Wilson County Emergency Management Agency Protocol Manual Protocols

Transcription

1 Carbon Monoxide Monitoring AEMT & Paramedic Standing Order With the technology of the Masmio RAD 57 carbon monoxide detector EMS personnel are now able to determine CO levels with the same simplicity as a pulse oximeter in the field. EMS personnel should utilize this equipment anytime CO exposure is suspected and all fire scenes where a working fire is indicated by command. Carbon monoxide (CO) is a colorless, odorless, invisible gas byproduct of most combustion reactions. CO is also produced from metabolism of methylene chloride, an agent found in paint strippers. CO is the most common cause of poisoning deaths worldwide. Classic symptoms include headache, altered mental status, shortness of breath, and nausea or vomiting. However, symptoms are often vague, rarely correlate to blood saturations of carboxyhemoglobin and frequently resemble other medical conditions such as viral illness, gastroenteritis, migraine, and acute coronary syndrome. CO poisoning is often missed; CO screening should be performed on all EMS patients, firefighters during rehabilitation, and all occupants of buildings with carbon monoxide detector alarm activations. CO-oximetry utilizes multiple wavelengths of light (both visible and invisible spectra) to measure oxyhemoglobin, carboxyhemoglobin, and (optionally) methemoglobin. When using CO-oximetry, attention to proper probe placement and shielding from extraneous light sources improves accuracy of measured SpCO levels. Elevated methemoglobin levels will falsely raise SpCO readings. Fetal hemoglobin has greater affinity for CO; pregnant patients should be treated more aggressively and receive early consideration for hyperbaric referral. Critically ill patients may have increased levels of carboxyhemoglobin related to the severity of their illness/injury. SpCO measurement should not replace clinical judgment. Any symptomatic patient should receive further medical evaluation. Indications Smoke inhalation Firefighter Rehab Firefighter Training (with live fire) Carbon Monoxide Alarms Any sign/symptom of CO exposure Common Signs and Symptoms of CO Exposure Malaise Vomiting Drowsiness Flu like symptoms Diarrhea Abdominal pain Chest pain Weakness Vision problems Confusion Seizures Agitation Depression Hallucination Coma Nausea Impulsiveness Death SpCO Severity Signs and Symptoms % Mild Headache, nausea, vomiting, dizzy, blurred vision % Moderate Confusion,syncope, chest pain, dyspnea, tachycardia, tachypnea % Severe Dsyrhythmias, hypotension, pulmonary edema, seizures, coma Above 60% Fatal Death Carbon Monoxide Monitoring Page 1 of 5 G 1.2

2 Treatment EMR EMT Basic assessment and management (up to your scope of practice) 100% oxygen via NRB RAD 57 for carbon monoxide and pulse oximeter monitoring Treat any associated s/s per appropriate protocol SpCO less than 5% no treatment is indicated SpCO greater than 5% should receive oxygen to lower CO EMR/EMT STOP Ø AEMT Vascular access AEMT STOP Ø PARAMEDIC Cardiac monitor and treat per protocol specific for the arrhythmia/dysrhythmia present. If SpCO is above 15% and patient is refusing cardiac monitor maybe utilized to rule out cardiac events PARAMEDIC STOP Ø Carbon Monoxide Monitoring Page 2 of 5 G 1.2

