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EMS Carbon Monoxide and CO-Ox monitoring Co Rad 57 Cole

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Robert Cole
Robert Cole

This is the updated version of the Co-Ox/Carbon Monoxide poisoning I have put together for my department.

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CO-Oximetry Use of the Rad-57 by ACP
Revision Info Revised 11-2008 Contact Information: Steve Cole Ada County Paramedics 208-287-2978 [email_address]
Credit where credit is due Sky Dumont, Paramedic (Ada County Paramedics): for his hard work and initial research in developing this presentation www.masimo.com for product information www.firehouse.com for street level input
Background
CO Poisoning Review Leading cause of poisoning deaths in United States and other industrialized countries 5000-6000 deaths annually in U.S. 50,000-60,000 ED admissions annually
Pathophysiology of CO Poisoning Impairs oxygen delivery resulting in cellular hypoxia CO binds to hemoglobin 230-270 times more avidly than oxygen resulting in carboxyhemoglobin (COHb) CO also binds to Myoglobin and Cytochromes disrupting storage of O2 in certain muscle cells and transfer of energy within cells
Pathophysiology of CO Poisoning (ctd.) Negative effect on central nervous system effecting cognitive abilities such as perception, reasoning, awareness, and judgment Negative effects on cardiovascular system by depressing myocardial function Respiratory system effected by potential damage to alveolar membranes
Signs and Symptoms of CO Poisoning Flu-like symptoms Headache Dizziness Fatigue Dyspnea Chest pain Palpitations Confusion Agitation Nausea Vomiting Abdominal pain Hypotension with tachycardia Cardiac dysrhythmias Myocardial ischemia Pulmonary edema Syncope Seizures Fecal/urinary incontinence Visual abnormalities Memory loss Coma Death
Exposure Risks Automobile exhaust fumes Propane-powered vehicle fumes House fires Heaters Indoor stoves Camp stoves Boat exhaust fumes Gas-powered electrical generators Cigarette smoke Charcoal-fired cook stoves Ovens Methylene chloride solvent inhalation (paint removers, adhesive removers)
Physiological and iatrogenic causes Sepsis- CO byproduct of SIRS induced Hymolysis Hemolysis 2 nd to blood disorders “ Monday Morning Syndrome” CO byproduct of anesthesia and “depleted scrubbers”. Nitric Oxide use Sodium Nitroprusside use
Substances That Can Cause Methemoglobinemia Inorganic agents Nitrates - Fertilizers, contaminated well water,preservatives, industrial products Chlorates Copper sulfate – Fungicides Organic nitrites/nitrates Amyl nitrite sobutyl nitrite Sodium nitrite Nitroglycerin Nitroprusside Nitric oxide Nitrogen dioxide TNT Others local anesthetics - Benzocaine, lidocaine, prilocaine, phenazopyridine (Pyridium) Antimalarials - Primaquine, chloroquine Antineoplastic agents - Cyclophosphamide, ifosfamide, flutamide Analgesics/antipyretics - Acetaminophen, acetanilid, phenacetin, celecoxib Herbicide – Paraquat Antibiotics - Sulfonamides, nitrofurans, P-amino-salicylic acid, dapsone Industrial/household agents - Aniline dyes, nitrobenzene, naphthalene (moth balls), aminophenol, nitroethane (nail polish remover)
Populations at Increased Risk Children Elderly Persons with heart disease Pregnant women (due to CO’s effect on fetus) Pt’s with increased O2 demand Pt’s with decreased O2-carrying capacity Pt’s with chronic respiratory insufficiency Miners Emergency personnel
Normal COHb Levels 3-5 Methylene chloride (100 ppm for 8 hours) Up to 20 Cigars 5 Urban commuter 7-9 2-3 packs per day 5-6 1 pack per day Tobacco smokers: 0.4-0.7 Endogenous (normal heme catabolism) COHb (%) Source
Signs and Symptoms vs. Exposure Levels Death 1-3 minutes 12,800 H/A, dizziness, nausea. Death within 25-30 minutes. 1-2 minutes 6400 H/A, dizziness, nausea. Death within one hour. 5-10 minutes 3200 H/A, dizziness, nausea. Death within 1 hour. 20 minutes 1600 Dizziness, nausea, convulsions. Unconscious within 2 hours. Death within 2-3 hours. 45 minutes 800 Serious H/A, -other symptoms intensify. Life-threatening >3 hours 1-2 hours 400 Mild headache, fatigue, nausea, dizziness 2-3 hours 200 Symptoms Duration of exposure PPM
