CyaIns_FE_0608 7/18/06 4:39 PM Page 2 SMOKE PERCEPTIONS, MYTHS, AND MISUNDERSTANDINGS

Photo: Steve Redick

Educational Supplement sponsored by the Cyanide Poisoning Treatment Coalition CyaIns_FE_0608 7/17/06 9:43 AM Page 3 Photo: David Traiforos

Table of Contents

INTRODUCTION ...... 1 By Rob Schnepp

FOREWORD ...... 2 By Chief David D. Costa

HYDROGEN CYANIDE IN FIRE SMOKE: AN UNRECOGNIZED THREAT TO THE AMERICAN FIREFIGHTER ...... 4 By Donald W. Walsh, PhD, EMT-P

AIR MANAGEMENT ON THE FIREGROUND: THE NEED- THE MANDATE - THE SOLUTION ...... 9 By Mike Gagliano, Casey Phillips, Phil Jose, and Steve Bernocco

FIRE OVERHAUL, REHAB, AND A COMPREHENSIVE RESPIRATORY PROTECTION PROGRAM ...... 12 By Phil Jose, Steve Bernocco, Mike Gagliano, and Casey Phillips

SMOKE ASSOCIATED CYANIDE EXPOSURE: THE IMPORTANCE OF PROMPT RECOGNITION AND PROTOCOLS FOR PREHOSPITAL TREATMENT ...... 15 By James Augustine, MD and Donald W. Walsh, PhD, EMT-P

ACUTE CYANIDE POISINING: A PARIS FIREFIGHTER RECOVERS FROM SEVERE SMOKE INHALATION...... 19 By J.L. Fortin, S. Waroux, A-M Arvis, JP. Giocanti, C Fuilla, D. Walsh, M Ruttiman, and M Eckstein CyaIns_FE_0608 7/17/06 9:43 AM Page 4

