© 2008 Masimo Corporation Includes a review on Carbon Monoxide Poisoning For Emergency Responders Version 2.0F, 07.02.08 Monitoring CO Poisoning with the.

© 2008 Masimo Corporation

Includes a review on Carbon Monoxide Poisoning For Emergency Responders

Version 2.0F, 07.02.08

Monitoring CO Poisoningwith the Rad-57TM


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.

• There are two versions of operating software that also include faceplate changes. Please review slide 28 for key version differences.


Section 1

Review: Carbon Monoxide Poisoning For Emergency Responders


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 the introduction of the Masimo Rad-57, testing for carbon monoxide can now be done quickly and easily, allowing for prompt screening and treatment.

• This training program covers carbon monoxide poisoning recognition and treatment and the use of the Masimo Rad-57 Pulse CO-OximeterTM. As always, seek direction and approval from your physician or Medical Director prior to using this training program or a Masimo Rad-57.


Definition

• Carbon monoxide is a colorless, odorless, tasteless, toxic gas that, when inhaled, can cause serious physical problems and even death.

• Carbon monoxide is often referred to as “CO”, which is its chemical symbol. Even at low levels, carbon monoxide may cause long-term cardiovascular and neurological disorders.

• Carbon monoxide can be a serious and sometimes deadly threat to Firefighters and EMS personnel. Firefighters have regular contact with carbon monoxide at fire and rescue scenes, increasing their health risks.


• Incomplete combustion of any carbon-based material will produce carbon monoxide. Closed or confined spaces are particularly hazardous. Common sources are:• Automobiles, trucks, buses• Boats, campers• Gas heaters, furnaces, and hot water heaters• Gas-powered generators• Small gasoline engines• Portable / space heaters• Barbecues / fireplaces• Cigarette smoke• Lanterns• Methylene chloride (paint stripper)

• Liver converts to CO• Structure / wildland fires

Common Sources


Physiology• Carbon monoxide is inhaled and

passes from the lungs to the blood where it binds with hemoglobin• Produces carboxyhemoglobin• Affinity to hemoglobin is greater than 200 X

that of oxygen• Reduces oxygen carrying capacity of blood• Alters release of remaining oxygen to cells

• Acts as an intracellular toxin• Poisons tissues and cells

• Binds with myoglobin in muscle• Interferes with heart and skeletal

muscle

• Immediate threat to life• Oxygen starvation• Cardiac arrhythmias• Alters judgment, reasoning

• Long-term health effects• Central nervous system damage• Cardiovascular damage


Signs and Symptoms

SpCO SpCO %% Clinical ManifestationsClinical Manifestations

0-4% None - Normal

5-9% Minor Headache

10-19% Headache, Shortness of Breath

20-29% Headache, Nausea, Dizziness, Fatigue

30-39% Severe Headache, Vomiting, Vertigo, ALOC

40-49% Confusion, Syncope, Tachycardia

50-59% Seizures, Shock, Apnea, Coma

60% -up Coma, Death

Koster LA, Rupp T.The Silent Killer, Recognizing and Treating Carbon Monoxide Poisoning. JEMS. October 2005


Treatment Considerations

• Scene safety, protect yourself:• Consider SCBA

• Remove patient away from the poison!

• ABC’s (airway, breathing and circulation)

• Check CO level with Pulse CO-Oximeter

• High levels treated with 100% oxygen:• Decrease half-life of CO in blood• Increase delivered oxygen in blood• Support ventilations as needed

• Transport to closest, most appropriate facility

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

• Monitor vital signs and SpCO®

• Always follow local EMS protocols


Suggested Triage Algorithm

Hampson NB, Weaver LK JEMS 2006

Measure SpCO

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


evaluation. Consider transport to hospital

with hyperbaric chamber

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


evaluation


evaluationSymptoms of CO

exposure?Symptoms of CO

exposure?


evaluation


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


Half-Life

• Half-life: The amount of time required to reduce the blood level of CO by 50%. These are estimates for patients that otherwise are healthy. Age and health will impact the half-life of CO.

