Carbon Monoxide
on the Fire Ground
& EMS Response
to CO Poisoning
Mike McEvoy, PhD, NRP, RN, CCRN
EMS Coordinator – Saratoga County, New York
EMS Editor – Fire Engineering Magazine
EMS Director – New York State Association of Fire Chiefs
Firefighter/Paramedic – West Crescent Fire Department
Chair – Resuscitation Committee – Albany Medical Center
Outline
1. CO science update
2. Fire ground air research update
•
Atmospheric monitoring
Changes to rehab practices
3. Recognizing/treating CO poisoning
•
•
Role of CO detector legislation
•
Appropriate FD response practices
www.mikemcevoy.com
www.thesilentkiller.net
Or, pick up a copy at the Masimo booth
Carbon Monoxide (CO)
“The Great Imitator”
• Invisible
• Masquerades
Signs and Symptoms
SpCO%
<5%
Clinical Manifestations
None
5-10%
Mild headache, tire easily
11-20%
Moderate headache, exertional SOB
21-30%
41-50%
Throbbing headache, mild nausea,
dizziness, fatigue, slightly impaired
judgment
Severe headache, vomiting, vertigo,
altered judgment
Confusion, syncope, tachycardia
51-60%
Seizures, unconsciousness
31-40%
Carbon Monoxide Poisoning Presents Like the Flu!
CO Poisoning: The Great Imitator
30-50 % of CO-exposed patients presenting to
Emergency Departments are misdiagnosed
Barker MD, et al. J Pediatr. 1988;1:233-43
Barret L, et al. Clin Toxicol. 1985;23:309-13
Grace TW, et al. JAMA. 1981;246:1698-700
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:
•
•
1
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
Hampson NB, Weaver LK. Carbon Monoxide poisoning: A new incidence for an old disease. Undersea and Hyperbaric Medicine
2007;34(3):163-168.
2 Mott
JA, Wolfe MI, Alverson CJ, MacDonald SC, Bailey CR, Ball LB, Moorman JE, Somers JH, Mannino DM, Redd SC. National Vehicle
Emissions policies and practices and declining US carbon monoxide-related mortality. JAMA 2002;288:988-995
3 Hampson
NB, Stock AL. Storm-Related Carbon Monoxide Poisoning: Lessons Learned from Recent Epidemics. Undersea Hyperb Med
2006;33(4):257-263
4 Cobb
N, Etzel RA, Unintentional Carbon monoxide-related deaths in the United States, 1979 through 1988. JAMA 1991;266(5):659.
5 Weaver
6 Henry
LK, et al. N Engl J Med, 2002;347(14):1057-067.
CR, et al. JAMA. 2006;295(4):398-402.
Source: USA Today November 29, 2011
compiled from National Conference of States
Legislatures and International Code Council
CO Detector Legislation 2013
Has the Incidence of CO Poisoning Changed?
• 18,159 confirmed cases of CO Poisoning in analysis of the
Nationwide Inpatient Sample (ICD-9-CM) between 2000 – 2009
• 2000: 5.9 cases per 100,000 population
NO Change!
• 2009: 5.7 cases per 100,000 population
• All cause hospital mortality unchanged at 3.01%, risk factors:
• Age > 65 (OR 2.57)
• Uninsured (OR 1.69)
• Need mechanical ventilation (OR 46.3)
• Median LOS unchanged at 2 days
• Increased need for mechanical ventilation (16.4%) and discharge
to skilled nursing facility (22.2%)
Hedge P, Kumar G, Sheel S, Taneja A, Nanchal R. 668: Carbon monoxide poisoning trends and
associated mortality: a nationwide analysis (2000-2009). [Abstract]. Crit Care Med 2012; 40(12)
(Suppl 1):1-328.
Unsuspected CO?
• Albany Medical Center Pediatric Cardiac Surgery
• Tested 468 units of banked blood
• Average COHb 0.78%
• 48 units (10.3%) were > 1.5%
• 26 units > 5%
• 1 unit > 12%
Ehlers M, Labaze G, Hanakova M, McCloskey D, Wilner G.
Alarming levels of carboxyhemoglobin in banked blood. J
Cardiothor Vascul Anesth 2009; 23:336-338.
Cardiac Effect
•19 year study 8,333 Swedish males ÷
smokers, non-smokers, never smokers.