READING SMOKE IS ONE THING - BREATHING IT IS COMPLETELY DIFFERENT BY ROB SCHNEPP, Supplement Editor

REVOLUTION: a drastic and far-reaching in the smoldering debris, breathing all smoke inhalation victims may be futile. change in thinking and behavior. those products of incomplete com- The last piece, written by Dr. Jean-Luc bustions? Why do we put so much effort Fortin, offers a look inside a successful Americans are, by and large, into rapid intervention teams, when the resuscitation of a firefighter in Paris, assaulted with a steady stream of current method of medically treating France. The firefighter, overcome by so-called “revolutions.” There’s been no someone after the rescue is largely smoke after getting lost inside a structure shortage of fitness and dietary revolu- ineffective? We’ve figured out a better way fire, is alive and well today because of tions over the years, each one offering to rescue our own, but have not com- aggressive pre-hospital care and an unbelievable results with a money pleted the loop by providing an effective antidote for cyanide poisoning. back guarantee. The ongoing technol- antidote to correct a potential cause of The bottom line is this - the fire ogy revolution has promised increased death in smoke inhalation victims - service needs to become better educated productivity and more free time, while cyanide poisoning. Typically, when about smoke. Hopefully, an increased the computerized banking industry someone dies in a fire, it’s attributed to level of knowledge will reinforce the has almost rendered cash obsolete. the nebulous cause of “smoke inhala- importance of respiratory protection on And while each of these examples has tion.” In truth, it’s more complicated the fireground, and the need to prop- had an impact on daily life, they appear than that - we just haven’t been looking erly manage your air supply. It’s better to be more evolutionary than revolu- at it the right way. We haven’t really digest- to avoid getting into trouble than tionary. It’s gotten to the point where ed the combustion chemistry to truly relying on a rapid intervention team to “revolution” has become synonymous understand why the smoke is so nasty. come in and find you! Unfortunately, a with benign terms like change, devel- Understanding the basics of combustion low air emergency does not come with opment, or progress. Unfortunately, chemistry is the first step toward a “money back” guarantee. such common usage of the term has gaining a new respect for an old foe. Smoke has become such a constant watered down its meaning. It’s fitting that this smoke revolution companion for us that we may have In reality, true revolutions are finds its roots in a busy fire department lost respect for it. According to Chief anything but benign. like Providence, Rhode Island - a key Costa, his department was shocked by Revolutions are fueled by a new player in the American Revolution. In the cyanide exposures. “We haven’t way of thinking, risk taking, and the this supplement, Chief of Department come up with a firm grasp of what will courage to do things completely dif- David Costa provides a detailed be different,” he says. “It’s too early to ferently. Something the American fire description of a series of fire incidents tell. There is, however, a lot of lively service is not entirely comfortable that are emerging as a shot heard discussion going on around the with. This is not to say that the fire ‘round the world for the fire service. firehouse coffee table.” service is backward or unable to He describes an investigation that And that’s what we need to better embrace new ideas. It is however, reached an unexpected conclusion: a appreciate the immediate and long accurately characterized as 200 years large number of his firefighters were terms effects of breathing smoke - a of tradition unimpeded by progress. exposed to cyanide - from the smoke - lively discussion. We also need a drastic Why all the talk of revolution? after fighting a series of structure fires. modification of our attitude toward Because the fire service is on the eve These firefighters were operating at the smoke. Most of all, it’s important to of one. A far-reaching and possibly same kind of fires occurring every day keep an open mind about the research tumultuous revolution that will chal- in each and every part of this country - and data presented here. You might lenge everything we thought we knew the typical residential structure fire. discover some solutions on the follow- about smoke - the constant companion I encourage you to read about ing pages, but more than anything, I of the firefighter. Chief Costa’s journey. A journey that hope it raises some questions. Research conducted over the years every Fire Chief hopes to avoid - one has proven that smoke is bad - we all that ends with a visit to a firefighter’s Rob Schnepp is the Chief of EMS and Special know that. We all know that smoke spouse, telling them that their loved Operations for the Alameda County (CA) Fire kills more people than flames and that one has been injured on the job. Department. He is the primary author of breathing smoke isn’t good. So why do I hope you’ll take the time to read a textbook entitled “Hazardous Materials: we still go to fires and not wear our the articles following Chief Costa’s Regulations, Response & Site Operations,” SCBA? And I’m not talking about wear- foreword. You’ll learn about combus- by Delmar Publishing, and is on the editorial ing the tank with the mask dangling tion chemistry, better ways to manage advisory board for Fire Engineering magazine. around your neck. After the fire is your air while fighting fire, the signs Rob is a member of the NFPA Technical and symptoms of smoke inhalation, knocked down, why is it that firefighters Committee on Hazardous Materials Response. drop their SCBA and perform overhaul and why current methods of treating

