© 2008 Masimo Corporation Includes a review on Carbon Monoxide Poisoning For Emergency Responders V.5 4 July 2010 Monitoring CO Poisoning with the Rad-57 TM

© 2008 Masimo Corporation IMPORTANT NOTICE This program is not meant as a substitute for a program or course of study in carbon monoxide recognition and treatment, or emergency medicine. This is for review only. Please refer to your physician or local Medical Director for approved content and medical protocols. This program is not meant as a substitute for the manufacturer’s operator manual for the Masimo Rad-57. Please refer to the manufacturer for complete operating instructions.

© 2008 Masimo Corporation Section 1 Review: Carbon Monoxide Poisoning For Emergency Responders

© 2008 Masimo Corporation Introduction Carbon monoxide is the leading cause of poisoning in the United States for the last 100 years and is a common hazard to First Responders. Until recently, the only way to reliably diagnose carbon monoxide poisoning was to draw blood and check the carbon monoxide levels in a lab. With Masimo’s RAD 57 Pulse CO-Oximetry, testing for carbon monoxide can now be done quickly, easily and non invasively, allowing for prompt screening and treatment in the field.

© 2008 Masimo Corporation 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): 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: Hampson NB, Stock AL. Storm-Related Carbon Monoxide Poisoning: Lessons Learned from Recent Epidemics. Undersea Hyperb Med 2006;33(4): Cobb N, Etzel RA, Unintentional Carbon monoxide-related deaths in the United States, 1979 through JAMA 1991;266(5): Weaver LK, et al. N Engl J Med, 2002;347(14): Henry CR, et al. JAMA. 2006;295(4):

© 2008 Masimo Corporation CO Poisoning: The Great Imitator % of CO-exposed patients presenting to Emergency Departments are misdiagnosed Barker MD, et al. J Pediatr. 1988;1: Barret L, et al. Clin Toxicol. 1985;23: Grace TW, et al. JAMA. 1981;246:

© 2008 Masimo Corporation Its NOT CO 2 ! Carbon monoxide is a colorless, odorless, tasteless toxic gas. Carbon Mono xide = CO Carbon Di oxide = CO 2 CO = Pulse CO-Oximetry CO 2 = Capnography

© 2008 Masimo Corporation Incomplete combustion of any carbon-based material will produce carbon monoxide. Closed or confined spaces are particularly hazardous. Common sources are: Gas heaters, furnaces water heaters Automobiles Boats, campers Gas-powered generators Portable / space heaters Barbecues / fireplaces Cigarette smoke Methylene chloride Structure / wildland fires Common Sources

© 2008 Masimo Corporation Pathophysiology Hypoxia Cellular, cardiac and cerebral Intracellular toxicity Cardiac and skeletal muscle dysfunction Inflammatory response Secondary to hypoxia Vasodilation Induced by Nitric Oxide release (hypotension) Free radical formation Endothelial and oxidative cerebral damage

© 2008 Masimo Corporation Cardiac Effect- Moderate to Severe Exposure “Myocardial injury occurs frequently in patients hospitalized for moderate to severe CO poisoning and is a significant predictor of mortality” A recent study demonstrates that a patient has a 3 times higher likelihood of cardiac death (within a 7 year follow-up period) from even one moderate to severe toxic CO exposure, when compared to a control group Myocardial Injury and Long-Term Mortality Following Moderate to Severe Carbon Monoxide Poisoning. Henry CR, Satran D, Lindgren B, Adkinson C, Nicholson C, Henry TD. JAMA. 2006;295(4):

© 2008 Masimo Corporation Cardiac Effect- Chronic, Low Level Exposure 19 year study 8,333 Swedish males divided into 3 groups: smokers, prior 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 of cardiovascular event 3.7 greater, risk of death 2.2 higher comparing the highest to the lowest quartiles Incidence of cardiovascular 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:

© 2008 Masimo Corporation Neurologic Effect Delayed Neurologic Syndrome Experienced by 11-30% of patients with CO Poisoning Long-Term/Chronic Sequelae Cognitive and personality changes, dementia, seizures, psychosis, amnesia, parkinsonism, depression, short-term memory loss, incontinence. Harper A et. al, Age and Aging. 2004;33(2): Kao LW et. al, Emerg Med Clin North Am Weaver LK, et al. N Engl J Med, 2002;347(14): Abelsohn A, CMAJ 2002:166 (13):

© 2008 Masimo Corporation Signs and Symptoms Headache Drowsiness Dizziness Confusion Fatigue Syncope Seizures Malaise Flu-like symptoms Fecal/ Urinary incontinence Bizarre neurologic symptoms Nausea/ vomiting/ diarrhea Gait disturbances Chest pain Palpitations Lethargy Coma Death

© 2008 Masimo Corporation Treatment Considerations Scene safety, protect yourself: Consider SCBA Remove patient(s) away from the poison! Check SpCO level with RAD 57 Treat elevated levels with 100% oxygen: Support ventilations as needed Consider hyperbaric treatment center: Adults >25%, Pedi & Pregnant female >15% Neurologic compromise Always follow local EMS protocols

© 2008 Masimo Corporation Fetal Damage Rucker J, Fisher J, Carbon Monoxide Poisoning, Chapter 63 Longo LD: The biological effects of carbon monoxide on the pregnant woman, fetus, and newborn infant. Am J Obstet Gynecol 1977;129: Theoretical effect of different treatments on maternal and fetal COHb levels over time

© 2008 Masimo Corporation Sample SpCO Protocol

© 2008 Masimo Corporation Half-Life Half-life: The amount of time required to reduce the blood level of CO by 50%. Age and health will impact the half-life of CO. Breathing Room Air: CO half-life in blood is 4-6 hours High Flow Oxygen via Non- Rebreather Mask: CO half-life minutes Hyperbaric Oxygen Treatment (HBOT): CO half-life minutes

© 2008 Masimo Corporation Severity of Intoxication: COHb and Duration Highlighted Area demonstrates current OSHA Standard for CO: [500ppm/30 minutes] Consider 500 ppm/60-90 minutes….

