional request that the device be approved for use by BLS as well as ALS crews. Lowering body temperature to a normal level is just one aspect of rehab; personnel should also be monitored for abnormal cardiovascular and CO levels. Develop and implement a rehab protocol for your agency to ensure this process starts early during high-acuity, high-demand incidents. Measuring CO Exposure & Levels Medical Director Craig Manifold, DO; Lieutenant Carl Jackson & Civilian Training Officer Terry Eaton TSan Antonio (Texas) Fire Department he San Antonio (Texas) Fire Department (SAFD) employs about 1,100 firefighters who protect a population of 1.5 million residents and a significant number of tourists. So when the department committed to purchasing a CO-oximeter, they went all in, buying units just over a year ago one for each on-duty EMS unit. The primary reason behind the purchase was the advocacy of SAFD medical director Craig Manifold, DO. One of the big drivers for us was the protection of our firefighters, he says. Manifold helped institute a new rehab protocol soon after his appointment as medical director. The challenge, he says, was to get the firefighters to view rehab as a formal assignment. As the unit demonstrated its usefulness, the firefighters were convinced. The department has begun collecting data from their rehab forms to compare CO levels of firefighters, officers and engineers. They re particularly interested in the CO exposure of engineers. On a few occasions, I have noticed that they have the highest readings, says training officer Terry Eaton. The most likely photo A.J. Heightman photo Michael J. Coppola The Silent Killer: CO Poisoning 17

18 CO Close Calls: continued causes are exhaust from the apparatus and plume shifts. Because engineers don t use self-contained breathing apparatus, Eaton believes that they re more susceptible to CO risks. Once firefighters began using the device, they found several additional uses for it. For example, they determined that it works well as a pulse oximeter for pediatric patients even better than a standard monitor, Eaton says. In addition, it has identified a few children who had CO poisoning that the firefighters didn t even suspect. t long ago, a crew giving breathing treatment to a sick infant used the device on the lethargic child. t only did the device measure the oxygen saturation of the patient s blood, it indicated that the child had slightly elevated levels of CO. A quick check of the rest of the family determined everyone else had normal CO levels, with the exception of one family member who was a smoker. Lieutenant Carl Jackson says the device not only indicates exposure but also the severity of exposure. It s been a great screening tool for our own [personnel] and our patients, he says. Conclusion From firefighters at a fire scene, to patients being poisoned in their own homes, there has been a need to measure and quantify CO levels. With the use of this new assessment tool for CO and oxygen saturation in the hands of prehospital providers, that job has become easier and the results have been impressive. Thanks E Series Monitors with Integrated CO Measurement By Teresa McCallion, EMT-B photos ZOLL Medical This past December, ZOLL Medical Corporation announced the introduction an integrated, non-invasive carbon monoxide (CO) assessment tool using Masimo Rainbow SET technology in the E Series monitor. The feature provides early detection and significantly reduces the immediate and long-term health risks associated with elevated CO levels. A number of agencies are ordering the new monitors outfitted with the CO-assessment feature. The San Bernardino City Fire Department (SBCFD) is converting from the M to the E Series monitors. The last couple of sets will have the CO monitoring included, says SBCFD EMS Captain Bernie Horak. He says the SBCFD is purchasing the monitors with the integrated monitoring capability for two 18 JEMS reasons first to protect their own personnel, and second to protect the public. We are very careful to monitor our personnel for CO levels, Horak says, adding that they re especially alert to possible CO poisoning during wildland fires. A number of common symptoms, such as headaches, fatigue, and confusion, can be caused by CO poisoning, and it s critical that we have the ability to assess our firefighters' CO levels so that it s not missed on the fire ground. The convenience of the new monitors with the integrated CO measurement technology was the reason SBCFD made the purchase. It s built right in, so it s seamless, Horak says. The easier we can make it to monitor CO, the more likely it will be done.

