CO exposure -- what would you have done?

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squid

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An internet buddy of mine just told me this story, and I thought it brought up a question or two.

Two adults were burning wood in a fireplace, shut the flue before the coals died, and late in the evening as they were going to bed the CO detector goes off with a reading of 270 in one room and 120 in another. Both adults have mild headaches, feeling a little disoriented, and believe their "symptoms" are more due to staying up late and being tired than anything else. One of the adults is pregnant.

In this case, you're responding with the fire department in an ambulance. What do you do?
 
I would get everyone out of the house, apply o2 to all and transport. And I would probably like to see the pregnant pt be kept overnight tomake sure the unborn child is intact. And perhaps offer a little education on CO poisoning, and offer them to see the DHS about getting central heat and air installed at the residence at a reduced cost depending on financial circumstances to prevent this from happening again.

Also spending minimal time in the residence if no SCBA equipment is available, if SCBA is available Im wearing it inside the house to prevent myself from becomig a victim of CO poisoning.

-CP
 
If they can't walk out, don scba and escort them out. The treatment for CO Poisoning is the same weather you're an EMT or Paramedic. The only exception in PA is that ALS can use different masks. BLS could use 15LPM O2 by A Non-Rebreating Mask, and ALS could use 15-20 LPM O2 by a Venturi or High Concentration. Depending on the severity of the effects, I may choose to use 25LPM CPAP.

Everyone would get atleast a saline lock, so I would have vein access to draw labs. If they were really out of it, then I'd probably do a 4 lead EKG workup, IV w/ NS, KVO; Glucose check is a standard test to rule out other reasons for their lethargy. Maybe some Lasix and Albuterol, as there is no exact treatment for CO poisoning other than lots of O2 real fast. At least not in my regional protocols. In severe cases, perhaps intubation is appropriate, as it is sometimes necessary to transport them via air to a facility w/ a Hyperbaric Chamber. 100% Oxygen in a pressurized chamber is usually the best treatment for severe CO Poisoning.

Never use the pulse ox.. I take it off if I get in and find a BLS unit using it, for any call, because they tend to treat what the monitor says. They can be grey and puffing for air, but if it has a false reading of 100, they don't use the oxygen.
** Not all of them do that, but I find that "brand new" EMT's use their pulse ox to treat and diagnose. While it is a helpful tool, it should not affect ones decision to put a patient on oxygen. Of course if they have COPD and you're more than 2 hours from an ED, I'd start out with high flow till they get their color back, then switch to their regular dose of Oxygen.. Maybe a few ticks higher. Always be ready to bag em.

As far as the home, and how to evacuate the gas..
If they don't have PPE, i.e. SCBA, keep them at least 100 feet away. Evac nearby homes in necessary. I tend to find that the gas meter will begin to pick up high levels of Co gas upto 30 feet from a house with high levels. If a fireman doesn't feel well, even if they didn't before they came, put him back in the apparatus w. a cylinder and a high concentration mask. Or transport, what ever your SOG is on that.

Our FD would go in w/ SCBA and check the readings with their own gas meter, open all the windows, open the flue, clean their chimney, and ensure that all is working properly. If it isn't, they call in one of the Business members of the Department who is certified to do the work necessary, and they repair the problem. The insurance company is billed for the work, if they won't pay, then it's free. Can't just open the windows and leave them without heat, pipes will freeze, and they may not be able to afford to have the necessary repairs made.
 
Whew, I was beginning to think I was being way overcautious...

I think it would be perfectly safe to enter the house without SCBA, but they were out of the house already, and I really don't think you can be too cautious, so why not? After all, they had it on scene. Should have mentioned that the folks were outside the house already, though (the dispatcher told them to leave; yay for good dispatchers!). And the fireplace is just for fun, but good idea on getting a safer furnace for those cases where it is not ... thanks!

The EMTs measured their O2 sat with a pulse oximeter, took vitals (one was normal, the preganant one was slightly high pulse and BP), and said they were fine and left... :blink: Even if they were fine, I would think that just as a CYA you should treat.