•Never smokers split into quartiles:
• 0.13 – 0.49% COHb
• 0.50 – 0.57%
• 0.58 – 0.66%
• 0.67 – 5.47%
• Relative risk CV event 3.7, death 2.2
highest to lowest quartiles
•Incidence CV disease & death in nonsmokers related to COHb%
COHb% as a marker of cardiovascular risk in never
smokers: Results from a population-based cohort study.
Hedblad BO, Engstrom G, Janzon E, Berglund G, Janzon
L. Scand J Pub Health. 2006;34:609-615.
CO Research
firefightercoexposure.com
New Fire Ground CO Study
Sacramento Fire: September 2010 through June 2011
Baseline SpCO at start of each shift for every firefighter
Remeasured at conclusion of overhaul, apparatus position noted
48 fires with 201 paired measurements
• Baseline 1.0 + 1.6%
No difference
p = 0.1408
• Following overhaul 1.2 + 1.6%
• 10 occurrences of SpCO > 5% after overhaul
•
•
•
•
Mackey K, Filbrun T, Schatz D, Hostler D, Ogan L. Do carbon monoxide levels rise
in firefighters during overhaul operations following a structure fire? [Abstract].
Prehosp Emerg Care 2012; 16:153-154.
Smoke Characterization Study
www.ul.com
Smoke Characterization Study
Firefighter Exposure to Smoke Particulates
Live Fire Study
• Chicago Fire Dept. – February through May, 2009
• Rescue Squad Company No. 5
• 44 fires (40 residential and 4 commercial)
• Measurements during all phases of fire through overhaul:
• Air monitoring (direct air monitoring and personal monitors)
• Measurement of smoke particle sizes and content
• Gloves and hoods sent to lab for analysis
Air Monitoring – Particle Sizes
Particulate Sizes
Size (μm)
10
5 – 10
Example
large dust particles
mold, pollen, medium
dust particles
1 – 5 small dust particles, large
bacteria (anthrax, TB)
0.3 – 1 metallic fumes, smaller
bacteria (staph)
0.1 – 0.3 dust mites, allergens,
viruses
Visible
Inhaled Filtered
(flashlight)
(cilia)
Yes
Rarely
Yes
Yes
Yes
Yes
No
Yes
Yes
No
Yes
No
No
Yes
No
1 micron (μm) = 0.1 mm, width of a human hair ≈ 90 microns
Air Monitoring – Particulate Observed
•
•
•
•
•
•
•
•
•
•
•
•
Aluminum
Calcium
Iron
Most prevalent elements in earth’s crust
Magnesium
Zinc
Potassium
Chromium – chrome plating, coloring, wood preservative
Lead – brass, coloring, PVC electrical cords
Antimony – fire retardant
Arsenic – wood preservative
Strontium – television and monitor cathode ray tubes
Cobalt – rechargeable batteries, coloring
Fire Particulates and Airborne Agents
Metals and volatile organic compounds (VOCs) measured in air,
on hoods, gloves and PPE:
• Arsenic
• Cadmium
• Chromium
• Nickel
• Benzene
• Formaldehyde
• Styrene
• Phthalate esters
• Polycyclic aromatic hydrocarbons (PAH)
• Lead
• Mercury
Peak Gas Concentrations at Fires
Gas
HCN
NH3
SO2
NO2
H2S
CO
NIOSH – IDLH
(ppm)
50
300
100
20
100
1200
Max (ppm)
30.0
4.0
150.0*
2.3
133.9
1500*
Mean
(ppm)
7.0
1.8
31.0*
0.7
18.4
774*
* sensor limited values – true values would be higher
Health Specific Impacts
Gas
HCN
NH3
Name
Health effects
hydrogen cyanide
Asphyxiant. Confusion, weakness.
ammonia
Eye, skin, airway irritant. Respiratory compromise with
prolonged exposure.
SO2
sulfur dioxide*
Strong eye, airway irritant. Asphyxiant at high levels.
Prolonged exposures lead to respiratory compromise.
NO2
nitrogen dioxide
Eye, airway irritant. Bronchitis leading to pulmonary
edema with low level exposure. Respiratory failure with
prolonged exposure.
H2S
hydrogen sulfide
Irritant, neurotoxicant. Respiratory failure with
prolonged exposure.
