CO-OximetryCO-Oximetry

Use of the Rad-57 by ACPUse of the Rad-57 by ACP

Revision InfoRevision Info

• Revised 11-2008Revised 11-2008

• Contact Information:Contact Information:– Steve ColeSteve Cole– Ada County ParamedicsAda County Paramedics– 208-287-2978208-287-2978– colemedic@hotmail.comcolemedic@hotmail.com

Credit where credit is dueCredit where credit is due

• Sky Dumont, Paramedic (Ada County Sky Dumont, Paramedic (Ada County Paramedics): for his hard work and initial Paramedics): for his hard work and initial research in developing this presentationresearch in developing this presentation

• www.masimo.comwww.masimo.com for product information for product information

• www.firehouse.comwww.firehouse.com for street level input for street level input

BackgroundBackground

CO Poisoning ReviewCO Poisoning Review

• Leading cause of poisoning deaths in Leading cause of poisoning deaths in United States and other industrialized United States and other industrialized countriescountries

• 5000-6000 deaths annually in U.S.5000-6000 deaths annually in U.S.

• 50,000-60,000 ED admissions annually 50,000-60,000 ED admissions annually

Pathophysiology of CO Pathophysiology of CO PoisoningPoisoning

• Impairs oxygen delivery resulting in cellular Impairs oxygen delivery resulting in cellular hypoxiahypoxia

• CO binds to hemoglobin 230-270 times more CO binds to hemoglobin 230-270 times more avidly than oxygen resulting in avidly than oxygen resulting in carboxyhemoglobin (COHb)carboxyhemoglobin (COHb)

• CO also binds to Myoglobin and Cytochromes CO also binds to Myoglobin and Cytochromes disrupting storage of O2 in certain muscle cells disrupting storage of O2 in certain muscle cells and transfer of energy within cells and transfer of energy within cells

Pathophysiology of CO Pathophysiology of CO Poisoning (ctd.)Poisoning (ctd.)

• Negative effect on central Negative effect on central nervous system effecting nervous system effecting cognitive abilities such as cognitive abilities such as perception, reasoning, perception, reasoning, awareness, and judgmentawareness, and judgment

• Negative effects on Negative effects on cardiovascular system by cardiovascular system by depressing myocardial depressing myocardial functionfunction

• Respiratory system Respiratory system effected by potential effected by potential damage to alveolar damage to alveolar membranesmembranes

Signs and Symptoms of CO Signs and Symptoms of CO PoisoningPoisoning

• Flu-like symptomsFlu-like symptoms• HeadacheHeadache• DizzinessDizziness• FatigueFatigue• DyspneaDyspnea• Chest painChest pain• PalpitationsPalpitations• ConfusionConfusion• AgitationAgitation• NauseaNausea• VomitingVomiting• Abdominal painAbdominal pain

• Hypotension with Hypotension with tachycardiatachycardia

• Cardiac dysrhythmiasCardiac dysrhythmias• Myocardial ischemiaMyocardial ischemia• Pulmonary edemaPulmonary edema• SyncopeSyncope• SeizuresSeizures• Fecal/urinary incontinenceFecal/urinary incontinence• Visual abnormalitiesVisual abnormalities• Memory lossMemory loss• ComaComa• Death Death

Exposure RisksExposure Risks

• Automobile exhaust Automobile exhaust fumesfumes

• Propane-powered Propane-powered vehicle fumesvehicle fumes

• House firesHouse fires• HeatersHeaters• Indoor stovesIndoor stoves• Camp stovesCamp stoves• Boat exhaust fumesBoat exhaust fumes

• Gas-powered Gas-powered electrical generatorselectrical generators

• Cigarette smokeCigarette smoke• Charcoal-fired cook Charcoal-fired cook

stovesstoves• OvensOvens• Methylene chloride Methylene chloride

solvent inhalation solvent inhalation (paint removers, (paint removers, adhesive removers)adhesive removers)

Physiological and iatrogenic causesPhysiological and iatrogenic causes

• Sepsis- CO byproduct of SIRS induced Sepsis- CO byproduct of SIRS induced HymolysisHymolysis

• Hemolysis 2Hemolysis 2ndnd to blood disorders to blood disorders

• ““Monday Morning Syndrome” CO Monday Morning Syndrome” CO byproduct of anesthesia and “depleted byproduct of anesthesia and “depleted scrubbers”. scrubbers”.