Signs and Symptoms vs. COHb Levels Death Fatal >60% Dysrhythmias, hypotension, cardiac ischemia, palpitations, respiratory arrest, pulmonary edema, seizures, coma, cardiac arrest Severe 41-50% Confusion, syncope, chest pain, dyspnea, tachypnea, tachycardia, weakness Moderate 21-40% H/A, N/V, dizziness, blurred vision Mild <15-20% S and Sx Severity COHb
Real World Reports “ In the cases I've come across, it's generally been described by the pt's as &quot;flu-like&quot; symptoms (N/V, headache) after low-level exposure of a few hours. I work as a firefighter as well, and after a fire one night where some members were not wearing SCBA during overhaul, two of them were complaining the next day of severe headache and nausea. Neither of them made any connection to the fire until we had a rep come in that afternoon selling CO monitors (similar to SpO2 monitoring) and their levels were much, much higher than average…” -emtjon Post from EMS forum on Firehouse.com
Real World Reports “… I've only dealt with a few cases, and the most recent gave me a reading in the high 90's. He was unresponsive as well. As far as skin color, this pt was more pale to normal. I've heard also that the pink/red skin is a very late sign and seen after extended exposure. I'm not sure how accurate that is, just something I've heard…” - tkrueger “… In more severe cases you may run accross ST elevation on your 12 lead due to lack of 02 being transported….” - Medic115 Also from Firehouse.com
The Rad Series
Benefits Uses “Signal Extraction technology” (AKA SET) This new generation can be potentially used for SPO2, SPCO2, SpHg and SPMET.
The Rad-57 SET technology was originally developed to be a “low perfusion state” and “Motion resistant” SPO2, whose technology was expanded to CO-Oxometry Early device specific research papers focused on neonates, alternative sensing locations, and anesthesia settings.
Downfalls Very sensitive, can be “spoofed” by strobes and high ambient light. Cover the probe when “Zero”-ing to the patient Approx. $4,000 retail
Treatment Recommendations: Scene safety, protect yourself: Consider SCBA’s Remove patient safe distance from the CO! Remember Co is heavier than air! ABC’s (airway, breathing and circulation). 100% High-flow oxygen with non-rebreather mask: Wash poison out of system. 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%. Consider air transport for extended distance. Monitor all ABC’s, vital signs and SpCO.
How its being used in EMS nationally Asymptomatic patients – Screening when there is a CO alarm, Hx of potential exposure, or for rehab situations Asymptomatic Patients with elevated readings may be screened and reevaluated after 15 minutes of High Flow O2 and Medical Control Consult Asymptomatic patients without elevated levels may be released on scene. Symptomatic patients Transport all symptomatic patients Screening for severity and diversion to HBO (Hyperbaric therapy)
Carbon Monoxide: Suggested Triage Algorithm SpCO TRIAGE ALGORITHM Measure SpCO 0-3% >3% No further medical evaluation of SpCO needed Loss of consciousness or neurological impairment or SpCO >25% Yes No Transport on 100% oxygen for ED evaluation. Consider transport to hospital with hyperbaric chamber SpCO >12 SpCO <12 Transport on 100% oxygen for ED evaluation Symptoms of CO exposure? Transport on 100% oxygen for ED evaluation No further evaluation of SpCO needed. Determine source of CO if nonsmoker Yes No
KEY POINT: Some systems use an SPCO of 11% as threshold for transport.
How its being used locally BFD: Deployed on BFD ALS Engines (3) MFD: Deployed on 5 ALS MFD Engines NFD: Rehab truck, 1 engine (pending)
State of Idaho Unofficial Stance: may be used by EMT-B/FF in rehab situations only UPDATE- Soon to be approved at BLS level (11/08) May be used by Paramedics in Patient Care Situations. No written clarification (yet).
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. Extra sensor pocket. Reference card holder. Department ID holder. Pen holder. Spare battery 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 25% battery life. Use only Alkaline batteries. BATTERY COMPARTMENT Located in back panel. Holds 4 “AA” batteries. Operates up to 8 hours.