1 CyaIns_FE_0608 7/17/06 9:44 AM Page 5

About 5:45 PM, I received a telephone symptoms of cyanide poisoning. FOREWORD call at home from a dispatcher saying Including the initial 16 firefighters who that a member that operated at the received medical attention, 28 sought DAVID D. COSTA restaurant fire earlier in the day was at evaluation and treatment. Cyanide Chief of Department Rhode Island Hospital and had been exposure was confirmed in 27 firefight- Providence Rhode Island Fire Department diagnosed with high levels of cyanide in ers, 8 of whom were identified as having his blood. The firefighter had received high levels of cyanide in their blood. the standard cyanide antidote kit. Exposure to cyanide from the Having consulted with the fire- products of combustion is much more fighter and his doctor, I decided that prevalent than many in the fire service March 23, 2006 began like most days every firefighter who responded to the are aware. A graduate of the Executive in the City of Providence. I started the restaurant fire should be instructed to Fire Officer Program at the National day by attending several meetings seek medical treatment if they experi- Fire Academy with a Bachelors Degree dealing with the administrative issues enced symptoms possibly indicative of in Fire Science, I was disturbed that I that every chief of a fire department cyanide poisoning. Sixteen firefighters was not aware that cyanide is pervasive encounters. I did not know that the sought medical treatment; 4 of the 16 in fire smoke. While every firefighter is next 24 hours would trigger a series of were confirmed to have high levels of taught the basic information about the incidents that would thrust me into cyanide in their blood. dangers related to hydrogen cyanide the forefront of a nationwide debate As I discussed the situation further and other products of combustion, the over the testing and treatment of with doctors, my officers, and fellow depth of our understanding pales in smoke inhalation victims and air man- firefighters, there did not seem to be a comparison to the information available agement at fireground operations. clear answer to what could have in medical journals. The Providence Fire Department is a fully paid fire department with a uni- formed strength of 469 personnel. We “ The cyanide exposure incidents have brought a protect the capital city of Rhode Island, which has a population of 173,618 in a harsh reality to our department about the real 20-square-mile area. The population swells to approximately 300,000 on dangers of our profession.” business days. At 10:31 AM on March 23, fire com- panies were dispatched to a structure caused these poisonings, which were Following the cyanide exposure fire in the south end of the city. They unexpected for us. The feeling was that incidents, I requested a Health Hazard found a one-story restaurant with fire this must be an isolated incident and Evaluation by the National Institute blazing from the cooking equipment that something unusual must have of Occupational Safety and Health into a concealed ceiling space and far- been present at the restaurant fire. (NIOSH), and I appointed a five-mem- ther into a five-foot overhanging facade At approximately 2:30 AM on March ber team of fire department personnel that lined the exterior of the building 24, 2006, I received a telephone call from to investigate fully the cause of our at the roofline. Most of the suppression a dispatcher that one of our firefighters firefighters’ exposure. The fire depart- effort focused on an exterior attack in collapsed at the scene of a house fire ment report has been issued, and I which firefighters used their air packs and that cardiopulmonary resuscitation expect NIOSH to issue their report some intermittently while opening the sof- (CPR) was under way. The firefighter was time in the fall. The recommendations fits to get at the bulk of the fire. The transported to Rhode Island Hospital, from the fire department investigation operations appeared routine, and fire where he was successfully resuscitated. team include awareness training for companies returned in service by 12:05 While treatment continued in the firefighters and the medical community; PM. At 2:15 PM, one firefighter that emergency room, a test for cyanide deployment of cyanide detection operated at the fire was transported to exposure was conducted. The test equipment; enhanced compliance with Rhode Island Hospital when he began confirmed that the firefighter had a existing mandatory mask regulations; talking incoherently and experienced high level of cyanide in his blood. The physical training with self contained a headache, dizziness, shortness of standard antidote was administered. breathing apparatus (SCBA); immediate breath, and coughing. Having learned that we had positive deployment of an Air Supply Unit to At 5:35 PM the same day, fire com- tests for cyanide exposure at two aid in air management; additional panies responded to a fire in a six-unit separate incidents, we issued a directive command support for accountability apartment building. The fire started in that every firefighter who responded and incident management; routine a rear bedroom of an apartment on the to any of the three structure fires in the testing for cyanide in smoke inhalation first floor. The fire was brought under past 16 hours should be contacted. victims; and additional research. control at 6:07 PM, and no injuries They were instructed to seek medical The fire service has seen dramatic were reported. treatment if they experienced any technological advances and has gained

2 CyaIns_FE_0608 7/17/06 9:44 AM Page 6

“Firefighters need to understand and know that today’s fire smoke is more dangerous then ever.”

incredible experience since I joined the fire service 30 years ago. Examples include new and improved air packs, PASS devices, thermal imaging cameras, and the Fire Service Joint Labor Management Wellness/Fitness Initiative. But do we take full advantage of the knowledge we have gained throughout the years to protect ourselves? What are the real ramifications and true cost of our injuries? Besides monetary costs such as medical bills, overtime costs due to lost time, and pension costs for dis- ability, there are the pain and trauma to the injured firefighters. There is also a cost to the firefighter’s family. What are the emotional scars that a spouse, a child, or a parent is left with when they live through their loved one’s injury? I hope I never have to inform another firefighter’s spouse that a loved one is in grave condition because of smoke exposure or another job-related injury. The cyanide-exposure incidents have awakened our department to the harsh reality of another of the real dan- gers of our profession. It is our respon- sibility to learn from our experiences, strive for improvements, and promote safety for every firefighter. This educa- tional supplement was developed to educate the fire service on a deadly toxicant in fire smoke that has gone relatively undetected and certainly unreported. I encourage every firefight- er to pass along the information in this supplement and read the full report of the Investigation Committee into the Cyanide Poisonings of Providence Firefighters, available online at http://www.rifirechiefs.com/.