• Nitric Oxide useNitric Oxide use

• Sodium Nitroprusside useSodium Nitroprusside use

Substances That Can Cause Substances That Can Cause MethemoglobinemiaMethemoglobinemia

• Inorganic agentsInorganic agents– Nitrates - Fertilizers, contaminated well water,preservatives, industrial productsNitrates - Fertilizers, contaminated well water,preservatives, industrial products– ChloratesChlorates– Copper sulfate – FungicidesCopper sulfate – Fungicides– Organic nitrites/nitratesOrganic nitrites/nitrates

• Amyl nitriteAmyl nitrite• sobutyl nitritesobutyl nitrite• Sodium nitriteSodium nitrite• NitroglycerinNitroglycerin• NitroprussideNitroprusside• Nitric oxideNitric oxide• Nitrogen dioxideNitrogen dioxide• TNTTNT

• OthersOthers– local anesthetics - Benzocaine, lidocaine, prilocaine, phenazopyridine (Pyridium)local anesthetics - Benzocaine, lidocaine, prilocaine, phenazopyridine (Pyridium)– Antimalarials - Primaquine, chloroquineAntimalarials - Primaquine, chloroquine– Antineoplastic agents - Cyclophosphamide, ifosfamide, flutamideAntineoplastic agents - Cyclophosphamide, ifosfamide, flutamide– Analgesics/antipyretics - Acetaminophen, acetanilid, phenacetin, celecoxibAnalgesics/antipyretics - Acetaminophen, acetanilid, phenacetin, celecoxib– Herbicide – ParaquatHerbicide – Paraquat– Antibiotics - Sulfonamides, nitrofurans, P-amino-salicylic acid, dapsoneAntibiotics - Sulfonamides, nitrofurans, P-amino-salicylic acid, dapsone– Industrial/household agents - Aniline dyes, nitrobenzene, naphthalene (moth balls), Industrial/household agents - Aniline dyes, nitrobenzene, naphthalene (moth balls),

aminophenol, nitroethane (nail polish remover)aminophenol, nitroethane (nail polish remover)

Populations at Increased Risk Populations at Increased Risk

• ChildrenChildren• ElderlyElderly• Persons with heart diseasePersons with heart disease• Pregnant women (due to CO’s effect on fetus)Pregnant women (due to CO’s effect on fetus)• Pt’s with increased O2 demandPt’s with increased O2 demand• Pt’s with decreased O2-carrying capacityPt’s with decreased O2-carrying capacity• Pt’s with chronic respiratory insufficiencyPt’s with chronic respiratory insufficiency• MinersMiners• Emergency personnelEmergency personnel

Normal COHb LevelsNormal COHb LevelsSourceSource COHb (%)COHb (%)

Endogenous (normal Endogenous (normal heme catabolism)heme catabolism)

0.4-0.70.4-0.7

Tobacco smokers:Tobacco smokers:

1 pack per day1 pack per day 5-65-6

2-3 packs per day2-3 packs per day 7-97-9

CigarsCigars Up to 20Up to 20

Urban commuterUrban commuter 55

Methylene chloride (100 Methylene chloride (100 ppm for 8 hours)ppm for 8 hours)

3-53-5

Signs and Symptoms vs. Exposure Signs and Symptoms vs. Exposure LevelsLevels

PPMPPM Duration of Duration of exposureexposure

SymptomsSymptoms

200200 2-3 hours2-3 hours Mild headache, fatigue, nausea, dizzinessMild headache, fatigue, nausea, dizziness

400400 1-2 hours1-2 hours Serious H/A, -other symptoms intensify. Life-threatening Serious H/A, -other symptoms intensify. Life-threatening >3 hours>3 hours

800800 45 minutes45 minutes Dizziness, nausea, convulsions. Unconscious within 2 Dizziness, nausea, convulsions. Unconscious within 2 hours. Death within 2-3 hours.hours. Death within 2-3 hours.

16001600 20 minutes20 minutes H/A, dizziness, nausea. Death within 1 hour.H/A, dizziness, nausea. Death within 1 hour.