© 2008 Masimo Corporation Firefighter Risk CO levels may be highest during the post- fire or overhaul Periods that self-contained breathing apparatus (SCBA) are not worn or not functioning properly CO poisoning is often unrecognized due to the presence of exhaustion, heat stress, illness or injuries Elevated levels can be immediate threats to health and safety, and cause cardiovascular injury CO exposure is just one of the many reasons why rehab is so vitally important on the fire/training ground!

© 2008 Masimo Corporation CO Assessment in FF Rehab Suggested in NFPA 1584 CO induces death secondary to V Fib VF initial rhythm in 90% interior FF deaths Should not leave rehab if > 5% COHb

© 2008 Masimo Corporation Carbon Monoxide and Cyanide Signs and symptoms of shock, seizures, cardiac arrest, AND a normal or low SpCO? Consider cyanide and have a low threshold for treatment (preferably with hydroxocobalamin). Cyanide

© 2008 Masimo Corporation Section 2 Overview: Using the RAD-57 Pulse CO-Oximeter Note: This is NOT intended to replace or act as a substitute for the Operators Manual. Please refer to the manufacturer’s Operator Manual for complete information on the operation and safety of the RAD-57 Pulse CO-Oximeter.

© 2008 Masimo Corporation RAD-57 EMS Carry Case Lightweight: 13 oz. Small: 6.2” x 3.0” x 1.4” Portable: operates on 4 “AA” batteries Supplied with high-visibility, water-resistant protective case Clear protective cover Reference card holder Pen holder Spare battery pocket Extra sensor pocket

© 2008 Masimo Corporation RAD-57 Operation / Powering Up POWER Press to turn ON Press and HOLD to turn OFF Battery Indicator 4 Green LED’s Each represents approximately 25% battery life Use only Alkaline batteries Do Not use rechargeable batteries Battery Compartment Located in back panel Holds 4 “AA” alkaline batteries Operates 8-10 hours

© 2008 Masimo Corporation RAD-57 Operation / Sensor Placement Sensor placement is VERY IMPORTANT Use only the index, middle or ring fingers. Do NOT use toes. Insert finger until the tip of the finger hits the black STOP Block. Do NOT shove the finger too far into sensor There is a top and bottom to the sensor; the cable should be on top of the hand INCORRECT SENSOR PLACEMENT CAN CAUSE A FALSELY ELEVATED SpCO!! Optimal LED path

© 2008 Masimo Corporation RAD-57 Operation / Startup Sequence Place sensor on finger (relatively clean & dry) Press green “Power” button Calibration begins: Takes ~10 seconds Calculation begins: Scrolling zeroes 0 – 0 – 0 followed by dashed lines on screen May take up to 20 seconds Do not move sensor during this phase Begin patient monitoring: Defaults to carboxyhemoglobin screen * Refer to operator’s manual for additional verifications prior to patient monitoring.

© 2008 Masimo Corporation RAD-57 Operation / Measuring CO Display after Startup: Carboxyhemoglobin (SpCO) level on top, in % Dashed lines on the bottom The Period denotes which parameter is displayed. CONFIRM ALL ELEVATED SpCO READINGS by taking a total of 3 readings on 3 different fingers. Use the average of the three as the SpCO.

© 2008 Masimo Corporation RAD-57 Operation / Measuring SpO 2 and Pulse Rate Pulse oximeter (SpO2) reading top; heart rate on bottom. SIQ- Signal Identification and Quality- identifies the quality of the SpO2 signal. Press Yellow “Bell” button to silence alarms. Press “Display” button ONCE for SpO 2 and pulse rate readings. Press “Display” button a SECOND time for the PI reading, a THIRD time to return to SpCO screen. Alarm Silence Button

© 2008 Masimo Corporation RAD 57 Operation / Measuring PI Press the ‘Display’ button to display the PI parameter. PI = Perfusion Index. A measurement of blood flow to the extremity the sensor is on. The same principal as capillary refill. The greater the number, the greater the perfusion- with 0 being no perfusion at all. Displayed both numerically and graphically. Perfusion Index Bar Graph

© 2008 Masimo Corporation Light Shield Use The presence of intense ambient light can interrupt (no reading) or interfere (falsely elevate reading) with the SpCO reading. SHIELD THE SENSOR FROM INTENSE AMBIENT LIGHT!! This includes strobes and sunlight. Insert the sensor all the way into the light shield; ensure the cable is coming out of the top of the opening. Once sensor is in place, insert finger into sensor. Apply pressure to open sensor

© 2008 Masimo Corporation SpCO Accuracy The SpCO parameter has an accuracy of +/- 3% (for one standard deviation, which is 67% of patients) Example: A reading of 4% could actually be between 1% - 7% Measurements may vary from reading to reading, even on the same patient, within the accuracy specification If an elevated SpCO is detected, ALWAYS confirm by measuring 2 additional fingers. Use the rough average of the readings as the person’s SpCO value.

© 2008 Masimo Corporation RAD-57 Operation / Warnings and Cautions Good arterial perfusion along with correct sensor placement will provide a stable CO reading. Inaccurate measurements may be caused by: Incorrect sensor placement Elevated levels of methemoglobin Intense ambient light Low arterial perfusion Motion artifact

© 2008 Masimo Corporation Thank You QUESTIONS?