Carbon Monoxide Response: Advanced Strategies for EMS and Fire Dept

This blog post will discuss advanced strategies for EMS and fire departments in handling carbon monoxide poisoning incidents, including:

• Recognizing the signs and symptoms of CO poisoning
• Utilizing advanced technologies and equipment
• Implementing best practices for response and treatment
• Training and education programs for first responders
• The latest research and developments in CO poisoning treatment and prevention

Recognizing Carbon Monoxide Poisoning

CO poisoning can mimic the symptoms of other illnesses, such as the flu or food poisoning, making it difficult to diagnose. Common symptoms include:

• Headache
• Dizziness
• Weakness
• Nausea or vomiting
• Shortness of breath
• Confusion
• Blurred vision
• Loss of consciousness

It is crucial for EMS and fire department personnel to maintain a high index of suspicion for CO poisoning, especially during the winter months when CO incidents are more prevalent due to increased use of heating systems and fuel-burning appliances. The legal airborne permissible exposure limit (PEL) for CO, as defined by OSHA, is 50 ppm averaged over an 8-hour workshift.

When responding to a potential CO incident, first responders should be aware of the following warning signs:

• Unconscious and unresponsive patients
• Incapacitated or deceased animals
• Activated CO detectors
• Suicide notes or warnings
• Bystanders or neighbors complaining of CO poisoning symptoms

It's important to remember that CO can permeate through walls, and a normal CO detector reading does not definitively rule out CO poisoning. Therefore, first responders must combine detector readings with a thorough assessment of patient symptoms and a careful evaluation of the scene, considering potential CO sources such as:

• Fires
• Malfunctioning cooking appliances
• Tobacco smoke
• Clogged chimneys
• Auto exhaust or idling vehicles
• Malfunctioning water heaters
• Malfunctioning oil, wood, gas, or coal furnaces
• Malfunctioning gas clothes dryers
• Wood-burning fireplaces or gas log burners
• Gas or fuel-burning appliances in cabins or campers, barbecue grills, pool or spa heaters, or ceiling-mounted heating units
• Generators that run on gasoline
• Open-air exposure to motorboat exhaust

Common types of CO exposure include incidents involving generators, automobiles/RVs, boats, kerosene/gas space heaters, power tools, fuel-burning appliances, portable fuel-burning grills/stoves, fires, charcoal grills, and charcoal briquettes used for cooking and heating indoors. Furthermore, it is crucial to consider CO poisoning as a possible cause of altered mental status, even when other potential causes, such as drug overdose or underlying medical conditions, are present.

Advanced Technologies and Equipment

Advanced technologies and equipment are essential for effective CO poisoning response. These tools help first responders quickly and accurately assess the situation, ensuring the safety of both victims and personnel. Some of the key technologies and equipment include:

• Multi-gas Monitors: These devices can detect various hazardous gases, including CO, hydrogen sulfide (H2S), hydrogen cyanide (HCN), and low oxygen levels (O₂). Fire departments should ensure all personnel entering a potentially hazardous environment are equipped with a portable multi-gas monitor. These monitors should be regularly calibrated and bump tested before each use to ensure accurate readings.
• Pulse CO-Oximeters: Unlike regular pulse oximeters, which can give false readings in the presence of CO, pulse CO-oximeters specifically measure CO levels in the blood. This allows for rapid and accurate assessment of the severity of CO poisoning. It is important to note that the time elapsed since the patient left the toxic environment can impact COHgb levels.
• Environmental Monitoring Systems: These systems continuously measure CO levels in the workplace or other environments, providing real-time data and alerts. Advanced systems may include CO sensors, gateways for remote monitoring, and IoT controllers for integration with other devices.
• Hyperbaric Oxygen Therapy (HBOT): HBOT involves administering 100% oxygen to patients in a pressurized chamber, typically at pressures 2 to 3 times greater than normal atmospheric pressure. This increases the amount of oxygen dissolved in the blood, helping to displace CO from hemoglobin and accelerate its elimination. HBOT is often recommended for patients with severe CO poisoning, particularly those with a COHgb level of more than 25–30%, evidence of cardiac involvement, severe acidosis, transient or prolonged unconsciousness, neurological impairment, or abnormal neuropsychiatric testing. It is also considered at lower COHgb levels if suggested by the patient's clinical condition, history of exposure, or the presence of specific conditions like cardiac involvement or neurological impairment. HBOT is the treatment of choice for pregnant women, even if they are less severely poisoned, due to its safety and effectiveness in this population.

Response and Treatment Strategies

Upon arrival at a suspected CO incident, EMS and fire department personnel should follow established protocols and safety procedures. These may include:

• Scene Safety: Secure the scene and assess potential hazards, such as fire or explosion risks. Request a hazmat team response if necessary.
• Personal Protective Equipment (PPE): All personnel entering the hot zone should wear appropriate PPE, including bunker gear and SCBA, to protect against CO exposure and potential fire hazards.
• Victim Removal: Quickly remove victims from the CO-contaminated environment. If victims are conscious and responsive, assist them in evacuating. If unconscious, perform a line-of-sight rescue.
• Decontamination: If necessary, decontaminate victims by removing contaminated clothing and providing basic life support, such as airway management and oxygen administration. If the victim has stopped breathing, begin rescue breathing using universal precautions, and if heart action has stopped, initiate CPR.
• Oxygen Administration: Administer 100% oxygen via a non-rebreather mask or advanced airway device to all suspected CO poisoning victims, regardless of initial pulse oximeter readings. This helps to reduce the half-life of CO in the body.
• Medical Monitoring: Continuously monitor patients' vital signs, ECG rhythm, mental status, and motor function.
• Transport: Transport patients to the appropriate medical facility for further evaluation and treatment. Consider HBOT for severe cases.

Effective CO incident response often requires coordination with other agencies, including medical personnel, poison control centers, and utility companies. It is also crucial to emphasize the need for continuous monitoring of CO levels, even after a fire has been extinguished, particularly during overhaul operations when CO levels can still be elevated.