3 Firefighter Rehab 1. Measure any firefighter exposed to smoke (including pump operators and command staff) 2. Initial CO assessment parameters: 0 5% Considered normal 5 10% Considered normal in a smoker > 10% Abnormal in any person consider high flow oxygen > 15% Significantly abnormal in any person treatment mandated 3. CO reassessment parameters: 0 5% Acceptable for return to firefighting activities if medically cleared 5 10% Consider high flow oxygen until at or below 5% regardless of symptoms > 10% Abnormal, assess for symptoms, consider high flow oxygen > 15% Significantly abnormal, treatment mandated, consider transport The specifics of setup, etc. will be in the department Standard Operating Guidelines and/or policy. EMS personnel should staff the rehab area. Personnel staffing the rehab area shall. 1. Perform a visual evaluation for signs of heat/cold related issues or altered mental status upon arrival at rehab area. 2. Document all personnel into rehab and allow rehydration and rest. 3. After rest and rehab personnel may be release when ALL of the following are met a. Reports being adequately rested b. Reports hydrating at least 1000 ml or water or 500 ml sports drink c. Heart rate (by RAD 57) is less than 110, Sp02 is above 92, and SpCO is less than 5%. 4. If any one (1) of indications above is not met the firefighter will rest 10 more minutes. Once the firefighter meets all the criteria above they may be released. 5. Aquire and interpret 12 lead EKG on any new irregular pulse, chest pain, Altered Mental Status, or SPCO above 15%. 6. Transport is mandated for any firefighter if vital signs remain outside the parameters in #3 after resting for 50 minutes. 7. Document when the firefighter is released or transported. 8. An EMS report shall be completed on any person transported to the ED or refuses transport when outside the parameters above. Carbon Monoxide Monitoring Page 3 of 5 G 1.2

4 Special Notes If a smoker, consider last time they had tobacco use. Revaluate after rest, removal from possible source for at least 10 minutes. Anyone with a SpCO above 15% or Sp02 below 90% should get 100% oxygen and encouraged for transport for smoke inhalation situations due to the possible cyanide exposure as well. All rest cycles should be at least 10 minutes before evaluation of vital signs. Blood pressure is proven not to be a valuable vital sign for firefighter rehab. Remember FF rehab differs slightly because they have a higher chance of expose on the fire scene. Carbon Monoxide Alarms (CO Detector Alarm Activation) 1. Atmospheric monitoring following fire Carbon Monoxide Alarm SOG 2. Screen all building occupants for CO symptoms and measure SpCO% a. Assess occupants and measure SpCO b. Suspect CO exposure if multiple patients > 3% (non-smokers) or > 8% (smokers) c. Occupants closest to CO source will have higher SpCO% (relay this information to Fire Department interior personnel) 3. Treat any symptomatic patient(s) with high flow oxygen regardless of SpCO reading and consider transport 4. Follow Routine Assessment parameters (below) for asymptomatic patients with abnormal SpCO readings Carbon Monoxide Monitoring Page 4 of 5 G 1.2

5 All Patients (Routine Assessment) 1. The vague nature of CO symptoms and lack of correlation to carboxyhemoglobin blood levels suggest routine assessment of SpCO in every patient 2. Initial CO assessment parameters: 0 5% Considered normal in non-smokers. When > 3% with symptoms, consider high flow oxygen and evaluate environment for CO sources. Consider measuring others in same room/office/vehicle as patient. In absence of symptoms, no further medical evaluation of SpCO needed. 5 10% Considered normal in smokers, abnormal in non-smokers. If symptoms are present, consider high flow oxygen and inquire if others are ill % Abnormal in any patient. Assess for symptoms, consider high flow oxygen. Evaluate environment for CO sources. > 15% Significantly abnormal in any patient. Administer high flow oxygen, assess for symptoms, consider transport. Evaluate environment for CO sources. 3. CO reassessment parameters: 0 5% If symptoms persist, recommend transport regardless of SpCO readings. If symptoms resolved, no further medical evaluation of SpCO needed. 5 10% If symptoms persist, recommend transport regardless of SpCO readings. If symptoms resolve and SpCO remains > 5% in any patient, recommend further medical evaluation. Non-smokers should be encouraged to have their home/work environment evaluated for CO % If symptoms persist or SpCO remains > 10% in any patient, recommend transport. Encourage patient to have home/work environment evaluated for CO. > 15% Recommend transport regardless of symptoms. Ensure that others in patient s home or workplace are not ill. SpCO (Carbon Monoxide) Assessment Parameters developed by Mike McEvoy, PhD, REMT-P, RN, CCRN EMS Coordinator Saratoga County, NY Used with permission (download from Approved Roger McKinney, MD Date 7/1/18 Version 4.1 Revision(s) Carbon Monoxide Monitoring Page 5 of 5 G 1.2