CO
carbon monoxide* Asphyxiant. Long term cardiac and neurologic effects.
* sensor limited values – true values would be higher
Firefighter Health: the Obvious
Carbon Monoxide – Action Levels?
• PEL = 50 ppm
• REL = 35 ppm
• 8 hour TWA
• 8 hour TWA
• 200 ppm ceiling
• TLV = 25 ppm
• 8 hour TWA and 40 hour work week
Carbon Monoxide – Action Level
• Most logical
number on
fireground is
probably 35 ppm
Total Gas Concentrations at Fires
Gas
HCN
NH3
SO2
NO2
H2S
CO
NIOSH -STEL
(ppm)
4.7
35
5
1
10a
200a
TWA (ppm)
10b
25
2
5b
10
35
Mean
(ppm)
27.4
8.8
200.2*
0.9
146.2
5,313*
a 10 minute exposure limits
b OSHA limit (in general, NIOSH limits are more conservative)
* sensor limited values – true values would be higher
Carbon Monoxide (CO)
• Gas:
• Colorless
• Odorless
• Tasteless
• Nonirritating
• Physical Properties:
• Vapor Density = 0.97
• LEL/UEL = 12.5 – 74%
• IDLH = 1200 ppm
14,438 Patient Brown University Study
• Partridge and Jay (Rhode Island Hospital, Brown University
Medical School), assessed carbon monoxide (CO) levels of
10,856 ED patients
• 11 unsuspected cases of CO Toxicity (COT) were discovered.
Overall mean SpCO was 3.60%
• Occult COT was 4 in 10,000 during cold, 1 in 10,000 during
warm months
• They concluded “unsuspected COT may be identified using
noninvasive COHb screening and the prevalence of COT may
be higher than previously recognized”
Non-Invasive Pulse CO-Oximetry Screening in the Emergency Department Identifies
Occult Carbon Monoxide Toxicity. Suner S, Partridge R, Sucov A, Valente J, Chee K,
Hughes A, Jay G. J Emerg Med 2008 Department of Emergency Medicine, Rhode
Island Hospital, Brown Medical School, Providence, RI.
New Safety Practice?
• Vienna Municipal Ambulance Service, Austria
• 61 ambulances, 12 stations, 120,000 calls/year, AMPDS
• Personal CO monitors attached to EMS bags Feb 2010 –
Feb 2011
• 40 alarms (2 false), peak in winter months
• Mean CO 167 ppm, main source was
gas furnaces
• 115 hospitalized (included 22 staff)
• Represents 1:1,000 EMS patients
Roth D, Bayer A, Schrattenbacher G, Malzer R, Herkner H, Schreiber W,
Havel C. Exposure to carbon monoxide for patients and providers in an urban
emergency medical service. Prehosp Emerg Care 2013; 17:354-360.
Message: Your EMS Bag Needs a Meter
Haunted Houses or CO Poisoning?
• Wilmer W. “Mr. and Mrs. H.” Amer J
Ophthalmology. 1921
• Purchased new home, c/o headaches
& fatigue. Heard bells and footsteps
during nights with sightings of
mysterious figures.
• Investigation revealed prior owners
had similar experiences.
• Furnace chimney found blocked,
venting CO into home.
CO Detector Legislation 2013
UL 2034: listings for CO alarms
• Revised 1992, 1995, 1998
• Presently:
• 30 PPM for 30 days
• 70 PPM for 1 – 4 hours
• 150 PPM for 10 – 50 minutes
• 400 PPM for 4 – 15 minutes (6 min reset > 70 PPM)
• Non-alarm status CO2 < 5,000 PPM
• Non-alarm limits for methane, butane, heptane,
ethyl acetate and isopropyl alcohol
46th UHMS Annual Scientific Meeting, June 13-15, 2013
46th UHMS Annual Scientific Meeting, June 13-15, 2013
CO Alarms: Bring Everyone to the ED?
