Presentation of Secret Firefighter Killers given during OEMTA Public Safety Conference in 2013. Discusses the Toxic Twins and Emergency Smoke Inhalation Treatment including Cyanokit.

1. Secret
Firefighter Killers

2. Joe Sherrell
EMS Officer
Tulsa Fire Department
(918) 596-9808
jsherrell@cityoftulsa.org

3. Objectives
 Define Smoke
 Discuss the contents of fire smoke
 List the physical properties of CO and CN
 Describe the effects of CO & CN
 List the symptoms related to CO & CN
exposure
 Discuss the assessment method
 Discuss the treatment for smoke inhalation
 Understand the use of Cyanokit

5.  RIT has removed the downed
firefighter…

6. SMOKE

7. Smoke
the gaseous products of burning
materials especially of organic origin
made visible by the presence of small
particles of carbon
a suspension of particles in a gas
ww.merriam-webster.com

8. Read It – Don’t Breathe ItRead It – Don’t Breathe It
Advantages:Advantages:
 LocationLocation
 IntensityIntensity
 ProgressionProgression
 EffectivenessEffectiveness
 Tactical MarkerTactical Marker

9. Smoke ContentsSmoke Contents
•Hydrochloric AcidHydrochloric Acid
•Sulfur DioxideSulfur Dioxide
•Oxides of NitrogenOxides of Nitrogen
•AmmoniaAmmonia
•Carbon DioxideCarbon Dioxide
•Hydrogen CyanideHydrogen Cyanide
•Carbon MonoxideCarbon Monoxide
•Hydrogen SulfideHydrogen Sulfide

10. Smoke = PoisonSmoke = Poison

11. TOXIC TWINS

12. Toxic Twins
 Carbon Monoxide (CO)
 Hydrogen Cyanide (HCN)

13. Carbon
Monoxide
(CO)

14. Properties
 Colorless
 Odorless
 Tasteless
 Flammable
 Gas

15. Where does it come from?
 Produced when carbonaceous
materials are burned with
insufficient oxygen.

16. Annual Stats
 Over 2,000 deaths
 Several hundred thousand exposed
 20-40% suffer health damage

17. Physiologic Effects
 250 times the affinity for hemoglobin
 Displaces O2
 Leads to Hypoxia

19. Symptoms
 Headache
 Lethargy/Fatigue
 Nausea
 Dizziness
 Confusion
 Dyspnea
 Palpitations
 Convulsions
 Paralysis
 LOC
 Coma
 Death

20. Hydrogen
Cyanide
(HCN)

21. Properties
 Colorless
 Bitter Almond Odor
 Gas

22. Sources in Fire Products
 Polyurethane Foam
 Synthetic Rubber
 Nylon
 Asphalt
 Wool
 Silk

23. Physiologic Effects
 Prohibits the cells from using oxygen
 Respiratory Paralysis
 Cardiac Irregularities

24. Symptoms – Low Levels
 Bitter almond odor
 Burning taste
 Numb Throat
 Salivation
 Nausea/Vomiting
 Anxiety
 Confusion
 Vertigo
 Ataxia
 Giddiness

25. Symptoms – Moderate Levels
 Hyperpnea
 Dyspnea
 Tachypnea
 Short Inspiration
 Prolonged Expiration
 Tachycardia

26. Symptoms – High Levels
 LOC
 Coma
 Protruding
eyeballs
 Pupils dilated
 Bradycardia
 Respiratory Arrest
 Arrhythmias
 Convulsion
 Hypotension
 Incontinence
 Paralysis
 Sweating

27. Toxic Twins
 Carbon Monoxide
 Attacks the blood
 Hydrogen
Cyanide
 Attacks the cells

28. ASSESSMENT

29. 1st
Priority
 Move to a safe area
 Remove Gear
 Emergency Decon

30. Initial Assessment
 ABCs
 Mental Status
 EtCO2
 CO
Treat Life-Threats
Immediately

31. TREATMENT

32. BLS
 Airway
 Suction
 Airway Adjunct
 Breathing
 High-flow O2
 NRB or BVM
 Circulation
 CPR

33. ALS
 Advanced Airway
 Establish IV/IO
 Large Bore

34. Treat for CN Poisoning
Confined space with smoke?
Soot around mouth/nose?
Altered Mental Status?

35. Cyanokit Study
69 Patients
73% Survived
 Of the 19 subjects who did not
survive, 13 were presented in cardiac
arrest.

36. Blood Draw
 Cyanokit may interfere with lab tests
 If time allows, draw 2 vials of blood

37. Mechanism
 Attaches to cyanide ion
 Allows cells to utilize O2
 Excreted in urine

38. Contraindication
 Hx of allergic reaction
 Safety not established in pediatrics
 Safe even without cyanide exposure

39. Side Effects
 Hypertension
 Red Discoloration

40. Precaution
 Use a separate IV/IO line

41. Dosing
 5g over 15 minutes

42. Preparation
 Glass Bottle
 Mix 200 cc of NS
 Don’t Shake

43. Administration
 IV/IO
 Mix with 200 cc Saline
 Leave box in place
 15 minutes
 “Power Syringe”

44. Tulsa Kit
Carried by:
District Chiefs
EMS Supervisor (C835)

45. Assigned
Apparatus
Expiration
Security
Seals

46. Tulsa Kit
 Cyanokit
 Drug
 Transfer Spike
 Vented IV Tubing
 NS 100cc (2)
 Syringe 30cc
 Stopcock
 Extension Set
 Needle
 Vaccutainer (2)

47. TRANSPORT

48. Hyperbaric Oxygen Therapy
 Consider if:
 GCS ≤ 13
 Pregnancy
 Consult OLMC
 Facilities
 OSUMC (Tulsa)
 Integris Baptist (OKC)

49. Care Transfer
 Describe Scene
 Cyanokit Use
 Provide Blood Samples

50. Summary
•Toxic Twins
•Move to a safe area
•Rapid Assessment
•Oxygenation/Ventilatory Support
•Cyanokit

51. Questions

52. References
Bledsoe, Malone, Slattery, Carrison, Evans, Johnson. Cyanide, Carbon Monoxide or Both? A protocol
for an Organized Response to the Downed Firefighter or Victim of Toxic Gas Exposure.
Cyanokit Administration Guide
Eckstein, Mark & Manisacalco, Paul. Focus on Smoke Inhalation – The most Common Cause of Acute
Cyanide Poisoning. 2006.
Mcevoy, Mike. Cyanokit Setup and Administration. www.firengineering.com
Penney, David G. The Toxic Twins: An advanced Perspective on Cyanide and Carbon Monoxide
Poisoning
Shapiro, Arnold. Rescue 911 Episdoe-522.
State of Oklahoma Department of Health EMS Protocols
Smoke Inhalation & Hydrogen Cyanide Poisoning. Journal of Emergency Medical Services. 2004.
Schnepp, Rob. To Hell and Back. The Peoples Burn Foundation
Zemeckis, Robert, 1994. Forrest Gump. Paramount.