Monitoring CO Poisoning with the Rad-57TM Includes a review on Carbon Monoxide Poisoning For Emergency Responders Version 2.0F, 07.02.08

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.

Review: Carbon Monoxide Poisoning For Emergency Responders 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.

Common Sources 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

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 % Clinical 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 Measure SpCO SpCO 0-3% SpCO >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? No further evaluation of SpCO needed. Determine source of CO if nonsmoker Hampson NB, Weaver LK JEMS 2006

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 Technology Analyzes 7+ wavelengths of light Accurately 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 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 Optimal LED path 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)

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 PI Scale Low SIQ LED Alarm Silence LED Display button toggles from SpO2 to SpCO 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 Slow: Low SpCO Confidence Fast: SpCO Alarm 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 CO label when SpCO is displayed

RAD-57 Operation / Troubleshooting Error Messages: “NO Cbl” Cable not seated properly into top of Rad-57 Defective cable “SEN OFF” Sensor off finger Sensor misaligned “bAd CbL” 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 * Contact your Masimo sales rep to order a Masimo Light Shield.

RAD-57 Operation / Light Shield Use Optimal LED path 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 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 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 800-326-4890 www.Firerehab.com www.firegrantshelp.com www.emsgrantshelp.com www.naemse.org www.naemt.org www.iaff.org www.carbonmonoxidekills.com/ www.epa.gov/iaq/pubs/coftsht.html www.carbon-monoxide-poisoning.com www.nlm.nih.gov/medlineplus/carbonmonoxidepoisoning.html www.emedicinehealth.com/carbon_monoxide_poisoning/article_em.htm www.osha.gov/OshDoc/data_General_Facts/carbonmonoxide-factsheet.pdf www.cdc.gov/co/ www.bt.cdc.gov/disasters/carbonmonoxide.asp www.postgradmed.com/issues/1999/01_99/tomaszewski.htm Masimo Corporation 40 Parker Irvine, CA 92618 949-297-7000 All Rights Reserved Masimo