• 23 NY & NJ Emergency Departments, CO
poisonings Jan 2000 – Oct 2006 = 1,006 of total
4,187,015 visits (0.024%) – peaked in December
• 251 had CO detector alarming, only 5 admitted
• Median COHb 2.3%
• 3% admitted, their mean COHb was 12%
• All patients with COHb > 10% had symptoms
(headache, nausea, dizzy, cough, syncope)
• Asymptomatic patients do not need COHb levels
Fiesseler F, Kairam N, Salo D, Riggs R, Reedman L, Destefano S, Amato. Are
carboxyhemoglobin levels required in asymptomatic patients whose carbon monoxide
detector alarms? Ann Emer Med [Abstract] 2008; 52:S94:166
Protocols for CO Assessment & Treatment
JEMS supplement –
October 2010
Response Protocol for CO Alarms
1. Atmospheric monitoring (per FD SOGs)
2. Screen all building occupants for CO
symptoms and measure SpCO%
• If EMS not on scene, FD should assess occupants
• Suspect CO exposure if multiple patients > 3% (nonsmokers) or > 8% (smokers)
• Occupants closest to CO source will have higher SpCO%
(relay this information to interior personnel)
Response Protocol for CO Alarms
3. Treat any symptomatic patient(s) with
high flow oxygen regardless of SpCO%
and consider transport
4. Follow “Routine Assessment”
parameters for asymptomatic patients
with abnormal SpCO readings
Routine Assessment of SpCO
• The vague nature of
CO symptoms and
lack of correlation to
carboxyhemoglobin
blood levels suggest
routine assessment
of SpCO in every
patient
Exhaled CO Meters
 Estimation COHb from alveolar CO
concentration first described in 1948
(Sjostrand T. Acta Physiol Scand 16:201-7)
 Predominantly used to monitor smoking
cessation
 Compact, portable, well validated
 Requires 20 second breath holding (awake,
alert patient)
 Disposable mouthpieces, regular gas
calibration
 Despite widespread availability since 1970’s
utilization very low
www.micro-direct.com
Noninvasive Pulse CO-Oximetry
 FDA approved January 2006
 Compact, portable, well validated
 Continuous carboxyhemoglobin measurement
 Can be used on any patient (even unconscious)
 No disposables, no calibration necessary
 Wider adoption than exhaled devices after
shorter time in marketplace
 Also measures oxyhemoglobin (SpO2),
methemoglobin (SpMet), perfusion index (PI),
hemoglobin (SpHb) and Pleth Variability Index
(PVI).
www.masimo.com
Hgb Signatures: Physics of O2 Pathways
Eagles XIII - Dallas
RAD-57 Accuracy: Touger
• 120 ED patients at Jacobi Medical Center (Bronx, NY)
– 23 patients >15% CO
• Lab CO < 15%: RAD-57 identified 96/97
– Reported specificity 99%
• Lab CO >15%: RAD-57 identified only 11 of 23 patients
– Reported sensitivity 48%
• Suggests the RAD-57 cannot reliably exclude CO
poisoning in any potentially poisoned patient
Touger, et al. Performance of the RAD-57 Pulse Co-Oximeter
Compared to standard laboratory CO measurement. Ann Emerg
Med 2010;56:382-388
There are MANY studies, results differ
2011
RAD-57 Accuracy: Roth
• 1,578 ED patients at AKH Vienna
– 17 patients poisoned
• Lab CO compared to RAD-57: specificity 77%
• Lab CO compared to RAD-57: sensitivity 94%
• Suggests the RAD-57 can be used to reliably screen large
numbers of patients for CO poisoning
Roth D, et al. Accuracy of noninvasive multiwave pulse oximetry compared with
carboxyhemoglobin from blood gas analysis in unselected emergency department
patients. Ann Emerg Med 2011; 58:74-79
RAD-57 Accuracy: Weaver
• 1,363 ED patients at Intermountain Med Ctr (Murray, UT)
– 4 patients poisoned
• Lab CO compared to RAD-57: underpowered for specificity
and/or sensitivity, however:
– 9% met researcher criteria for false positive
– 18% met researcher criteria for false negative
• Suggests the RAD-57 should not be used to direct triage or
patient management
• Editorial by Wilcox et al suggests RAD-57 has insufficient
evidence for broad clinical use
Weaver LK, et al. False positive rate of carbon monoxide saturation by pulse
oximetry of emergency department patients. Respir Care 2013; 58:232-240
Wilcox SR, Richards JB. Noninvasive carbon monoxide detection: insufficient
evidence for broad clinical use. Respir Care 2013; 58:376-379