32003200 5-10 5-10 minuteminutess

H/A, dizziness, nausea. Death within one hour.H/A, dizziness, nausea. Death within one hour.

64006400 1-2 1-2 minuteminutess

H/A, dizziness, nausea. Death within 25-30 minutes.H/A, dizziness, nausea. Death within 25-30 minutes.

12,80012,800 1-3 minutes1-3 minutes DeathDeath

Signs and Symptoms vs. COHb LevelsSigns and Symptoms vs. COHb Levels

COHbCOHb SeveritySeverity S and SxS and Sx

<15-20%<15-20% MildMild H/A, N/V, dizziness, H/A, N/V, dizziness, blurred visionblurred vision

21-40%21-40% ModerateModerate Confusion, syncope, Confusion, syncope, chest pain, dyspnea, chest pain, dyspnea, tachypnea, tachypnea, tachycardia, weaknesstachycardia, weakness

41-50%41-50% SevereSevere Dysrhythmias, Dysrhythmias, hypotension, cardiac hypotension, cardiac ischemia, palpitations, ischemia, palpitations, respiratory arrest, respiratory arrest, pulmonary edema, pulmonary edema, seizures, coma, cardiac seizures, coma, cardiac arrestarrest

>60%>60% FatalFatal DeathDeath

Real World ReportsReal World Reports

• ““In the cases I've come across, it's generally been In the cases I've come across, it's generally been described by the pt's as described by the pt's as "flu-like" symptoms"flu-like" symptoms (N/V, (N/V, headache) after low-level exposure of a few hours. I headache) after low-level exposure of a few hours. I work as a firefighter as well, and after a fire one night work as a firefighter as well, and after a fire one night where some members were not wearing SCBA during where some members were not wearing SCBA during overhaul, two of them were complaining the next day of overhaul, two of them were complaining the next day of severe headache and nausea. Neither of them made any severe headache and nausea. Neither of them made any connection to the fire until we had a rep come in that connection to the fire until we had a rep come in that afternoon selling CO monitors (similar to SpO2 afternoon selling CO monitors (similar to SpO2 monitoring) and their levels were much, much higher monitoring) and their levels were much, much higher than average…” -emtjonthan average…” -emtjon

• Post from EMS forum on Post from EMS forum on Firehouse.comFirehouse.com

Real World ReportsReal World Reports

• “…“…I've only dealt with a few cases, and the most I've only dealt with a few cases, and the most recent gave me a reading in the high 90's. He recent gave me a reading in the high 90's. He was unresponsive as well. As far as skin color, was unresponsive as well. As far as skin color, this pt was more pale to normal. I've heard also this pt was more pale to normal. I've heard also that the pink/red skin is a very late sign and that the pink/red skin is a very late sign and seen after extended exposure. I'm not sure how seen after extended exposure. I'm not sure how accurate that is, just something I've heard…” -accurate that is, just something I've heard…” -tkruegertkrueger

• “…“…In more severe cases you may run accross In more severe cases you may run accross ST elevation on your 12 lead due to lack of 02 ST elevation on your 12 lead due to lack of 02 being transported….” - being transported….” - Medic115Medic115

• Also from Also from Firehouse.comFirehouse.com

The Rad SeriesThe Rad Series

BenefitsBenefits

• Uses “Signal Extraction technology” (AKA Uses “Signal Extraction technology” (AKA SET)SET)

• This new generation can be potentially This new generation can be potentially used for SPO2, SPCO2, SpHg and used for SPO2, SPCO2, SpHg and SPMET.SPMET.

The Rad-57The Rad-57

• SET technology was originally developed SET technology was originally developed to be a “low perfusion state” and “Motion to be a “low perfusion state” and “Motion resistant” SPO2, whose technology was resistant” SPO2, whose technology was expanded to CO-Oxometryexpanded to CO-Oxometry

• Early device specific research papers Early device specific research papers focused on neonates, alternative sensing focused on neonates, alternative sensing locations, and anesthesia settings. locations, and anesthesia settings.