RAD-57 Operation: Calibration POWER ON: SENSOR ON FINGER All LED’s light up. Calibration mode begins Spinning zeroes 0 - 0 – 0 . Completed in 20 second (avg.) DO NOT move sensor during calibration. Acquires reading and displays. DISPLAY Defaults to pulse rate and oxygen saturation reading. “ PI” bar graph displays strength of arterial perfusion.
KEY POINTS: CALIBRATION takes 20 seconds Look for the three spinning zeroes No movement during calibration Shield unit during calibration
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 shift 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 INITIAL CALIBRATION 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 signal quality Press SpCO to display % carboxyhemoglobin Press “Bell” to silence alarms
RAD-57 Operation: Pulse Rate and Saturation DISPLAY AFTER INITIAL CALIBRATION 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 signal quality Press SpCO to display % carboxyhemoglobin Press “Bell” to silence alarms PI scale 1 1 2 Low SIQ LED 2 4 SpCO key, changes display from SpO2 to SpCO 4 5 Battery level 5 3 Alarm LED 3
RAD-57 Operation: Alarms When violated, audible alarm will sound, parameter will flash Alarms adjust: Press “Mode/Enter” twice Press “Next” key to scroll through parameters Use up and down keys to adjust Reverts to Factory settings after turned off. Preset at factory: Sa02 (oxygen saturation) Low: 90% High: none Pulse Rate Low: 50 High: 140 SpCO (carboxyhemoglobin) Low: none High: 10% Alarm indicator Alarm silence
RAD-57 Operation: Measuring CO PRESS ORANGE SPCO BUTTON Display will toggle to CO mode for 10 seconds Carboxyhemoglobin reading in % on top “ CO” displayed on bottom confirming mode ALWAYS confirm high readings by taking several measurements on DIFFERENT fingers and average Real-time SpCO indicator continuously reads SpCO Green: 1-9% Orange: 10-19% Red : 20% and above
RAD-57 Operation: Troubleshooting WILL NOT TURN ON: Check battery compartment Replace batteries CALIBRATION MODE WILL NOT STOP: Shield from flashing lights , strobes or high ambient light Try other digits “ NO CBL” MESSAGE: Cable not seated into top of Rad-57 Defective cable “ SEN OFF” MESSAGE: Sensor off finger Sensor misaligned “ Err” MESSAGE Return for service CONTINUOUS SPEAKER TONE Internal failure, return for service
Research Review Small study, monitored by an IRB. Control sample was an ABG drawn by lab. “ The new Masimo Rad-57 pulse oximeter performed within its specifications in this volunteer study, measuring COHb% in volunteers with an uncertainty of about 2%.” “… This new technology represents a major advance in the monitoring of oxygenation. The same principles will allow the measurement of other dyshemoglobins, including methemoglobin.“ - Barker SJ, Morgan S, Bauder W. New Pulse Oximeter Measures Carboxyhemoglobin Levels in Human Volunteers Anesthesia & Analgesia 2006; 102(3S): S4
Research review Very large study (1,756 patients) of patients presenting to an urban ED triage area over a 12 day study period. Weakness, no control group No correlation of V/S and COHb levels. (read: traditional v/s not an effective screening tool for COHb levels) Smokers had a higher baseline reading than non-smokers. 3 cases of previously unsuspected CO poisoning were identified in triage using this method. Chee KJ, Suner S, Partridge RA, Sucov A, Jay GD. Noninvasive Carboxyhemoglobin Monitoring: Screening Emergency Department Patients for Carbon Monoxide Exposure Academy of Emergency Medicine 2006;13(5) suppl 1: A442.
Research Review FDNY Study Targeted patients with suspected CO exposure Followed up with ABGS drawn at hospital on transported patients. 149 patients, 22 (6.7%) had SPCO >11%, 11 of these had ABGs drawn Less than 2% variance between SPCO and ABG level of Co Ben-Eli D, Peruggia J, McFarland J, Werner A, Kaufman BJ, Freese J, Cox L, Fry A, Askew S, Prezant DJ. Detecting CO – FDNY Studies Prehospital Assessment of COHb JEMS 2007; October: 36-37.
