Scenario: CO Exposure

[WAS967 97]

I was thinking about this yesterday and figured I would post something to induce some thought in others. Plus since Art posted a fire scenario, why not do something EMS as well.

(The following is completely hypothetical and does not reflect or infer the involvement of any individual agency in any particular event.)

You are called to standby and assist your local fire department(s) at the scene of a house fire. On arrival you are presented with a family of four who were occupants of the house at the time of the incident and requested to "check them out".

While performing an exam of the first patient (lets say the father who is 40 years old), you decide to put on your agency's pulse oximeter which just happens to have the ability to detect carbon monoxide in the blood as well (CO-oximetry). After about thirty seconds the machine starts beeping to indicate an abnormal reading and the CO indicates a level of 12.

What do you do?

[if you are more intimately familiar with this topic, hold your answers for a little bit to see what others have to say. This will be a dynamic topic so if you have questions, do ask and we'll provide additional information.]

[vtach39680 23]

Well the first thing is to always treat your patient not a machine. I would get a good history while determining if the patient is symptomatic or asymptomatic, determine if the patient is a smoker as a 2 pack a day smoker could have a COHB level baseline of up to 15. I going to assume that we are a BLS unit? if so 100% O2 monitor vitals I am also glad you made mention of it being a co monitor. as we all know that pulse ox monitors the saturation of hemoglobin and using it alone will give you a false reading of O2 sat. sorry for the slight rant. I would confer with the FD to see where the high concentration levels of CO where in the house and the proximity of those high levels to the living space of the patients. asymptomatic patients transport to ED on 100% O2 with constant vitals. symptomatic patients 100% O2 to hospital with hyperbaric treatment and ALS for advanced mon. as ST changes are very possible.

just my 2 cents feel free to correct anything I have written. always good to learn

Don't be afraid to try new things, the Ark was built by armatures the Titanic my professionals

[if you are more intimately familiar with this topic, hold your answers for a little bit to see what others have to say. This will be a dynamic topic so if you have questions, do ask and we'll provide additional information.]

[WAS967 97]

Good post.

symptomatic patients 100% O2 to hospital with hyperbaric treatment and ALS for advanced mon. as ST changes are very possible.

Question for all: Do you know what hospitals in the Westchester/Hudson Valley areas have Hyperbaric capability?

[vtach39680 23]

Good post.

Question for all: Do you know what hospitals in the Westchester/Hudson Valley areas have Hyperbaric capability?

I know WMC and PHELPS do. Phelps chamber good for minor cases and wound care WMC for dive wound care and CO as not so much for the chamber itself but for the great amount of services available should the need arise. not sure anyother hospital in west.

[antiquefirelt 994]

Well the first thing is to always treat your patient not a machine.

CO Poisoning can be a case where little to no outwards signs or symptoms may be seen, in which case you'll need to treat the machine. The good thing is the 100% oxygen cannot hurt them. Fire victims are often very emotional and trying to get a read on their normal state of mind will be difficult and the old "cherry reddening" has been proven to be a late stage high level CO poisoning indicator at best. When we first got our CO oximeter (RAD-57) we hooked everyone up to it. To a person, even regular 2 pack a day smokers no one was over 7 or 8. A reading of 12 would cause us to try very hard to convince the patient that their exposure could be worse than they are noticing and should be transported.

Most FD's won't be measuring for CO until after the fire is out if at all. The chances that the victim in a home experiencing a fire will be exposed to high levels of CO are very good. By the time the FD measures for CO, the ventilation effort will have greatly changed the location of CO concentration and thus should not be an indicator. Most times the FD measures CO it is to determine if it is safe to operate without masks, and even this is likely not a good indicator given the host of other toxins that may be still in the air.

Edited April 19, 2010 by antiquefirelt

[WAS967 97]

I know WMC and PHELPS do. Phelps chamber good for minor cases and wound care WMC for dive wound care and CO as not so much for the chamber itself but for the great amount of services available should the need arise. not sure anyother hospital in west.

