2. Cognitive 1. Define carbon monoxide and carbon monoxide poisoning. 2. Describe the causes of carbon monoxide poisoning. 3. Identify signs and symptoms of carbon monoxide poisoning.

3. Cognitive 4. Describe the care and treatment for a patient suffering carbon monoxide poisoning. 5. Discuss methods for diagnosing carbon monoxide poisoning. 6. Identify the risks of carbon monoxide poisoning to EMS providers.

4. Psychomotor 1. Demonstrate the steps in emergency care of a patient with suspected carbon monoxide poisoning. 2. Demonstrate operation and usage of the Rad 57 for detection of SpCO.

5. ● Chemical symbol – CO ● Colorless ● Odorless ● Tasteless ● “Silent Killer ● “Great Imitator”

6. ● 6,000 fatalities annually in US. ● 40,000-50,000 people seek ED care for CO related problems annually. ● Often called “Silent Killer,” CO’s initial symptoms are often vague, subtle and easily misdiagnosed.

7. ● Incomplete combustion of carbon Carbon- containing fuels. ○ Home heating oils ○ Charcoal ○ Kerosene ○ Coal ○ Gas

8. ● Faulty Furnaces, heaters ● Auto exhaust ● Gas generators ● Charcoal grills used indoor ● Tobacco smoke ● Fires ● Small gas engines or equipment ● Gas appliances ● Gas heaters in enclosed areas

9. ● CO is 200-250 times more desirable that Oxygen to RBC’s. ● CO readily displaces oxygen from the hemoglobin and forms a compound called carboxyhemoglobin, which does not carry oxygen. ● Carboxyhemoglobin is delivered to cells in place of oxygen resulting in tissue hypoxia. ● Creates suffocation type of environment at cellular level.

10. ● Amount of carbon (concentration) ● Time (duration) ● Activity level (during exposure) ● Health ● Age

11. ● Specific Occupations (Fire & EMS) ● Elderly ● Children ● Infants ● Pregnant mothers ● People with existing health problems

12. ● Headache● Dizziness ● Weakness● Weakness ● Nausea● Vomiting ● Chest Pain● Altered LOC ● Flu-like● Coma ● Death

13. ● Suspect Carbon Monoxide poisoning when: ○ Several symptoms are reported at the same time. ○ No other cause can be identified. ○ More than one person at scene reports similar symptoms/onset.

14. ● Even low-level exposure to carbon monoxide results in long-term impairment of higher cognitive functions such as memory, new learning ability, attention, and concentration. ● Effects may mimic a stroke (The great Imitator) ● Coma and Brain death

15. ● Hypotension ● Tachycardia ● Dysrhythmia’s ● Myocardial Ischemia ● Symptoms may mimic an MI ● Ultimately Ventricular Fibrillation

16. ● Rescuer safety is #1 priority ● Never Enter hazardous scene without proper PPE. ● Evacuate occupants/victims ● Ventilate as needed

17. ● Pulse Oximeters can not detect CO ● Rad-57, non-invasive and continuous method of detecting Carbon Monoxide in patients. ○ Detects carboxyhemoglobin levels ○ Detects oxyhemoglobin levles ○ Obtains pulse rate ○ Small, handheld battery operated ○ Finger clamp similar to a pulse oximeter.

18. ● The Masimo Rad 57C is the only FDA-approved Pulse CO-Oximeter that noninvasively and continuously monitors Carbon Monoxide levels in the bloodstream in seconds. EMS professionals can quickly and easily diagnose carbon monoxide poisoning on the scene. Just slip the sensor on the patient’s finger and press a button. The Masimo Rad 57C accurately detects the percentage of Carbon Monoxide in the bloodstream in just seconds, allowing for prompt and possibly life saving treatment.

19. ● Any patient with suspected carbon monoxide poisoning should receive oxygen via NRB mask. ● The RAD-57C may be used as a screening tool for ASYMPTOMATIC potentially exposed people: ○ If there is a CO alarm in a residence, the RAD-57C may be used to test for levels on the occupants of the location. ○ Any asymptomatic patient with a level of greater than 15% should receive oxygen for 30 minutes, then reassess the patient.

20. ● The RAD-57C may be used as a screening tool for SYMPTOMATIC patients: ○ If there is a CO alarm in a residence, the RAD-57C may be used to test for levels on the ill occupants of the location. ○ Carbon monoxide poisoning does not have specific, clear cut symptoms, and other medical conditions may present with dizziness, nausea or confusion. ○ All symptomatic patients should be transported, regardless of RAD-57C level.