Research review Survey Based Study, Large area, Respected Journal 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 patients for treatment. “ The average time to get a result is 10 ± 10 min in hospitals with co-oximetry and 904 ± 1360 min in those without, a difference of 15 h …” “ Over 90% of CO-poisoned patients referred for hyperbaric treatment came from hospitals able to measure COHb..” This means that the majority of CO poisensings in rural or non-COHb hospitals received a Dx and treatment. “ .. Fewer than one-half of acute care hospitals in a four-state region have the capability to measure COHb levels. This has the potential to significantly impact diagnosis or treatment of patients with acute CO poisoning.” Neil B. Hampson, Karen L. Scott and Jennette L. Zmaeff Carboxyhemoglobin measurement by hospitals: Implications for the diagnosis of carbon monoxide poisoning Journal of Emergency Medicine, Volume 31, Issue 1, July 2006, Pages 13-16  
Research Review 7 month study in France targeting patients with suspected CO poisoning. COHg was measured by the Rad-57 and ABG analysis. Approx 1.5-2% variation with the Rad-57 tending to overestimate. “ This preliminary result demonstrates that this simple rapid noninvasive technology could be useful before and after arrival at the ED.” Reliability of new pulse CO-oximeter in victims of carbon monoxide poisoning. Undersea Hyperb Med. 2008 Mar-Apr;35(2):107-11
Research Review Large Study over nine months on 10,850 patients at Rhode Island Hospital in the ED . Respected Journal. 28 cases of CO toxicity (in this study defined as: SpCO >9% for nonsmokers and >13% for smokers) were found. 11 of the cases were unexpected and identified with the aid of the Rad-57. In all CO toxicity cases identified, venous or arterial COHb confirmations of elevated SpCO measurements were verified by lab analysis of blood samples taken with data results showing a “good correlation” between 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 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.
Summery CO toxicity can come from numerous environmental, pathological, and iatrogenic sources. CO toxicity presents with generally non specific s/s. A high index of suspicion is required SPCO is a supplement to good clinical assessment and high index of suspicion, not a replacement for it.
Questions?

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EMS Carbon Monoxide and CO-Ox monitoring Co Rad 57 Cole

  • 1. CO-Oximetry Use of the Rad-57 by ACP
  • 2. Revision Info Revised 11-2008 Contact Information: Steve Cole Ada County Paramedics 208-287-2978 [email_address]
  • 3. Credit where credit is due Sky Dumont, Paramedic (Ada County Paramedics): for his hard work and initial research in developing this presentation www.masimo.com for product information www.firehouse.com for street level input
  • 5. CO Poisoning Review Leading cause of poisoning deaths in United States and other industrialized countries 5000-6000 deaths annually in U.S. 50,000-60,000 ED admissions annually
  • 6. Pathophysiology of CO Poisoning Impairs oxygen delivery resulting in cellular hypoxia CO binds to hemoglobin 230-270 times more avidly than oxygen resulting in carboxyhemoglobin (COHb) CO also binds to Myoglobin and Cytochromes disrupting storage of O2 in certain muscle cells and transfer of energy within cells
  • 7. Pathophysiology of CO Poisoning (ctd.) Negative effect on central nervous system effecting cognitive abilities such as perception, reasoning, awareness, and judgment Negative effects on cardiovascular system by depressing myocardial function Respiratory system effected by potential damage to alveolar membranes
  • 8. Signs and Symptoms of CO Poisoning Flu-like symptoms Headache Dizziness Fatigue Dyspnea Chest pain Palpitations Confusion Agitation Nausea Vomiting Abdominal pain Hypotension with tachycardia Cardiac dysrhythmias Myocardial ischemia Pulmonary edema Syncope Seizures Fecal/urinary incontinence Visual abnormalities Memory loss Coma Death
  • 9. Exposure Risks Automobile exhaust fumes Propane-powered vehicle fumes House fires Heaters Indoor stoves Camp stoves Boat exhaust fumes Gas-powered electrical generators Cigarette smoke Charcoal-fired cook stoves Ovens Methylene chloride solvent inhalation (paint removers, adhesive removers)
  • 10. Physiological and iatrogenic causes Sepsis- CO byproduct of SIRS induced Hymolysis Hemolysis 2 nd to blood disorders “ Monday Morning Syndrome” CO byproduct of anesthesia and “depleted scrubbers”. Nitric Oxide use Sodium Nitroprusside use