• Breathing Room Air: Carbon Monoxide half-life in blood is ~ 240 minutes

• High-flow oxygen (“100%”) via non-rebreather mask: Decreases CO Half-life in blood to 40-60 minutes

• Hyperbaric Oxygen Treatment (HBOT) at 2.5 to 3 Atmospheres: Decreases CO half-life in blood to 20 -24 minutes


Understanding PPM & SpCO

• PPM or “Parts Per Million” is the atmospheric concentration of the gas

• PPM is common fireground safety measurement, often misleading as CO forms in pockets

• SpCO - noninvasive measurement of CO in the blood

• SpCO as measured by RAD-57 is a function of PPM CO and total time of exposure of the poison

• Age, health and respiratory rate may be a factor

• Even low PPM levels can lead to high SpCO if exposure is long enough, common in overhaul

• Even an exposure of 50 PPM for 60 minutes requires assessment and possible medical treatment with oxygen


Firefighter Risk

• CO levels may be highest during the post-fire or “overhaul” phase, search & rescue operations and wildland firefighting

• 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

• Studies have shown low levels of untreated CO lead to central nervous system and cardiovascular disease

• Moderate to high levels are immediate threats to health and safety, and cause cardiovascular injury


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.


RAD-57 Pulse CO-Oximeter

• The Masimo RAD-57 is the world’s first and only Pulse CO-Oximeter• Signal Extraction Technology (SET®)

SpO2 (oxygen saturation)Pulse rate Measure through motion and low perfusion

• Rainbow® SET TechnologyAnalyzes 7+ wavelengths of lightAccurately measures carboxyhemoglobin (SpCO) levels noninvasively, in SECONDS!

• PI (perfusion index, strength of arterial pulse) • Low Signal IQ® indicator (poor SpO2 signal quality)• Continuous color-coded CO bar graph• Adjustable parameter alarms


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• Protective cover• Reference card holder• Department ID holder• Pen holder• Spare battery pocket• Extra sensor pocket


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


RAD-57 Operation / Startup Sequence

• Place sensor on finger (relatively clean & dry)

• Press “Power” button

• Verify All LED’s light up and a 1 second tone is heard*

• Startup mode begins• All preset configurations are displayed• Scrolling zeroes 0 – 0 – 0 and flashes

dashed lines• May take up to 25 seconds• Do not move sensor during startup• When complete reading is displayed

• Begin patient monitoring• Defaults to pulse rate and oxygen

saturation reading• “PI” bar graph displays strength of

arterial perfusion

* Refer to operator’s manual for additional verifications prior to patient monitoring.


RAD-57 Operation / Sensor Placement

• Sensor placement is very IMPORTANT

• When possible, use ring finger, non-dominant hand

• Insert finger until the tip of finger hits the STOP Block

• Sensor should not rotate or move freely on finger

• LED’s (red light) should pass through mid-nail, not cuticle

• There is a top and bottom, cable should be on top (nail side)

Optimal LED path


RAD-57 Operation / Pulse Rate and Saturation

• Display after Startup• 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

SpO2 signal quality

• Press “Display” to display % carboxyhemoglobin

• Press “Bell” to silence alarms

Display button toggles from

SpO2 to SpCO

PI Scale

Low SIQ LED

Alarm Silence LED

Battery level


RAD-57 Operation / Alarms

• When parameter is violated, audible alarm will sound, parameter will flash

• Preset at factory:• Sp02 (oxygen saturation)

• Low: 90%• High: none

• Pulse Rate• Low: 50• High: 140

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

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

parameters• Use up and down keys to adjust• Changes remain until user restores to

factory defaults

Alarm Indicator(flashes)


RAD-57 Operation / Measuring CO

• Press “Display” button for SpCO reading

• To scroll back to SpO2 mode press “Display” again

• Carboxyhemoglobin displayed in % on top

• “CO” displayed on bottom confirming mode

• Real-time SpCO indicator continuously reads SpCO• Green: 1-3%• Yellow: 4-11%• Red: 12% and above

• Confirm abnormal readings by taking several measurements on different fingers and average the readings

Slow: Low SpCO Confidence

Fast: SpCO Alarm

CO label when SpCO is displayed


RAD-57 Operation / TroubleshootingError Messages:• “NO Cbl”