DownfallsDownfalls

• Very sensitive, can be “spoofed” by Very sensitive, can be “spoofed” by strobes and high ambient light. strobes and high ambient light. – Cover the probe when “Zero”-ing to the Cover the probe when “Zero”-ing to the

patientpatient

• Approx. $4,000 retail Approx. $4,000 retail

Treatment Recommendations:Treatment Recommendations:• Scene safety, protect yourself:Scene safety, protect yourself:

– Consider SCBA’sConsider SCBA’s

• Remove patient safe distance from the CO!Remove patient safe distance from the CO!• Remember Co is heavier than air!Remember Co is heavier than air!

• ABC’s (airway, breathing and circulation).ABC’s (airway, breathing and circulation).

• 100% High-flow oxygen with non-rebreather mask:100% High-flow oxygen with non-rebreather mask:– Wash poison out of system.Wash poison out of system.– Decrease half-life of CO in blood.Decrease half-life of CO in blood.– Increase delivered oxygen in blood.Increase delivered oxygen in blood.– Support ventilations as needed.Support ventilations as needed.

• Transport to Transport to closest most appropriateclosest most appropriate facility. facility.

• Consider hyperbaric treatment center:Consider hyperbaric treatment center:– Adults >25%, Pedi & Pregnant female >15%.Adults >25%, Pedi & Pregnant female >15%.

• Consider air transport for extended distance.Consider air transport for extended distance.

• Monitor all ABC’s, vital signs and SpCO.Monitor all ABC’s, vital signs and SpCO.

How its being used in EMS How its being used in EMS nationallynationally

• Asymptomatic patients – Asymptomatic patients – – Screening when there is a CO alarm, Hx of potential Screening when there is a CO alarm, Hx of potential

exposure, or for rehab situationsexposure, or for rehab situations– Asymptomatic Patients Asymptomatic Patients with elevated readingswith elevated readings may be may be

screened and reevaluated after 15 minutes of High screened and reevaluated after 15 minutes of High Flow O2 and Medical Control ConsultFlow O2 and Medical Control Consult

– Asymptomatic patients without elevated levels may be Asymptomatic patients without elevated levels may be released on scene.released on scene.

• Symptomatic patientsSymptomatic patients– Transport all symptomatic patientsTransport all symptomatic patients– Screening for severity and diversion to HBO Screening for severity and diversion to HBO

(Hyperbaric therapy)(Hyperbaric therapy)

Carbon Monoxide:Carbon Monoxide: Suggested Triage Algorithm Suggested Triage AlgorithmMeasure SpCO

0-3%0-3% >3%>3%

No further medical evaluation of SpCO

needed

No further medical evaluation of SpCO

needed

Loss of consciousness or neurological impairment or

SpCO >25%

Loss of consciousness or neurological impairment or

SpCO >25%

YesYes NoNo

Transport on 100% oxygen for ED evaluation.

Consider transport to hospital with hyperbaric

chamber

Transport on 100% oxygen for ED evaluation.

Consider transport to hospital with hyperbaric

chamber

SpCO >12SpCO >12 SpCO <12SpCO <12

Transport on 100% oxygen for ED evaluation

Transport on 100% oxygen for ED evaluation

Symptoms of CO exposure?

Symptoms of CO exposure?

Transport on 100% oxygen for ED evaluation

Transport on 100% oxygen for ED evaluation

No further evaluation of SpCO needed. Determine source of CO if nonsmoker

No further evaluation of SpCO needed. Determine source of CO if nonsmoker

YesYes NoNo

SpCO TRIAGE ALGORITHMSpCO TRIAGE ALGORITHM

KEY POINT: Some systems use an KEY POINT: Some systems use an SPCO of 11% as threshold for SPCO of 11% as threshold for

transport. transport.

How its being used How its being used locallylocally

• BFD: Deployed on BFD BFD: Deployed on BFD ALSALS Engines (3) Engines (3)

• MFD: Deployed on 5 ALS MFD EnginesMFD: Deployed on 5 ALS MFD Engines

• NFD: Rehab truck, 1 engine (pending)NFD: Rehab truck, 1 engine (pending)

State of IdahoState of Idaho

• Unofficial Stance: may be used by EMT-Unofficial Stance: may be used by EMT-B/FF in rehab situations onlyB/FF in rehab situations only– UPDATE- Soon to be approved at BLS level UPDATE- Soon to be approved at BLS level

(11/08)(11/08)

• May be used by Paramedics in Patient May be used by Paramedics in Patient Care Situations. Care Situations.