  • 11. Substances That Can Cause Methemoglobinemia Inorganic agents Nitrates - Fertilizers, contaminated well water,preservatives, industrial products Chlorates Copper sulfate – Fungicides Organic nitrites/nitrates Amyl nitrite sobutyl nitrite Sodium nitrite Nitroglycerin Nitroprusside Nitric oxide Nitrogen dioxide TNT Others local anesthetics - Benzocaine, lidocaine, prilocaine, phenazopyridine (Pyridium) Antimalarials - Primaquine, chloroquine Antineoplastic agents - Cyclophosphamide, ifosfamide, flutamide Analgesics/antipyretics - Acetaminophen, acetanilid, phenacetin, celecoxib Herbicide – Paraquat Antibiotics - Sulfonamides, nitrofurans, P-amino-salicylic acid, dapsone Industrial/household agents - Aniline dyes, nitrobenzene, naphthalene (moth balls), aminophenol, nitroethane (nail polish remover)
  • 12. Populations at Increased Risk Children Elderly Persons with heart disease Pregnant women (due to CO’s effect on fetus) Pt’s with increased O2 demand Pt’s with decreased O2-carrying capacity Pt’s with chronic respiratory insufficiency Miners Emergency personnel
  • 13. Normal COHb Levels 3-5 Methylene chloride (100 ppm for 8 hours) Up to 20 Cigars 5 Urban commuter 7-9 2-3 packs per day 5-6 1 pack per day Tobacco smokers: 0.4-0.7 Endogenous (normal heme catabolism) COHb (%) Source
  • 14. Signs and Symptoms vs. Exposure Levels Death 1-3 minutes 12,800 H/A, dizziness, nausea. Death within 25-30 minutes. 1-2 minutes 6400 H/A, dizziness, nausea. Death within one hour. 5-10 minutes 3200 H/A, dizziness, nausea. Death within 1 hour. 20 minutes 1600 Dizziness, nausea, convulsions. Unconscious within 2 hours. Death within 2-3 hours. 45 minutes 800 Serious H/A, -other symptoms intensify. Life-threatening >3 hours 1-2 hours 400 Mild headache, fatigue, nausea, dizziness 2-3 hours 200 Symptoms Duration of exposure PPM
  • 15. Signs and Symptoms vs. COHb Levels Death Fatal >60% Dysrhythmias, hypotension, cardiac ischemia, palpitations, respiratory arrest, pulmonary edema, seizures, coma, cardiac arrest Severe 41-50% Confusion, syncope, chest pain, dyspnea, tachypnea, tachycardia, weakness Moderate 21-40% H/A, N/V, dizziness, blurred vision Mild <15-20% S and Sx Severity COHb
  • 16. Real World Reports “ In the cases I've come across, it's generally been described by the pt's as &quot;flu-like&quot; symptoms (N/V, headache) after low-level exposure of a few hours. I work as a firefighter as well, and after a fire one night where some members were not wearing SCBA during overhaul, two of them were complaining the next day of severe headache and nausea. Neither of them made any connection to the fire until we had a rep come in that afternoon selling CO monitors (similar to SpO2 monitoring) and their levels were much, much higher than average…” -emtjon Post from EMS forum on Firehouse.com
  • 17. Real World Reports “… I've only dealt with a few cases, and the most recent gave me a reading in the high 90's. He was unresponsive as well. As far as skin color, this pt was more pale to normal. I've heard also that the pink/red skin is a very late sign and seen after extended exposure. I'm not sure how accurate that is, just something I've heard…” - tkrueger “… In more severe cases you may run accross ST elevation on your 12 lead due to lack of 02 being transported….” - Medic115 Also from Firehouse.com
  • 19. Benefits Uses “Signal Extraction technology” (AKA SET) This new generation can be potentially used for SPO2, SPCO2, SpHg and SPMET.
  • 20. The Rad-57 SET technology was originally developed to be a “low perfusion state” and “Motion resistant” SPO2, whose technology was expanded to CO-Oxometry Early device specific research papers focused on neonates, alternative sensing locations, and anesthesia settings.
  • 21. Downfalls Very sensitive, can be “spoofed” by strobes and high ambient light. Cover the probe when “Zero”-ing to the patient Approx. $4,000 retail
  • 22. Treatment Recommendations: Scene safety, protect yourself: Consider SCBA’s Remove patient safe distance from the CO! Remember Co is heavier than air! ABC’s (airway, breathing and circulation). 100% High-flow oxygen with non-rebreather mask: Wash poison out of system. 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%. Consider air transport for extended distance. Monitor all ABC’s, vital signs and SpCO.