I'll get back to this in a short bit, but you kinda have the capabilities of the two hosptials reversed.

CO Poisoning can be a case where little to no outwards signs or symptoms may be seen, in which case you'll need to treat the machine. The good thing is the 100% oxygen cannot hurt them. Fire victims are often very emotional and trying to get a read on their normal state of mind will be difficult and the old "cherry reddening" has been proven to be a late stage high level CO poisoning indicator at best. When we first got our CO oximeter (RAD-57) we hooked everyone up to it. To a person, even regular 2 pack a day smokers no one was over 7 or 8. A reading of 12 would cause us to try very hard to convince the patient that their exposure could be worse than they are noticing and should be transported.

This is a VERY interesting point. There were several studies done on the effectiveness of the Massimo SET system before it was granted FDA approval. In several cases the unit was used on patients just as a matter of routine in the triage area of a hospital (something like 1700 patients over an 8 day period). There were several cases where the unit actually caught CO poisoning in patients who were otherwise asymptomatic and who would have otherwise gone untested and unchecked for CO levels.

Now the question I post to the providers out there is this. At what blood percentage should we cross the line between BLS and ALS? Should we transport every patient who has abnormal (depending on who you ask that level can vary but the Massimo unit in the new lifepak 15s considers over 10% as abnormal) values ALS? Or should there be a point at which we say, okay someone from 1-x% is BLS, and above that it's ALS. OR better yet, make a protocol where the provider uses good clinical judgement and technological diagnostic tools to make a sound decision on transport modality and destination. (Wishful thinking? Perhaps.)

[Remember585 815]

I was thinking about this yesterday and figured I would post something to induce some thought in others. Plus since Art posted a fire scenario, why not do something EMS as well.

Dude, I'm not Art!!!!! Thems is fightin' words!

[WAS967 97]

LOL. Man I can't keep track of who is who on here.

[ny10570 745]

ALS for respiratory distress, potential airway burns, or suspected cyanide poisoning. What is ALS going to do for someone with an extremely high CO level? As long as the airway is patent it'll be air and stare.

I'm not sure of WMC's capabilities but a simple CO poisoning could easily go to Phelps. Their chamber is a monster. Holds 12 patients and is capable of diving up to 6 atmospheres. Its bigger than anything else in the tri-state area. If you've got associated burns or trauma then WMC who's chamber I believe is pretty small. If you're on the south side of the county Jacobi loves the business, and can dive just about anyone.

[efdcapt115 1,511]

This is a VERY interesting point. There were several studies done on the effectiveness of the Massimo SET system before it was granted FDA approval. In several cases the unit was used on patients just as a matter of routine in the triage area of a hospital (something like 1700 patients over an 8 day period). There were several cases where the unit actually caught CO poisoning in patients who were otherwise asymptomatic and who would have otherwise gone untested and unchecked for CO levels.

Now the question I post to the providers out there is this. At what blood percentage should we cross the line between BLS and ALS? Should we transport every patient who has abnormal (depending on who you ask that level can vary but the Massimo unit in the new lifepak 15s considers over 10% as abnormal) values ALS? Or should there be a point at which we say, okay someone from 1-x% is BLS, and above that it's ALS. OR better yet, make a protocol where the provider uses good clinical judgement and technological diagnostic tools to make a sound decision on transport modality and destination. (Wishful thinking? Perhaps.)

And meanwhile the old time cop and the fireman are saying, "just put 'em in the bus and get 'em outa here!"

Just kidding. Really, it's amazing to read about all the gadgetry and equipment you guys/gals carry and use everyday. God bless our EMS personel; lifesavers all of them.

Edit: oh yeah, and an excellent topic too.

Edited April 27, 2010 by efdcapt115

[wraftery 1,275]

I had CO exposure symptoms for months. I thought I had the source identified with the stove as the culprit. If the stove was on for an hour or so making supper, I would finish supper and then fall asleep in a chair. Turns out, I was just tired.

Sorry, guys, I just couldn't pass up the chance