• No written clarification (yet). No written clarification (yet).

RAD-57RAD-57 EMS Carry Case EMS Carry Case

• Lightweight: Lightweight: 13 oz13 oz..• Small: Small: 6.2” x 3.0” x 1.4”.6.2” x 3.0” x 1.4”.• Portable: Portable: operates on 4 operates on 4

“AA” batteries.“AA” batteries.• Supplied with high-visibility, Supplied with high-visibility,

water-resistant protective water-resistant protective case.case.– Protective cover.Protective cover.– Extra sensor pocket.Extra sensor pocket.– Reference card holder.Reference card holder.– Department ID holder.Department ID holder.– Pen holder.Pen holder.– Spare battery pocketSpare battery pocket..

• POWERPOWER– Press to turn Press to turn ON.ON. – Press and Press and HOLDHOLD to turn to turn OFF.OFF.

RAD-57 Operation:RAD-57 Operation: Powering Up Powering Up

• BATTERY INDICATORBATTERY INDICATOR– 4 Green LED’s.4 Green LED’s.– Each represents 25% battery life.Each represents 25% battery life.– Use only Use only Alkaline batteries.Alkaline batteries.

• BATTERY COMPARTMENTBATTERY COMPARTMENT– Located in back panel.Located in back panel.– Holds 4 “AA” batteries.Holds 4 “AA” batteries.– Operates up to Operates up to 8 hours.8 hours.

RAD-57RAD-57 Operation: Operation: CalibrationCalibration

• POWER ON: SENSOR ON FINGERPOWER ON: SENSOR ON FINGER

– All LED’s light up.All LED’s light up.

– Calibration mode beginsCalibration mode begins

• Spinning zeroes Spinning zeroes 0 - 0 – 00 - 0 – 0..

• Completed in Completed in 2020 second second (avg.)(avg.)

• DO NOTDO NOT move sensor during move sensor during calibration.calibration.

• Acquires reading and Acquires reading and displays.displays.

• DISPLAYDISPLAY– Defaults to pulse rate and oxygen saturation reading.Defaults to pulse rate and oxygen saturation reading.– ““PI” bar graphPI” bar graph displays displays

strength of arterial perfusion.strength of arterial perfusion.

KEY POINTS:KEY POINTS:

• CALIBRATION takes 20 secondsCALIBRATION takes 20 seconds

• Look for the three spinning zeroesLook for the three spinning zeroes

• No movement during calibrationNo movement during calibration

• Shield unit during calibrationShield unit during calibration

RAD-57RAD-57 Operation: Operation: Sensor PlacementSensor Placement

• SENSOR SENSOR PLACEMENT IS PLACEMENT IS VERY IMPORTANTVERY IMPORTANT– When possible, use ring When possible, use ring

finger, non-dominant hand.finger, non-dominant hand.

– Insert finger until the tip of Insert finger until the tip of finger hits the finger hits the STOP Block.STOP Block.

– Sensor should not rotate or Sensor should not rotate or shift freely on finger.shift freely on finger.

– LED’s (red light) should LED’s (red light) should pass through mid-nail, pass through mid-nail, notnot cuticle.cuticle.

– There is a top and bottomThere is a top and bottom, , cable should be on top cable should be on top (nail side).(nail side).

Optimal LED path

RAD-57 Operation:RAD-57 Operation: Pulse Rate Pulse Rate and Saturationand Saturation

• DISPLAY AFTER DISPLAY AFTER INITIAL CALIBRATIONINITIAL CALIBRATION– Oxygen Saturation on top in Oxygen Saturation on top in

RedRed

– Pulse Rate on bottom Pulse Rate on bottom in in GreenGreen

– Green PI scale, indicates Green PI scale, indicates strength of arterial pulsestrength of arterial pulse

– Low SIQ LED indicates poor Low SIQ LED indicates poor signal qualitysignal quality

– Press SpCO to display % Press SpCO to display % carboxyhemoglobincarboxyhemoglobin