21. SpCO %Clinical Manifestations 0-3%None - Normal 4-9%Minor Headache 10-19%Headache, Shortness of Breath 20-29%Headache, Nausea, Dizziness, Fatigue 30-39% Severe Headache, Vomiting, Vertigo, ALOC 40-49%Confusion, Syncope, Tachycardia 50-59%Seizures, Shock, Apnea, Coma 60% -upComa, Death Koster LA, Rupp T.The Silent Killer, Recognizing and Treating Carbon Monoxide Poisoning. JEMS. October 2005

22. Measure SpCO SpCO 0-3% SpCO >3% No further medical evaluation of SpCO needed Loss of consciousness or neurological impairment or SpCO >25% ? Yes No Transport on 100% oxygen for ED evaluation. Consider transport to hospital with hyperbaric chamber SpCO >12 SpCO <12 Transport on 100% oxygen for ED evaluation Symptoms of CO exposure? Transport on 100% oxygen for ED evaluation No further evaluation of SpCO needed. Determine source of CO if nonsmoker Yes No

23. ● Remove patient from environment ● Apply high-flow oxygen ● Obtain SAMPLE history ● Complete an assessment ● Obtain vital signs ● Use Rad 57C if available ● Transport to most appropriate facility

24. ● Re-Assess LOC & vital signs ● Evaluate respiratory system ● IV ● EKG monitoring ● Use Rad 57C, if available ● Transport to most appropriate facility

25. ● Hyperbaric oxygen treatment (HBO) may be recommended if SpCO >30 and/or the patient is unconscious, has altered mental status, or the patient is pregnant. ● Follow local protocols for guidance.

26. PPM or “Parts Per Million” is the atmospheric concentration of the gas PPM is common fireground safety measurement, often misleading as CO forms in pockets SpCO - noninvasive measurement of CO in the blood SpCO as measured by RAD-57 is a function of PPM CO and total time of exposure of the poison Age, health and respiratory rate may be a factor Even low PPM levels can lead to high SpCO if exposure is long enough, common in overhaul Even an exposure of 50 PPM for 60 minutes requires assessment and possible medical treatment with oxygen

27. 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.

28. 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 Protective cover Reference card holder Department ID holder Pen holder Spare battery pocket Extra sensor pocket

29. 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

30. RAD-57 Operation / Startup Sequence Place sensor on finger (relatively clean & dry) Press “Power” button Verify All LED’s light up and a 1 second tone is heard* Startup mode begins All preset configurations are displayed Scrolling zeroes 0 – 0 – 0 and flashes dashed lines May take up to 25 seconds Do not move sensor during startup When complete reading is displayed Begin patient monitoring Defaults to pulse rate and oxygen saturation reading “PI” bar graph displays strength of arterial perfusion

31. RAD-57 Operation / Sensor Placement Sensor placement is very IMPORTANT When possible, use ring finger, non-dominant hand Insert finger until the tip of finger hits the STOP Block Sensor should not rotate or move freely on finger LED’s (red light) should pass through mid-nail, not cuticle There is a top and bottom, cable should be on top (nail side) Optimal LED path

32. RAD-57 Operation / Pulse Rate and Saturation Display after Startup Oxygen Saturation on top in Red Pulse Rate on bottom in Green Green PI scale, indicates strength of arterial pulse Low SIQ LED indicates poor SpO 2 signal quality Press “Display” to display % carboxyhemoglobin Press “Bell” to silence alarms Display button toggles from SpO 2 to SpCO PI Scale Low SIQ LED Alarm Silence LED Battery level

33. RAD-57 Operation / Alarms When parameter is violated, audible alarm will sound, parameter will flash Preset at factory: Sp0 2 (oxygen saturation) Low: 90% High: none Pulse Rate Low: 50 High: 140 SpCO (carboxyhemoglobin) Low: none High: 10% Alarms adjust: Press “Mode/Enter” twice Press “Next” key to scroll through parameters Use up and down keys to adjust Changes remain until user restores to factory defaults Alarm Indicator (flashes)

