Carbon Monoxide and the Rad-57 by TgH1xH8


									Carbon Monoxide and the
Jeremy T. Cushman, MD, MS, EMT-P
Monroe County EMS Medical Director
Division of Prehospital Medicine, URMC
CO-Related Deaths in 2000
What is it?
   Carbon Monoxide (CO) is a
    colorless and odorless gas.
   It is poisonous to people and animals,
    because it displaces oxygen in the blood.
   It is produced by the incomplete burning of solid, liquid, and
    gaseous fuels.
   Appliances fueled with natural gas, liquefied petroleum (LP
    gas), oil, kerosene, coal, or wood may produce CO. Burning
    charcoal and running combustion engines (cars, motorcycles,
    generators, etc) produce CO.
How much causes symptoms?
Normal Hemoglobin
•   Normal oxygenation of the
    tetrameric (ie. 4 subunits)
    hemoglobin molecule.

•   As it goes from
    (deoxy)hemoglobin to
    oxyhemoglobin the color
    changes from blue, as in
    venous blood, then to pink,
    as in arterial blood.
•   Here carbon monoxide
    (CO) enters the picture,
    and through its very high
    affinity for hemoglobin,
    displaces the oxygen from
    the hemoglobin.
•   This prevents oxygen being
    carried to the tissues and
    organs of the body.
•   Carboxyhemoglobin is
    reddish in color.
Normal Physiology
• Oxygen is carried from
  the lungs by the blood
  hemoglobin to the
  tissues, here the
  beating heart is shown,
  and normal healthy
  oxidative metabolism
  goes on.
CO Poisoning
• During Carbon
  Monoxide poisoning,
  CO is carried from the
  lungs by the blood
  hemoglobin to the
  tissues, preventing
  oxygen from being
  carried, and blocking
  normal oxidative
Symptoms of CO Poisoning
SpCO Level   Clinical Manifestations
    >5%      Mild headache
    10%      Mild headache, shortness of breath with exertion
  10-20%     Moderate headache, shortness of breath
  20-30%     Worsening headache, nausea, dizziness, fatigue
             Severe headache, vomiting, vertigo, altered
  40-50%     Confusion, syncope, tachycardia
  50-60%     Seizures, shock, apnea, coma

   Symptoms DO NOT always correlate with the
    SpCO level

   If symptomatic, and exposed to CO, the
    patient should be transported to the hospital
    for definitive determination REGARDLESS
    of the CO level read by the Rad-57
The Rad-57
   Noninvasive
    measurement of both
    SpO2 (pulse oximetry)
    and SpCO (pulse CO-

   Two settings for its use:

       Screening patients for suspected exposure

       Screening emergency services personnel during

   We’ll first concentrate on the use of the device, then
    the specific protocol for each setting.
Using the Rad-57
1.   Connect the sensor cable to the
     Patient Cable Connector of the
     oximeter. Make sure the connection
     is secure and the cable is not twisted,
     sliced, or frayed.

2. Remove any substances (nail polish,
     paint, etc) on the patient’s second,
     third, or fourth digit that may interfere
     with the transmission of light between
     the sensor’s light source and photo
    Sensor Placement
3. Attach the sensor to the patient, applying it to the
    index (second), middle (third), or ring (fourth)
    digits. Only these digits can be accurately
    used by the CO-Oximiter.

      When possible, use ring (fourth) finger, non-
       dominant hand.
        Insert finger until the tip of finger hits the
         STOP Block.
        Sensor should not rotate or shift freely on
        LED’s (red light) should pass through mid-
         nail, not cuticle.
        There is a top and bottom, cable should be on
         top (nail side).
Turning the device on
4.   Press the Power button ON.

          POWER
             Press to turn ON.
             Press and HOLD to turn OFF.

             4 Green LED’s.
             Each represents 25% battery life.
             Use only Alkaline batteries.
4.       The machine will go through a self-test procedure:
           All LED’s light up.
           Calibration mode begins
                Spinning zeroes 0 - 0 – 0.

                Completed in 20 second (avg.)

                DO NOT move sensor during calibration.