– Press “Bell” to silence alarmsPress “Bell” to silence alarms

RAD-57 Operation:RAD-57 Operation: Pulse Pulse Rate and SaturationRate and Saturation

PI scale1111

22 Low SIQ LED

22

44 SpCO key, changes display from SpO2 to SpCO

44

55 Battery level

55

33 Alarm LED

33

• DISPLAY AFTER DISPLAY AFTER INITIAL CALIBRATIONINITIAL CALIBRATION– Oxygen Saturation on top in Oxygen Saturation on top in

RedRed

– Pulse Rate on bottom Pulse Rate on bottom in in GreenGreen

– Green PI scale, indicates Green PI scale, indicates strength of arterial pulsestrength of arterial pulse

– Low SIQ LED indicates poor Low SIQ LED indicates poor signal qualitysignal quality

– Press SpCO to display % Press SpCO to display % carboxyhemoglobincarboxyhemoglobin

– Press “Bell” to silence alarmsPress “Bell” to silence alarms

• Alarms adjust:Alarms adjust:– Press “Mode/Enter” twicePress “Mode/Enter” twice– Press “Next” key to scroll through Press “Next” key to scroll through

parametersparameters– Use up and down keys to adjustUse up and down keys to adjust– Reverts to Factory settings after turned off.Reverts to Factory settings after turned off.

• Preset at factory:Preset at factory:– Sa02 (oxygen saturation)Sa02 (oxygen saturation)

• Low: 90%Low: 90%• High: noneHigh: none

– Pulse RatePulse Rate• Low: 50Low: 50• High: 140High: 140

– SpCO (carboxyhemoglobin)SpCO (carboxyhemoglobin)• Low: noneLow: none• High: 10% High: 10%

RAD-57 Operation:RAD-57 Operation: Alarms Alarms• When violated, audible When violated, audible

alarm will sound, alarm will sound, parameter will parameter will flashflash

Alarm indicator

Alarm silence

RAD-57 Operation:RAD-57 Operation: Measuring CO Measuring CO

• PRESS PRESS ORANGE ORANGE SPCO BUTTONSPCO BUTTON• Display will toggle to CO mode for 10 Display will toggle to CO mode for 10

secondsseconds

• Carboxyhemoglobin reading in % on Carboxyhemoglobin reading in % on toptop

• ““CO” displayed on bottom confirming CO” displayed on bottom confirming modemode

• ALWAYS confirm high readings by ALWAYS confirm high readings by taking several measurements on taking several measurements on DIFFERENT fingers and averageDIFFERENT fingers and average

• Real-time SpCO indicator Real-time SpCO indicator continuously reads SpCOcontinuously reads SpCO– Green:Green: 1-9% 1-9%– Orange:Orange: 10-19% 10-19%– RedRed: 20% and above: 20% and above

RAD-57 Operation:RAD-57 Operation: TroubleshootingTroubleshooting

1.1. WILL NOT TURN ON:WILL NOT TURN ON:– Check battery compartmentCheck battery compartment– Replace batteriesReplace batteries

2.2. CALIBRATION MODE WILL NOT STOP:CALIBRATION MODE WILL NOT STOP:– Shield from Shield from flashing lightsflashing lights, strobes, strobes or or

high ambient lighthigh ambient light– Try other digitsTry other digits

3.3. ““NO CBL” MESSAGE:NO CBL” MESSAGE:– Cable not seated into top of Rad-57Cable not seated into top of Rad-57– Defective cableDefective cable

4.4. ““SEN OFF” MESSAGE:SEN OFF” MESSAGE:– Sensor off fingerSensor off finger– Sensor misalignedSensor misaligned

5.5. ““Err” MESSAGEErr” MESSAGE– Return for serviceReturn for service

6.6. CONTINUOUS SPEAKER TONECONTINUOUS SPEAKER TONE– Internal failure, return for serviceInternal failure, return for service

Research ReviewResearch Review

• Small study, monitored by an IRB. Control sample was Small study, monitored by an IRB. Control sample was an ABG drawn by lab. an ABG drawn by lab.

• ““The new Masimo Rad-57 pulse oximeter performed The new Masimo Rad-57 pulse oximeter performed within its specifications in this volunteer study, measuring within its specifications in this volunteer study, measuring COHb% in volunteers with an uncertainty of about 2%.”COHb% in volunteers with an uncertainty of about 2%.”

