Monitoring CO Poisoning
with the Rad-57TM
Includes a review on Carbon Monoxide
Poisoning For Emergency Responders
V.5 4 July 2010
© 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:
•
•
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.
© 2008 Masimo Corporation
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
© 2008 Masimo Corporation
Its NOT CO2!
• Carbon monoxide is a colorless,
odorless, tasteless toxic gas.
• Carbon Monoxide = CO
Carbon Dioxide = CO2
• CO = Pulse CO-Oximetry
CO2 = Capnography
© 2008 Masimo Corporation
Common Sources
• 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
© 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):398-402
© 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;34:609-615.
© 2008 Masimo Corporation
Neurologic Effect
Delayed Neurologic Syndrome
Experienced by 11-30%
of patients with CO
Poisoning
Harper A et. al, Age and Aging. 2004;33(2):105-9.
Kao LW et. al, Emerg Med Clin North Am. 2004
Weaver LK, et al. N Engl J Med, 2002;347(14):1057-067
Long-Term/Chronic Sequelae
Cognitive and personality changes,
dementia, seizures, psychosis,
amnesia, parkinsonism,
depression, short-term memory
loss, incontinence.
Abelsohn A, CMAJ 2002:166 (13):1685-90
© 2008 Masimo Corporation
Signs and Symptoms
• Headache
• Nausea/ vomiting/ diarrhea
• Drowsiness
• Gait disturbances
• Dizziness
• Chest pain
• Confusion
• Palpitations
• Fatigue
• Lethargy
• Syncope
• Coma
• Seizures
• Death
• Malaise
• Flu-like symptoms
• Fecal/ Urinary incontinence
• Bizarre neurologic symptoms
© 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
Theoretical effect of
different treatments
on maternal and fetal COHb
levels over time
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: 69-103.
© 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 NonRebreather Mask:
CO half-life 40-60 minutes
• Hyperbaric Oxygen Treatment
(HBOT):
CO half-life 20 -24 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 postfire 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
Optimal LED path
• 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!!
© 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 SpO2 and Pulse Rate
• Pulse oximeter (SpO2) reading top;
heart rate on bottom.
• SIQ- Signal Identification and Qualityidentifies the quality of the SpO2
signal.
• Press Yellow “Bell” button to silence
alarms.
• Press “Display” button ONCE for SpO2
and pulse rate readings.
• Press “Display” button a SECOND time
for the PI reading, a THIRD time to
return to SpCO screen.
© 2008 Masimo Corporation
Alarm Silence
Button
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.
© 2008 Masimo Corporation
Perfusion Index
Bar Graph
Light Shield Use
• The presence of intense ambient
light can interrupt (no reading) or
interfere (falsely elevate reading)
with the SpCO reading.
Apply pressure
to open sensor
• 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.
© 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?
© 2008 Masimo Corporation