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

2. 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.

3. Review: Carbon Monoxide Poisoning For Emergency Responders
Section 1
Review: Carbon Monoxide Poisoning For Emergency Responders

4. 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.

5. 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.

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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 minutes
Hyperbaric Oxygen Treatment (HBOT) at 2.5 to 3 Atmospheres: Decreases CO half-life in blood to minutes

12. 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

13. 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

14. 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.

15. 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

16. 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

17. 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

18. 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.

19. 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)

20. 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

21. 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)

22. 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

23. 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

24. 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
Continuous Speaker Tone
Power down and remove batteries
* Contact your Masimo sales rep to order a Masimo Light Shield.

25. 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

26. 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

27. 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

28. 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%

29. Resources
For more information on carbon monoxide poisoning and the Masimo Rad-57
or call
Masimo Corporation
40 Parker
Irvine, CA 92618
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Masimo