ED nurses uncover 'hidden' cases of CO poisoning
ED nurses uncover 'hidden' cases of CO poisoning
Toxicity cases may be unexpected
Carbon monoxide (CO) poisoning often is overlooked in the ED, in part because symptoms are similar to the flu, but very few EDs screen patients for this condition, says Selim Suner, MD, MS, associate professor of emergency medicine, surgery, and engineering at Brown University and director of disaster medicine in the Department of Emergency Medicine at Rhode Island Hospital, both in Providence.
Rhode Island's ED nurses screened more than 10,000 patients for CO poisoning over a nine-month period, using a handheld device at triage, the SET Rad-57 Pulse CO-Oximeter, manufactured by Masimo. The ED nurses found 28 cases of CO toxicity, of which 11 were unexpected, according to a study headed by Suner.1
Some patients required treatment with hyperbaric oxygen as a result of the screening, and others were treated with high-dose oxygen. "In some cases, serious sources of CO were uncovered, including a faulty boiler in one apartment complex, which put nearly 30 other residents at risk for CO poisoning," says Suner. "In another case, a husband and wife were poisoned with CO because their chimney was blocked by a dead raccoon."
For every CO toxicity case identified, venous or arterial carboxyhemoglobin confirmations of elevated measurements were verified by lab analysis of blood samples, and all correlated with the handheld tool's findings.
The researchers estimate that as many as 11,000 CO poisoning cases go undetected annually. Identifying CO toxicity in the ED often is challenging, because many patients might not know or suspect that they were exposed, says Suner. If CO toxicity is missed and the patient returns to the site of exposure, this can lead to further toxicity and possible long-term neurological, psychiatric, or cardiovascular complications, he adds.
All ED nurses received a half-hour training session, covering CO poisoning and common sources of CO, conducted by the study's investigators during shift changes. "The nurses were then familiarized with the device. Since the device is very similar to a pulse oximeter, this was not difficult," says Suner.
The investigators posed as patients and allowed the ED nurses to practice on them while answering questions. "Pitfalls such as thin fingers and soot or dirt on the fingers were explained," says Suner. "Nurses were instructed to clean the fingers with alcohol swabs and question the readings if patients had very thin fingers. Alternatively, a pediatric probe can be used for these patients."
Next, the devices were placed at triage points, and the nurses were asked to record a level on every patient that presented to the ED. "ED records were modified to accommodate this new 'vital sign,'" says Suner. "I believe this practice is valuable, and it has been adopted as standard practice in our ED. It has resulted in the discovery of multiple hidden cases of CO."
CO screening now is included in the routine vital signs taken by triage nurses, says Terry Cottrell, RN, an ED triage nurse at Rhode Island Hospital. "The whole process of taking the patient's pulse, pulse oximetry, and CO monitoring takes less than a minute," she says.
Before, triage nurses only screened for CO if the patient reported possible exposure or poor ventilation in the home, or if the patient presented with obvious symptoms such as pink skin and dizziness, she says. "Now everyone gets screened," says Cottrell.
In two cases, nurses identified family members of patients who also had high CO levels, adds Suner. "The family members were accompanying the patients, and the nurses had the foresight to screen them as well," he says. "They were asymptomatic and were treated with high-dose oxygen."
Reference
- Suner S, Partridge R, Sucov A, et al. Noninvasive pulse CO-oximetry screening in the emergency department identifies occult carbon monoxide toxicity. J Emerg Med. Published online Jan. 26, 2008.
Sources/Resources
For more information on screening ED patients for carbon monoxide poisoning, contact:
- Terry Cottrell, RN, Emergency Department, Rhode Island Hospital, Providence. E-mail: [email protected].
- Selim Suner, MD, MS, Directory of Disaster Medicine, Department of Emergency Medicine, Rhode Island Hospital, Providence. Phone: (401) 444-6653. E-mail: [email protected].
For more information about the Masimo Rad-57 Pulse CO-Oximeter, which costs $3,995, contact: Masimo Corp., 40 Parker, Irvine, CA 92618. Telephone: (800) 257-3810 or (949) 297-7000. Web: www.masimo.com/rad-57.
Carbon monoxide (CO) poisoning often is overlooked in the ED, in part because symptoms are similar to the flu, but very few EDs screen patients for this condition, says Selim Suner, MD, MS, associate professor of emergency medicine, surgery, and engineering at Brown University and director of disaster medicine in the Department of Emergency Medicine at Rhode Island Hospital, both in Providence.Subscribe Now for Access
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