• “…“…This new technology represents a major advance in This new technology represents a major advance in the monitoring of oxygenation. The same principles will the monitoring of oxygenation. The same principles will allow the measurement of other dyshemoglobins, allow the measurement of other dyshemoglobins, including methemoglobin.“including methemoglobin.“

• - Barker SJ, Morgan S, Bauder W. - Barker SJ, Morgan S, Bauder W. New Pulse Oximeter Measures New Pulse Oximeter Measures Carboxyhemoglobin Levels in Human VolunteersCarboxyhemoglobin Levels in Human Volunteers Anesthesia & Anesthesia &

Analgesia Analgesia 2006; 102(3S): S42006; 102(3S): S4

Research reviewResearch review

• Very large study (1,756 patients) of patients presenting Very large study (1,756 patients) of patients presenting to an urban ED triage area over a 12 day study period.to an urban ED triage area over a 12 day study period.

• Weakness, no control group Weakness, no control group • No correlation of V/S and COHb levels. (read: traditional No correlation of V/S and COHb levels. (read: traditional

v/s not an effective screening tool for COHb levels)v/s not an effective screening tool for COHb levels)• Smokers had a higher baseline reading than non-Smokers had a higher baseline reading than non-

smokers.smokers.• 3 cases of previously unsuspected CO poisoning 3 cases of previously unsuspected CO poisoning

were identified in triage using this method. were identified in triage using this method.

• Chee KJ, Suner S, Partridge RA, Sucov A, Jay GD. Chee KJ, Suner S, Partridge RA, Sucov A, Jay GD. Noninvasive Noninvasive Carboxyhemoglobin Monitoring: Screening Emergency Department Carboxyhemoglobin Monitoring: Screening Emergency Department

Patients for Carbon Monoxide ExposurePatients for Carbon Monoxide Exposure Academy of Emergency Academy of Emergency Medicine Medicine 2006;13(5) suppl 1: A442.2006;13(5) suppl 1: A442.

Research ReviewResearch Review

• FDNY StudyFDNY Study• Targeted patients with suspected CO exposureTargeted patients with suspected CO exposure• Followed up with ABGS drawn at hospital on transported Followed up with ABGS drawn at hospital on transported

patients. patients. • 149 patients, 22 (6.7%) had SPCO >11%, 11 of these 149 patients, 22 (6.7%) had SPCO >11%, 11 of these

had ABGs drawnhad ABGs drawn• Less than 2% variance between SPCO and ABG level of Less than 2% variance between SPCO and ABG level of

CoCo

• Ben-Eli D, Peruggia J, McFarland J, Werner A, Kaufman BJ, Freese Ben-Eli D, Peruggia J, McFarland J, Werner A, Kaufman BJ, Freese J, Cox L, Fry A, Askew S, Prezant DJ. J, Cox L, Fry A, Askew S, Prezant DJ. Detecting CO – FDNY Detecting CO – FDNY

Studies Prehospital Assessment of COHb Studies Prehospital Assessment of COHb JEMS 2007; October: JEMS 2007; October: 36-37.36-37.

Research reviewResearch review• Survey Based Study, Large area, Respected JournalSurvey Based Study, Large area, Respected Journal• This study looked at the Pacific NW (Including Idaho). It evaluated the This study looked at the Pacific NW (Including Idaho). It evaluated the

potential impact of a device like the Rad-57 on the rapid Dx and referral of potential impact of a device like the Rad-57 on the rapid Dx and referral of patients for treatment.patients for treatment.

• ““The average time to get a result is 10 ± 10 min in hospitals with co-oximetry The average time to get a result is 10 ± 10 min in hospitals with co-oximetry and 904 ± 1360 min in those without, and 904 ± 1360 min in those without, a difference of 15 ha difference of 15 h…”…”

• “ “ Over 90% of CO-poisoned patients referred for hyperbaric treatment came Over 90% of CO-poisoned patients referred for hyperbaric treatment came from hospitals able to measure COHb..”from hospitals able to measure COHb..”– This means that the majority of CO poisensings in rural or non-COHb hospitals This means that the majority of CO poisensings in rural or non-COHb hospitals

received a Dx and treatment. received a Dx and treatment. • ““.. .. Fewer than one-half Fewer than one-half of acute care hospitals in a four-state region have of acute care hospitals in a four-state region have

the capability to measure COHb levels. This has the potential to significantly the capability to measure COHb levels. This has the potential to significantly impact diagnosis or treatment of patients with acute CO poisoning.”impact diagnosis or treatment of patients with acute CO poisoning.”