                Acquires reading and displays.

        DISPLAY
           Defaults to pulse rate and oxygen saturation
           “PI” bar graph displays strength of arterial
Initial Display
   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 signal
   Press SpCO to display %
   Press “Bell” to silence alarms
 Measuring SpCO
 Display will toggle to CO mode for 10
 Carboxyhemoglobin reading in % on top

 “CO” displayed on bottom confirming
 ALWAYS confirm high readings by
  taking several measurements on
  DIFFERENT fingers and average

   Real-time SpCO indicator
    continuously reads SpCO
        Green: 1-9%
        Orange: 10-19%
        Red: 20% and above
Important Notes!
   The device is not approved for use in patients
    weighing less than 30 kg (66 lbs)

   When examining multiple patients, turn the
    device OFF then ON to recalibrate between
       Failure to do so could give you incorrect
Alarms                                         Alarm indicator

   When violated, audible alarm will
    sound, parameter will flash
   Preset at factory:
       Sa02 (oxygen saturation)
            Low: 90%
            High: none
       Pulse Rate
            Low: 50
            High: 140
       SpCO (carboxyhemoglobin)
            Low: none                           Alarm silence
            High: 10%
   To adjust alarms:
       Press “Mode/Enter” twice
       Press “Next” key to scroll through parameters
       Use up and down keys to adjust
       Reverts to Factory settings after turned off.
Care and Cleaning
   Once monitoring is complete, remove the
    sensor from the patient and turn the device
   Wipe the sensor and device with a soft cloth
    dampened with mild soap and water.
   Never submerge the sensor or the monitoring
The Low SIQ Indicator…
   If the device indicates a “Low SIQ,” this refers to a low signal
    IQ and flashes when the SpO2 and SpCO measurements may
    be compromised. If this occurs:
       Reassess the patient.
       Check the sensor to ensure it is properly applied to the patient and
        inserted into the Rad-57 device.
       Determine if an extreme change in the patient’s physiology and blood
        flow at the monitoring site has occurred (e.g. an inflated blood
        pressure cuff, tourniquet, severe hypotension, hypothermia, or cardiac
       After completing this check, if the “Low SIQ” indication occurs
        frequently or continuously, you cannot rely on the device for either
        SpO2 or SpCO levels.
    The Perfusion Index…
    The Perfusion Index (PI) is a relative assessment of perfusion at the
     monitoring site.
    PI is displayed on a 10 segment LED bar on the right of the display ranging
     from <0.1% (very weak perfusion) to >5% (strong perfusion).
    The PI is shown as a “bouncing bar” indicator, where the peak of the bar
     coincides with the peak of an arterial pulsation.
        The highest LED will remain lit continuously to allow a PI level to be viewed.
    If evidence of low perfusion (<1%) is frequently displayed, find a better
     perfusion monitoring site and be sure the sensor is placed properly and there
     are no substances on the finger that could impede the emitter and
        Very high ambient light situations can also produce falsely low PI.
    Should a low PI be persistent after these measures, review the procedure for
     “Low SIQ”.
    If a low PI still persists you cannot rely on the device for either SpO2 or
     SpCO levels.
Cyanide and Methemeglobinemia
   Cyanide toxicity and methemoglobinemia cannot be readily
    determined by this device.

   The CO-Oximeter should be used in addition to clinical
    judgment and a normal reading in the setting of a patient with
    severe respiratory distress or cyanosis should not rule out a
    significant oxygen-transfer deficit (cyanide, met-
    hemoglobinemia, sulfhemoglobinemia, or profound anemia)
    requiring aggressive airway management and high-flow

   Always treat the patient first and not the reading on the CO-
Special note for Fire Personnel

   Unlike your gas meters, the RAD-57 is not
    intrinsically safe and should not be used in the
    presence of flammable substances!
What to do with the numbers…
   The CO-Oximeter may be used on any patient
    greater than 30 kg where there is a concern for
    carbon monoxide exposure.

