Carbon Monoxide on the Fire Ground & EMS Response to CO Poisoning

1. 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

2. Outline • CO science update • Fire ground air research update • Atmospheric monitoring • Changes to rehab practices • Recognizing/treating CO poisoning • Role of CO detector legislation • Appropriate FD response practices www.mikemcevoy.com

3. www.thesilentkiller.net Or, pick up a copy at the Masimo booth

4. Carbon Monoxide (CO) “The Great Imitator” • Invisible • Masquerades

5. Signs and Symptoms Carbon Monoxide Poisoning Presents Like the Flu!

6. 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

7. 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):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 LK, et al. N Engl J Med, 2002;347(14):1057-067. 6 Henry CR, et al. JAMA. 2006;295(4):398-402.

8. Source: USA Today November 29, 2011 compiled from National Conference of States Legislatures and International Code Council

9. CO Detector Legislation 2013

10. 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 • 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%) NO Change! 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.

11. 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.

12. 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 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.

13. CO Research

14. firefightercoexposure.com

15. 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% • Following overhaul 1.2 + 1.6% • 10 occurrences of SpCO > 5% after overhaul No difference p = 0.1408 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.

16. Smoke Characterization Study www.ul.com

17. Smoke Characterization Study Carbon Monoxide

18. Firefighter Exposure to Smoke Particulates

19. 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

20. Air Monitoring – Particle Sizes

21. Particulate Sizes 1 micron (μm) = 0.1 mm, width of a human hair ≈ 90 microns

22. Air Monitoring – Particulate Observed • Aluminum • Calcium • Iron • 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 Most prevalent elements in earth’s crust

23. 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

24. Peak Gas Concentrations at Fires * sensor limited values – true values would be higher

25. Health Specific Impacts *sensor limited values – true values would be higher

26. Firefighter Health: the Obvious

27. Carbon Monoxide – Action Levels? • PEL = 50 ppm • 8 hour TWA • REL = 35 ppm • 8 hour TWA • 200 ppm ceiling • TLV = 25 ppm • 8 hour TWA and 40 hour work week

28. Carbon Monoxide – Action Level • Most logical number on fireground is probably 35 ppm

29. Total Gas Concentrations at Fires X number fires = your exposure a10 minute exposure limits bOSHA limit (in general, NIOSH limits are more conservative) * sensor limited values – true values would be higher

30. Carbon Monoxide (CO) • Gas: • Colorless • Odorless • Tasteless • Nonirritating • Physical Properties: • Vapor Density = 0.97 • LEL/UEL = 12.5 – 74% • IDLH = 1200 ppm

31. 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.

32. 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 wasgas 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.

33. Message: Your EMS Bag Needs a Meter

34. 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.

35. CO Detector Legislation 2013

36. 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

37. 46th UHMS Annual Scientific Meeting, June 13-15, 2013

38. 46th UHMS Annual Scientific Meeting, June 13-15, 2013 CONCLUSIONS: The porosity of gypsum board drywall allows relatively rapid CO diffusion. This likely explains many cases of CO poisoning in multiunit residences when only one unit had a CO source. Laws exempting all electric residences from mandatory CO alarm installation are allowing a subset of the population to remain at risk for CO exposure.

39. 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

40. Protocols for CO Assessment & Treatment JEMS supplement – October 2010

41. Response Protocol for CO Alarms • Atmospheric monitoring (per FD SOGs) • 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% (non-smokers) or > 8% (smokers) • Occupants closest to CO source will have higher SpCO% (relay this information to interior personnel)

42. Response Protocol for CO Alarms • Treat any symptomatic patient(s) with high flow oxygen regardless of SpCO% and consider transport • Follow “Routine Assessment” parameters for asymptomatic patients with abnormal SpCO readings

43. 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

44. 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

45. 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

46. Hgb Signatures: Physics of O2 Pathways

47. Eagles XIII - Dallas

48. 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

49. There are MANY studies, results differ 2011

50. 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