  • 23. How its being used in EMS nationally Asymptomatic patients – Screening when there is a CO alarm, Hx of potential exposure, or for rehab situations Asymptomatic Patients with elevated readings may be screened and reevaluated after 15 minutes of High Flow O2 and Medical Control Consult Asymptomatic patients without elevated levels may be released on scene. Symptomatic patients Transport all symptomatic patients Screening for severity and diversion to HBO (Hyperbaric therapy)
  • 24. Carbon Monoxide: Suggested Triage Algorithm SpCO TRIAGE ALGORITHM Measure SpCO 0-3% >3% No further medical evaluation of SpCO needed Loss of consciousness or neurological impairment or SpCO >25% Yes No Transport on 100% oxygen for ED evaluation. Consider transport to hospital with hyperbaric chamber SpCO >12 SpCO <12 Transport on 100% oxygen for ED evaluation Symptoms of CO exposure? Transport on 100% oxygen for ED evaluation No further evaluation of SpCO needed. Determine source of CO if nonsmoker Yes No
  • 25. KEY POINT: Some systems use an SPCO of 11% as threshold for transport.
  • 26. How its being used locally BFD: Deployed on BFD ALS Engines (3) MFD: Deployed on 5 ALS MFD Engines NFD: Rehab truck, 1 engine (pending)
  • 27. State of Idaho Unofficial Stance: may be used by EMT-B/FF in rehab situations only UPDATE- Soon to be approved at BLS level (11/08) May be used by Paramedics in Patient Care Situations. No written clarification (yet).
  • 28. 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. Extra sensor pocket. Reference card holder. Department ID holder. Pen holder. Spare battery pocket .
  • 29. RAD-57 Operation: Powering Up POWER Press to turn ON. Press and HOLD to turn OFF. BATTERY INDICATOR 4 Green LED’s. Each represents 25% battery life. Use only Alkaline batteries. BATTERY COMPARTMENT Located in back panel. Holds 4 “AA” batteries. Operates up to 8 hours.
  • 30. RAD-57 Operation: Calibration POWER ON: SENSOR ON FINGER All LED’s light up. Calibration mode begins Spinning zeroes 0 - 0 – 0 . Completed in 20 second (avg.) DO NOT move sensor during calibration. Acquires reading and displays. DISPLAY Defaults to pulse rate and oxygen saturation reading. “ PI” bar graph displays strength of arterial perfusion.
  • 31. KEY POINTS: CALIBRATION takes 20 seconds Look for the three spinning zeroes No movement during calibration Shield unit during calibration
  • 32. 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 shift 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
  • 33. RAD-57 Operation: Pulse Rate and Saturation DISPLAY AFTER INITIAL CALIBRATION 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 signal quality Press SpCO to display % carboxyhemoglobin Press “Bell” to silence alarms
  • 34. RAD-57 Operation: Pulse Rate and Saturation DISPLAY AFTER INITIAL CALIBRATION 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 signal quality Press SpCO to display % carboxyhemoglobin Press “Bell” to silence alarms PI scale 1 1 2 Low SIQ LED 2 4 SpCO key, changes display from SpO2 to SpCO 4 5 Battery level 5 3 Alarm LED 3
  • 35. RAD-57 Operation: Alarms When violated, audible alarm will sound, parameter will flash Alarms adjust: Press “Mode/Enter” twice Press “Next” key to scroll through parameters Use up and down keys to adjust Reverts to Factory settings after turned off. Preset at factory: Sa02 (oxygen saturation) Low: 90% High: none Pulse Rate Low: 50 High: 140 SpCO (carboxyhemoglobin) Low: none High: 10% Alarm indicator Alarm silence
  • 36. RAD-57 Operation: Measuring CO PRESS ORANGE SPCO BUTTON Display will toggle to CO mode for 10 seconds Carboxyhemoglobin reading in % on top “ CO” displayed on bottom confirming mode ALWAYS confirm high readings by taking several measurements on DIFFERENT fingers and average Real-time SpCO indicator continuously reads SpCO Green: 1-9% Orange: 10-19% Red : 20% and above
  • 37. RAD-57 Operation: Troubleshooting WILL NOT TURN ON: Check battery compartment Replace batteries CALIBRATION MODE WILL NOT STOP: Shield from flashing lights , strobes or high ambient light Try other digits “ NO CBL” MESSAGE: Cable not seated into top of Rad-57 Defective cable “ SEN OFF” MESSAGE: Sensor off finger Sensor misaligned “ Err” MESSAGE Return for service CONTINUOUS SPEAKER TONE Internal failure, return for service