• Neil B. Hampson, Karen L. Scott and Jennette L. Zmaeff Neil B. Hampson, Karen L. Scott and Jennette L. Zmaeff Carboxyhemoglobin measurement by Carboxyhemoglobin measurement by hospitals: Implications for the diagnosis of carbon monoxide poisoning hospitals: Implications for the diagnosis of carbon monoxide poisoning Journal of Journal of

Emergency Medicine, Volume 31, Issue 1, July 2006, Pages 13-16Emergency Medicine, Volume 31, Issue 1, July 2006, Pages 13-16   

Research ReviewResearch Review

• 7 month study in France targeting patients with 7 month study in France targeting patients with suspected CO poisoning. suspected CO poisoning.

• COHg was measured by the Rad-57 and ABG analysis. COHg was measured by the Rad-57 and ABG analysis. • Approx 1.5-2% variation with the Rad-57 tending to Approx 1.5-2% variation with the Rad-57 tending to

overestimate.overestimate.– ““This preliminary result demonstrates that this simple rapid This preliminary result demonstrates that this simple rapid

noninvasive technology could be useful before and after arrival noninvasive technology could be useful before and after arrival at the ED.”at the ED.”

• Reliability of new pulse CO-oximeter in victims of carbon monoxide Reliability of new pulse CO-oximeter in victims of carbon monoxide poisoning. Undersea Hyperb Med. 2008 Mar-Apr;35(2):107-11poisoning. Undersea Hyperb Med. 2008 Mar-Apr;35(2):107-11

Research ReviewResearch Review

• Large Study over nine months on 10,850 patients at Rhode Island Large Study over nine months on 10,850 patients at Rhode Island Hospital in the ED . Respected Journal. Hospital in the ED . Respected Journal.

• 28 cases of CO toxicity (in this study defined as: SpCO >9% for 28 cases of CO toxicity (in this study defined as: SpCO >9% for nonsmokers and >13% for smokers) were found. nonsmokers and >13% for smokers) were found.

• 11 of the cases were unexpected and identified with the aid of the Rad-11 of the cases were unexpected and identified with the aid of the Rad-57. 57.

• In all CO toxicity cases identified, venous or arterial COHb confirmations In all CO toxicity cases identified, venous or arterial COHb confirmations of elevated SpCO measurements were verified by lab analysis of blood of elevated SpCO measurements were verified by lab analysis of blood samples taken with data results samples taken with data results showing a “good correlation” between showing a “good correlation” between SpCO from the Masimo Rad-57 and COHb from the lab analysis.SpCO from the Masimo Rad-57 and COHb from the lab analysis.

• Suner S, Partridge R, Sucov A, Valente J, Chee K, Hughes A, Jay G. Non-invasive pulse Suner S, Partridge R, Sucov A, Valente J, Chee K, Hughes A, Jay G. Non-invasive pulse CO-oximetry screening in the emergency department identifies occult carbon monoxide CO-oximetry screening in the emergency department identifies occult carbon monoxide

toxicity. Journal of Emergency Medicine. 2008 May;34(4):441-50. Epub 2008 Jan 28. toxicity. Journal of Emergency Medicine. 2008 May;34(4):441-50. Epub 2008 Jan 28.

SummerySummery

• CO toxicity can come from numerous CO toxicity can come from numerous environmental, pathological, and environmental, pathological, and iatrogenic sources. iatrogenic sources.

• CO toxicity presents with generally non CO toxicity presents with generally non specific s/s.specific s/s.

• A high index of suspicion is requiredA high index of suspicion is required• SPCO is a supplement to good clinical SPCO is a supplement to good clinical

assessment and high index of suspicion, assessment and high index of suspicion, not a replacement for it. not a replacement for it.

Questions?Questions?