19 to this new monitoring technology, the days of masked vital signs are over. Teresa McCallion, EMT-B, is a freelance public safety writer living in Bonney Lake, Wash. She's a volunteer EMT for East Pierce Fire and Rescue. Disclosure: The author has reported no conflicts of interest with the sponsors of this supplement. Where there's smoke there's CO. Place rehab in a smoke-free location and monitor for CO exposure. photo michael coppola In Western Taney County (Mo.), officials are in the process of upgrading to monitors with the COmeasuring capabilities. I envision that everyone will be routinely checked for CO poisoning, says Western Taney County Fire Protection District Chief Chris Berndt. Taney County Ambulance has been using handheld Masimo Rad-57 units for some time and has identified several patients with elevated CO levels. We have been really impressed with it, Berndt says. The crews not only get a reading for patients suspected of CO poisoning, but they ve also been surprised to find patients who have been exposed in cases that weren t obvious. We feel that now more than ever, patients should be monitored for CO, he says, adding that he likes the new feature because it s simple to use. Berndt says that because the CO monitor works a lot like the pulse oximeter, training hasn t been an issue. If you feel it s worth putting a pulse oximeter on a patient, it s worth getting a CO reading too, he says. In northeast Missouri, Marion County Ambulance District officials knew they needed to measure CO levels, so they decided to upgrade existing E Series monitors and get the new CO measurement feature. Chief Training Officer John Clemens says that although some of the local fire departments that respond within the Marion County District employ the handheld Rad-57s, it s a tool the emergency medical providers also needed to have. Clemens says that upgrading their monitors to include CO measurement was a convenient and cost-effective solution. Clemens says they ve been shocked at how many patients register with elevated CO levels. Looking at those who are chronically exposed directly affects our paramedic s treatment modality, Clemens says. It also provides an important [exposure to] rule out. Identifying patients with CO poisoning and being able to quantify the level of exposure is increasingly becoming a standard assessment when evaluating patients and determining the best course of treatment. Using the integrated, auto-displayed CO assessment feature on the ZOLL E Series monitors allows emergency responders to quickly and accurately detect CO poisoning with the touch of a button. The Silent Killer: CO Poisoning 19

20 Proper sensor placement (with the finger tip positioned in line with the designated digit stop) will ensure fast, accurate readings. A Standard of Care Early results from FDNY point to the benefits of regular CO monitoring in patients & firefighters By John J. Peruggia, BSHuS, EMT-P, & Doug Isaacs, MD Illustration Masimo Corp. After successfully rescuing two trapped Fire Department of New York (FDNY) firefighters, an officer complained of lightheadedness and mild shortness of breath. Initial assessment revealed him to be normotensive, slightly tachycardic and tachypneic with a pulse oximetery reading of 100%. Paramedics using a CO-oximeter device determined his carboxyhemoblobin (COHb) level was 22% a dangerously high level; subsequently, he received ALS care and Doug Isaacs, MD was transported to a hospital facility. This is an example of why firefighters need to be screened for elevated COHb levels at emergency scenes. It supports the argument that CO assessment should be considered a standard of care, especially at potential CO exposure incidents. Screening in the Field Studies have shown that the emergency department (ED) misses the diagnosis 30 50% of the time. 1 3 If you extrapolate John Peruggia, BSHuS Over the past 18 months, we have identified several members who were found to be CO toxic and asymptomatic. that percentage to the unpredictable prehospital environment, you will realize the potential exposure to missed cases and service liability that CO exposures present. In 2008, the FDNY began using COoximeter monitoring in the field to determine COHb levels on symptomatic patients at the scene of emergencies where CO toxicity was suspected, as well as on asymptomatic occupants when elevated CO levels were detected by atmospheric gas CO monitors. In January 2009, this was expanded to evaluate all personnel at the scene of third-alarm or greater fires as part of our rehabilitation program and to evaluate long-term cardiovascular affects of elevated COHb levels. The region also began to implement a smoke-inhalation protocol that included the treatment for patients with suspected cyanide poisoning, along with monitoring for CO exposure. An initiative was also undertaken to develop a protocol to transport patients with signs and symptoms of CO intoxication or elevated levels of COHb directly to receiving hospitals that have the ability to provide emergent hyperbaric oxygen (HBO) therapy on a 24/7 basis. This protocol will further enhance our system s ability to rapidly identify, properly treat and ensure an appropriate continuum of care for these patients. Table 1 20 JEMS