I talked to a toxicologist who said fetuses tend to suffer much more in cases of CO poisoning, and you can't be too cautious with a pregnant woman with CO exposure. Apparently, if it causes unconsciousness in mum, it usually causes death in baby... and if it causes any symptoms in mum, it might have a much worse effect on baby...

Keep repsonding... want to hear your thoughts. :)
 
Nope, don't use a pulse ox w/ CO.

It should be in your protocols that CO is a contraindication for pulse ox use b/c CO levels in the blood make it show false readings.
 
Yeah, I thought that was pretty well known, but apparently not there... except I understand there are now pulse ox's made that can distinguish? Must use a different colour or different mechanism? Note to self: go look that up. Second note to self: Until then, try not to get sick in her town. :D
 
Originally posted by squid@Oct 27 2005, 11:47 PM
Yeah, I thought that was pretty well known, but apparently not there... except I understand there are now pulse ox's made that can distinguish? Must use a different colour or different mechanism? Note to self: go look that up. Second note to self: Until then, try not to get sick in her town. :D
Click to expand...
There are combination units... SAO2, HR & CO Levels.

Had an advertisment in JEMS about them, currently only available in the UK, but are being sold to the US by that company. Well, at least that was the story when I called them for info on it. And the cost........ only three times what a plain ole' pulse ox costs. :blink:
 
NRB @ 15 lpm for both. Try to transport to a hospital code 3 (lights and sirens for at least the pregnant woman) with a hyperbaric oxygen chamber. See if I can hear a fetal pulse. It's a good thing that they have a CO detector.

Have you seen the new pulse ox type things? It's aimed toward fire departments, supposedly it can read the level of CO in the blood, not sure how well it works but I assume it does. Would be nifty.
 
Sounds like both pt's. were ambulatory so hopefully 911 had the sense to tell both to get out of the house and wait for EMS. Assist both to ambulance, high-flow O2 to decrease half-life of CO, supportive care, and transport priority 3 (non-emergency) to the hospital. I would be extra concerned about the pregnant female since fetal-hemaglobin has a much greater infinity(x240) for CO then normal. But pre-hospital nothing different your going to do treatment wise except (L) side positioning as well depending on trimester. Also, BG monitoring, EKG, and IV. Pulse ox is useless since it cant distinguish between hemaglobin and carboxyhemaglobin. CO displaces O2.

Here's a nice little excerpt ::
"Pulse oximeters are "blind" to CO because of the two wavelengths of light used to make measurements. Unfortunately, COHb is lumped in with oxyhemoglobin (O2Hb), thus producing incorrect readings. A person could have 15% COHb on board (or more), plus 80% O2Hb, but the pulse-Ox reading would still be 95% saturation."

I wouldnt have felt comfortable about both refusing especially the female. But as long as they are CAOx4 nothing you can do.

As far as the house goes, leave it closed up and dont ventilate if pt's are outside. FD will enter and monitor air to find source and correct it. Do not enter without SCBA.
 
The optimal Dx tool for someone with CO poisoning is Arterial Blood Gasses. Which i snot done in the field here, but is in the EMT-P scope of practice. Both Pt's required high flow O2 and transport. I am unsure if I would go " Hot" with that just because the mother does not need that added stress. You could have your partner step it up though.
 
From the ALS level.... getting the patients on high flow O's, and draw a rainbow of blood tubes off of a hep lock. (Not an ABG, but better than nothing)

I'd get a Spo2, just so that I can say what it is if asked, but they will get high flow o2 no matter what.

If I had a SpO2+CO oximiter, I'd use it.... but I don't ;) My squad may be getting one, because we are starting to specialize in rehab, but that is a ways off.

Jon
 
I'd base whether or not I would run code 3 (high priority) on how I think the mother would react to it...then again maybe if she gets somewhat nervous she'll breathe in the oxygen faster and it'll help to get rid of some of the CO...just kidding!

Seriously, I would base it on how I think the mother would react. We have two patients to worry about and seeing as how fetus (that's both singular and plural; 4th declension Latin noun, nominative) are affected by the CO more, I would lean to high priority.
 
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