• Cable not seated properly into top of Rad-57• Defective cable

• “SEN OFF”• Sensor off finger• Sensor misaligned

• “bAd CbL” • Defective cable• Replace cable

• “CbL”• Incompatible cable• Connect appropriate cable

• “bAd SEN”• Defective sensor• Replace sensor

• “SEN”• Unrecognized sensor• Connect appropriate sensor


RAD-57 Operation / Troubleshooting• Will not power on

• Check battery compartment• Replace batteries

• Continuous Startup mode (Scrolling zeroes 0 – 0 – 0 and flashes dashed lines)• Shield sensor from flashing lights,

strobes or high ambient light with Masimo Light Shield*

• Try other fingers

• Single battery level indicator flashes (with audible alarm)• Battery level too low• Replace batteries immediately

• “Err” message• Return for service, Call 800-326-4890

• Continuous Speaker Tone• Power down and remove batteries• Return for service, Call 800-326-4890

* Contact your Masimo sales rep to order a Masimo Light Shield.


RAD-57 Operation / Light Shield Use

• Face protrusion of light shield down, and insert the end of the sensor into the hole

• Ensure that sensor hits the back of the light shield

• Orient the sensor so the cable is coming out of the top of the hole while in the light shield

• Open the sensor by applying pressure from the top and bottom of the light shield

• Insert finger until the tip of finger hits the STOP Block

• LED’s (red light) should pass through mid-nail, not cuticle

• Orient the sensor so the cable is running over the top of the patient’s hand

Optimal LED path

Apply pressure

to open sensor

Protrusion


RAD-57 Operation / Improving Accuracy

• The Rad-57 is designed with an accuracy of +/- 3 digits with a range of 1% - 40% for one standard deviation (67% of patients)• Example: A reading of 10% could have a range from

7% - 13%

• Measurements may vary from reading to reading, even on the same patient, within the accuracy specification

• Proper probe placement may improve accuracy

• If an abnormal level of CO is detected, always confirm by measuring other fingers and average

• Flashing lights, strobes or high ambient light may interfere, use a Masimo Light Shield or other means of shielding


RAD-57 Operation / Contraindications

• Small physiological changes and acceptable levels of 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 • Intravascular dyes such as indocyanine green or

methylene blue• Abnormal hemoglobin levels• Low arterial perfusion• Low arterial oxygen saturation levels• Elevated Total Bilirubin levels• Motion artifact


RAD-57 Version Differences

• Version 1• Faceplate design

changes (see image)• SpCO button displays

value for 10 seconds• Upon Startup all LEDs

flash, dashed lines, scrolling zeroes, followed by flash dashed lines

• Alarm settings revert back to factory settings upon power off

• SpCO bar graph changes color at 10% and 20%

• Version 2• Faceplate design changes

(see image) • Display button allows user

to scroll through modes (SpO2, SpCO and PI)

• PI can be displayed as a numeric value

• Upon Startup all LEDs flash, device presents all configurations, then scrolling zeroes and flash dashed lines

• Alarm settings are retained after power off

• SpCO bar graph changes color at 3% and 12%


Resources

For more information on carbon monoxide poisoning and the Masimo Rad-57

www.masimo.com or call 800-326-4890www.Firerehab.comwww.firegrantshelp.comwww.emsgrantshelp.comwww.naemse.orgwww.naemt.orgwww.iaff.orgwww.carbonmonoxidekills.com/www.epa.gov/iaq/pubs/coftsht.htmlwww.carbon-monoxide-poisoning.comwww.nlm.nih.gov/medlineplus/carbonmonoxidepoisoning.htmlwww.emedicinehealth.com/carbon_monoxide_poisoning/article_em.htmwww.osha.gov/OshDoc/data_General_Facts/carbonmonoxide-factsheet.pdfwww.cdc.gov/co/www.bt.cdc.gov/disasters/carbonmonoxide.aspwww.postgradmed.com/issues/1999/01_99/tomaszewski.htm

Masimo Corporation40 Parker

Irvine, CA 92618949-297-7000

All Rights Reserved

Masimo

© 2008 Masimo Corporation Includes a review on Carbon Monoxide Poisoning For Emergency Responders Version 2.0F, 07.02.08 Monitoring CO Poisoning with the.

Documents

carbon monoxide levels

carbon monoxide recognition

masimo rad

masimo corporation signs

masimo corporation section

tm slide

measure spco spco

symptoms spco