   For the non-rehabilitation scene, the following
    protocol applies
Using Pulse CO-Oximetry
   The SpCO reading is to be used as a screening measure.
   Definitive carboxyhemoglobin determinations are performed
    via blood draw in the hospital setting.
   Any patient with suspected carbon monoxide poisoning
    should receive oxygen by a non-rebreather mask until their
    CO level can be determined.
   Any patient with airway compromise, respiratory distress, or
    symptoms of significant carbon monoxide poisoning
    (nausea, vomiting, loss of judgment, chest pain, dizziness,
    muscle weakness, or a change in mental status) should be
    treated according to the MLREMS Standards of Care and
    transported with high-flow oxygen to an emergency
    department regardless of the SpCO reading.
Important Note!
   Pregnant women are at high risk in carbon
    monoxide exposure.
   The fetus is highly susceptible and the SpCO
    may be 10-15% higher than maternal
   All pregnant women with possible CO
    exposure should be transported to the
    emergency department for evaluation.
Who goes to the hospital?
   Any patient with a SpCO reading >12%,
    even if without symptoms, should be
    transported with high-flow oxygen to an
    emergency department.
   Any patient with a SpCO reading >25%,
    even if without symptoms, MUST be
    transported with high-flow oxygen to an
    emergency department.
Who can appropriately not be transported?
   Patients with carbon monoxide exposure and SpCO <25%
    may be treated and released provided the following
    conditions are met:
       The patient is asymptomatic.
       The patient exhibits no signs of respiratory distress, and pulse
        oximeter reading is above 92%.
       The SpCO must be below 5% in non-smokers, and 10% in smokers.
       The lungs are clear on auscultation.
       There are no other significant burn or traumatic injuries.
       Both the pulse oximetry and the CO levels must be documented.
       The patient has medical decision making capacity per the MLREMS
        Refusal of Care Policy.
   Use of the Rad-57 and serially recorded SpCO levels
    should be documented accordingly in the Prehospital
    Care report.
   It cannot be emphasized enough that the patient’s
    clinical presentation is what should drive routine
    medical care and not the SpCO level observed.
   If there is ever doubt regarding the patient’s
    disposition, provide high flow oxygen and transport
    to the hospital for evaluation.
Use in the Rehabilitation Sector
   When available, the use of pulse CO-
    oximetry is a valuable adjunct to assessment
    during rehabilitation.

   The use of hand-held pulse co-oximetry
    devices is optional, and not required for
    Incident Rehabilitation.
Use in the Rehabilitation Sector
   The SpCO reading is to be used as a screening
   Definitive carboxyhemoglobin determinations are
    performed via blood draw in the hospital setting.
   Any patient with complaints of chest pain,
    shortness of breath, or altered mental status should
    receive oxygen by a non-rebreather mask and
    moved to the Treatment Area, regardless of SpCO
Use in the Rehabilitation Sector
   If SpCO <5% and vital signs are within normal limits, the
    provider is encouraged to drink at least 16 ounces of fluid
    and may return to manpower/staging after a minimum of 10
    minutes rest.
   If SpCO ≥5% and <12%, the responder may breathe ambient
    air and may not leave the rehabilitation area until their CO
    level is below 5%.
   If SpCO ≥12% the responder should be moved to the
    Treatment Area and receive high-flow oxygen until the
    SpCO is <5%.
   If SpCO ≥25%, the responder will be moved to the
    Treatment Area and transported with high-flow oxygen to an
    emergency department.
   Documentation of SpCO levels can be made
    on the rehabilitation log.
   Responders moved to the treatment area
    should have values recorded on the
    prehospital care report.
   The Monroe-Livingston Region does not have
    the services of a hyperbaric chamber, often
    used for treating life-threatening CO
   All unstable patients with suspected CO
    poisoning should be transported to the nearest
    appropriate local facility for stabilization and
    serum carboxyhemoglobin determination.
   The Rad-57 is an important device to be used
    in the evaluation of patients with suspected
    CO poisoning.
   Proper use of the device is imperative to
    assure adequate readings.
   Readings provided by the device should
    NEVER override clinical assessment – treat
    the patient, not the CO-oximeter!

To top