  • 38. Research Review Small study, monitored by an IRB. Control sample was an ABG drawn by lab. “ The new Masimo Rad-57 pulse oximeter performed within its specifications in this volunteer study, measuring COHb% in volunteers with an uncertainty of about 2%.” “… This new technology represents a major advance in the monitoring of oxygenation. The same principles will allow the measurement of other dyshemoglobins, including methemoglobin.“ - Barker SJ, Morgan S, Bauder W. New Pulse Oximeter Measures Carboxyhemoglobin Levels in Human Volunteers Anesthesia & Analgesia 2006; 102(3S): S4
  • 39. Research review Very large study (1,756 patients) of patients presenting to an urban ED triage area over a 12 day study period. Weakness, no control group No correlation of V/S and COHb levels. (read: traditional v/s not an effective screening tool for COHb levels) Smokers had a higher baseline reading than non-smokers. 3 cases of previously unsuspected CO poisoning were identified in triage using this method. Chee KJ, Suner S, Partridge RA, Sucov A, Jay GD. Noninvasive Carboxyhemoglobin Monitoring: Screening Emergency Department Patients for Carbon Monoxide Exposure Academy of Emergency Medicine 2006;13(5) suppl 1: A442.
  • 40. Research Review FDNY Study Targeted patients with suspected CO exposure Followed up with ABGS drawn at hospital on transported patients. 149 patients, 22 (6.7%) had SPCO >11%, 11 of these had ABGs drawn Less than 2% variance between SPCO and ABG level of Co Ben-Eli D, Peruggia J, McFarland J, Werner A, Kaufman BJ, Freese J, Cox L, Fry A, Askew S, Prezant DJ. Detecting CO – FDNY Studies Prehospital Assessment of COHb JEMS 2007; October: 36-37.
  • 41. Research review Survey Based Study, Large area, Respected Journal 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 patients for treatment. “ The average time to get a result is 10 ± 10 min in hospitals with co-oximetry and 904 ± 1360 min in those without, a difference of 15 h …” “ Over 90% of CO-poisoned patients referred for hyperbaric treatment came from hospitals able to measure COHb..” This means that the majority of CO poisensings in rural or non-COHb hospitals received a Dx and treatment. “ .. Fewer than one-half of acute care hospitals in a four-state region have the capability to measure COHb levels. This has the potential to significantly impact diagnosis or treatment of patients with acute CO poisoning.” Neil B. Hampson, Karen L. Scott and Jennette L. Zmaeff Carboxyhemoglobin measurement by hospitals: Implications for the diagnosis of carbon monoxide poisoning Journal of Emergency Medicine, Volume 31, Issue 1, July 2006, Pages 13-16  
  • 42. Research Review 7 month study in France targeting patients with suspected CO poisoning. COHg was measured by the Rad-57 and ABG analysis. Approx 1.5-2% variation with the Rad-57 tending to overestimate. “ This preliminary result demonstrates that this simple rapid noninvasive technology could be useful before and after arrival at the ED.” Reliability of new pulse CO-oximeter in victims of carbon monoxide poisoning. Undersea Hyperb Med. 2008 Mar-Apr;35(2):107-11
  • 43. Research Review Large Study over nine months on 10,850 patients at Rhode Island Hospital in the ED . Respected Journal. 28 cases of CO toxicity (in this study defined as: SpCO >9% for nonsmokers and >13% for smokers) were found. 11 of the cases were unexpected and identified with the aid of the Rad-57. In all CO toxicity cases identified, venous or arterial COHb confirmations of elevated SpCO measurements were verified by lab analysis of blood samples taken with data results showing a “good correlation” between 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 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.
  • 44. Summery CO toxicity can come from numerous environmental, pathological, and iatrogenic sources. CO toxicity presents with generally non specific s/s. A high index of suspicion is required SPCO is a supplement to good clinical assessment and high index of suspicion, not a replacement for it.