34. RAD-57 Operation / Measuring CO Press “Display” button for SpCO reading To scroll back to SpO 2 mode press “Display” again Carboxyhemoglobin displayed in % on top “CO” displayed on bottom confirming mode Real-time SpCO indicator continuously reads SpCO Green: 1-3% Yellow: 4-11% Red: 12% and above Confirm abnormal readings by taking several measurements on different fingers and average the readings Slow: Low SpCO Confidence Fast: SpCO Alarm CO label when SpCO is displayed

35. RAD-57 Operation / Troubleshooting Error Messages: “NO Cbl” Cable not seated properly into top of Rad-57 Defective cable “SEN OFF” Sensor off finger Sensor misaligned “bAd CbL” Defective cable Replace cable “CbL” Incompatible cable Connect appropriate cable “bAd SEN” Defective sensor Replace sensor “SEN” Unrecognized sensor Connect appropriate sensor

36. RAD-57 Operation / Troubleshooting Will not power on Check battery compartment Replace batteries Continuous Startup mode (Scrolling zeroes 0 – 0 – 0 and flashes dashed lines) Shield sensor from flashing lights, strobes or high ambient light with Masimo Light Shield* Try other fingers Single battery level indicator flashes (with audible alarm) Battery level too low Replace batteries immediately “Err” message Return for service, Call 800-326- 4890 Continuous Speaker Tone Power down and remove batteries Return for service, Call 800-326- 4890

37. RAD-57 Operation / Light Shield Use Face protrusion of light shield down, and insert the end of the sensor into the hole Ensure that sensor hits the back of the light shield Orient the sensor so the cable is coming out of the top of the hole while in the light shield Open the sensor by applying pressure from the top and bottom of the light shield Insert finger until the tip of finger hits the STOP Block LED’s (red light) should pass through mid-nail, not cuticle Orient the sensor so the cable is running over the top of the patient’s hand Optimal LED path Apply pressure to open sensor Protrusion

38. RAD-57 Operation / Improving Accuracy The Rad-57 is designed with an accuracy of +/- 3 digits with a range of 1% - 40% for one standard deviation (67% of patients) Example: A reading of 10% could have a range from 7% - 13% Measurements may vary from reading to reading, even on the same patient, within the accuracy specification Proper probe placement may improve accuracy If an abnormal level of CO is detected, always confirm by measuring other fingers and average Flashing lights, strobes or high ambient light may interfere, use a Masimo Light Shield or other means of shielding

39. RAD-57 Operation / Contraindications Small physiological changes and acceptable levels of 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 Intravascular dyes such as indocyanine green or methylene blue Abnormal hemoglobin levels Low arterial perfusion Low arterial oxygen saturation levels Elevated Total Bilirubin levels Motion artifact

40. RAD-57 Version Differences Version 1 Faceplate design changes (see image) SpCO button displays value for 10 seconds Upon Startup all LEDs flash, dashed lines, scrolling zeroes, followed by flash dashed lines Alarm settings revert back to factory settings upon power off SpCO bar graph changes color at 10% and 20% Version 2 Faceplate design changes (see image) Display button allows user to scroll through modes (SpO 2, SpCO and PI) PI can be displayed as a numeric value Upon Startup all LEDs flash, device presents all configurations, then scrolling zeroes and flash dashed lines Alarm settings are retained after power off SpCO bar graph changes color at 3% and 12%

41. Resources For more information on carbon monoxide poisoning and the Masimo Rad-57 www.masimo.comwww.masimo.com or call 800-326-4890 www.Firerehab.com www.firegrantshelp.com www.emsgrantshelp.com www.naemse.org www.naemt.org www.iaff.org www.carbonmonoxidekills.com/ www.epa.gov/iaq/pubs/coftsht.html www.carbon-monoxide-poisoning.com www.nlm.nih.gov/medlineplus/carbonmonoxidepoisoning.html www.emedicinehealth.com/carbon_monoxide_poisoning/article_em.htm www.osha.gov/OshDoc/data_General_Facts/carbonmonoxide-factsheet.pdf www.cdc.gov/co/ www.bt.cdc.gov/disasters/carbonmonoxide.asp www.postgradmed.com/issues/1999/01_99/tomaszewski.htm Masimo Corporation 40 Parker Irvine, CA 92618 949-297-7000

42. ● Consider Carbon Monoxide poisoning when symptoms seem suspicious or if patient has been in an enclosed environment. ● Quick diagnosis and treatment is critically important in saving the patient and preventing others from being poisoned as well.

44. Roy L. Hunter roy.hunter@clemc.us roy.hunter@clemc.us