Technology Evolution: Post Touger
• New sensor released May 2011
• Dramatically improved CO accuracy in low sats
(range 90 – 95%)
• Will not report CO when sat < 90% or Met > 2%
• Another sensor revision May 2013
• Includes finger misalignment sensing
(Weaver reported SpCO values of zero
in 3 patients with COHb > 10%)
Some Thoughts and Considerations
• Pulse oximetry entered general use in 1980’s
• Initially horrific sensitivity and specificity
Some Thoughts and Considerations
• Oximetry improved accuracy to + 3% by 1990’s
• SpCO was born in 2006
• A valuable and continually improving screening
tool in the war on carbon monoxide poisoning
• Variable reports of accuracy reflect:
Evolution of the technology
Clinician understanding of its use
Patient Care Decisions
• No screening device should be used
in isolation
• Clinical assessment and confirmation
using appropriate laboratory testing is
imperative
• Despite years of serum potassium chemistry
testing, phlebotomy error remains the leading
cause of lab reported hyperkalemia
• No device can completely correct for operator error
Protocols for EMS
JEMS suppl Oct 2010
Protocols:
1. Routine care
2. FF Rehab
3. Response to CO
alarms
Routine Assessment of SpCO
• Caveat: SpCO
should not replace
clinical judgment.
Any symptomatic
patient should
received further
medical evaluation!
Carbon Monoxide
Firefighter Rehab
Driving Forces:
• Called attention to the
role of CO on the Fire
Ground
Driving Forces: NFPA 1584
• A.6.2.6.4(1)…Any fire
fighter exposed to CO or
presenting with
headache, nausea,
shortness of breath, or
gastrointestinal
symptoms at an incident
where CO is present
should be assessed for
carbon monoxide
poisoning.
IAFF Statement January 2008
• Routine testing of
any firefighter
potentially
exposed to CO
using a COoximeter
Driving Forces: Educational Resources
• Textbook and classroom
resources: Rehabilitation
and Medical Monitoring:
An Introduction to NFPA
1584 (2008 Standards).
NFPA 1584: 2014 Revisions
Roles and Responsibilities delineated:
• IC
• CO
• Rehab
Manager
• Members
(FF)
NFPA 1584: 2014 Revisions
Incident Commander:
• Establish rehab
• Assure staffing &
supplies
• Rotate members
NFPA 1584: 2014 Revisions
Company Officer:
• Awareness of FF
physical/mental
condition
• Assure hydration
• Assess his/her company every 45 min
• Wildland: evaluate heat stress conditions
NFPA 1584: 2014 Revisions
Rehab Manager:
• Operation,
supplies
• Food
• Release
• Records
NFPA 1584: 2014 Revisions
Member:
• Use rehab
• Hydrate
• Advise CO when
performance affected
• Awareness of others
NFPA 1584: 2014 Revisions
Science Updates:
• De-emphasis on sports drinks
• Caffeine permitted up to 400 mg/day
• Energy drinks banned
• Passive cooling before active
• Medical monitoring
parameters are a local decision
CO Assessment
1. Every patient,
every time.
2. All occupants at
CO alarm calls.
3. Firefighters.
Thank You
www.mikemcevoy.com
Fire Service CO Cases
• Elevated rehab CO levels in a Colorado FF led to
discovery of a defective gas stove in his apartment.
• A Colorado FD discovered CO poisoning while assessing a
seizure patient, averting additional harm to her boyfriend who
also had CO poisoning.
• A Washington Fire Captain traveled 3 hours to an EMS meeting
in a department SUV. There, a product demo led to discovery
of a CO leak in his vehicle.
• An Upstate New York FD discovered near fatal CO poisoning in
a patient who had been seen in two different Emergency
Departments over a three day period for headaches.
Fire Service CO Cases
• High CO levels in multiple FF at a multiple alarm fire in the
Midwest were traced to an engine exhaust leak into the rehab
area.
• FF in Upstate New York used CO-Oximetry to evaluate 200
nursing home patients, pinpointing the location of a CO leak
and averting transport of 182 patients for evaluation.
• FF in California transporting a dental patient with excessive
bleeding after a tooth extraction were alerted to high SpCO and
found her entire family unconscious at her residence.
• Your story here…
Thank You
www.mikemcevoy.com