3 CyaIns_FE_0608 7/17/06 9:44 AM Page 7

Photo: Steve Redick Research Institute (SNTRI), scientists identified fiberglass-based materials as producing some of the highest levels of cyanide in fire smoke. Use of fiberglass insulation in American building construction is much higher today than 30 years ago. Many fire departments’ tactical overhaul and extinguishing operations have not been updated to address these and other changes that make smoke increasingly dangerous. For their health and safety, firefighters need to understand that today’s fire smoke is more dangerous then ever. The days of the “smoke-eater” culture needs to end. THE PROVIDENCE FIREFIGHTER’S POISONING A recent case of cyanide poisoning of a firefighter occurred in early 2006 during a structural house fire in Providence, Rhode Island.6,7 During the fire, a firefighter collapsed into cardiac arrest while operating the engine pumps outside the fire building. The HYDROGEN CYANIDE firefighter of Engine 6 was resuscitated at Rhode Island Hospital and was IN FIRE SMOKE: found to have hydrogen cyanide in his AN UNRECOGNIZED THREAT TO THE AMERICAN FIREFIGHTER blood. The firefighter had no memory of the fire. BY DONALD W. WALSH, PhD, EMT-P Following the fire, the fire chief President Cyanide Poisoning Treatment Coalition (CPTC) had the poisoning investigated. Ninety- Assistant Deputy Fire Commissioner, Chicago Fire Department, Chicago, Illinois one of the department’s firefighters

Some parts of this manuscript were taken inadvertently allow for these practices. Photo: Tim Olk from the publication “Cyanide, a Ubiquitous NFPA 1404, Standard for Fire Service Product of Combustion in Modern Fires” Respiratory Protection Training,1 and (DW Walsh), which appeared in fireEMS in NFPA 1500, Standard on Fire Department May 2005. Occupational Safety and Health Program,2 establish standards for pro- INTRODUCTION tecting firefighters when fire smoke re American firefighters being and hazardous materials are present. A poisoned unknowingly during the However, the American fire service performance of their fire suppression still allow firefighters to perform venti- and rescue duties? Recent findings lation and overhaul activities without suggest that firefighters may in fact SCBA or appropriate protection. frequently be exposed, sometimes Current scientific research is unknowingly, to a dangerous toxicant: prompting the American fire service cyanide. leaders to look much more closely How many times have firefighters at allowable practices. In addition, fire seen their colleagues on building roofs service experts are further asking for ventilating in heavy smoke or perform- new, stronger fireground air-manage- ing overhaul functions in smoldering ment standards to protect firefighters. fire debris without self-contained Research in Sweden has identified breathing apparati (SCBA)? The fact is specific building materials that are that firefighters perform unprotected very dangerous when burning and fireground operations all the time. producing fire smoke.3-5 In a study by Many fire departmental standards the Swedish National Testing and

4 CyaIns_FE_0608 7/17/06 9:45 AM Page 8

responded to three fires in March of engine companies, a tower-ladder truck, The fire simulation experiments meas- 2006. Of those 91, 28 sought medical a rescue unit, and a battalion chief were ured temperature as well as concen- treatment, and 27 had their blood tested dispatched to the scene. The first trations of various combustion gases for cyanide. Eight of the firefighters, responding engine unit arrived at the in both sprinklered and un-sprinklered including the firefighter from Engine scene in less than 5 minutes after conditions. The un-sprinklered condi- 6, had high levels of cyanide in their receipt of the 911 call and began sup- tion reproduced that of the Station blood. The fire chief assembled a spe- pressing the fire with water. Ambulance nightclub, which did not have a cial task force to investigate the impact units and additional fire companies sprinkler system. Building codes did of cyanide in fire smoke. The task force were dispatched, and a mass casualty not require the Station nightclub to concurred with experts who have plan was implemented.9 have a sprinkler system given the size concluded that hydrogen cyanide is a much more significant threat to fire- fighters than previously understood: Figure 1. Timeline of the Rhode Island Nightclub Fire and emergency response to it.8 “It would appear that the Providence Fire Department and Rhode Island Hospital may have run into the tip of a 6 0:00 min 5:34 min very large iceberg,” the task force Ignition of Foam Flames out front door 24:00 min Roof Over Main report indicates. Bar Down The task force made 16 recom- 0:30 min Band stops playing 6:00 min Water on Fire - Booster 51:00 min Water on Fire - Master Hand Line - Engine 4 mendations to protect firefighters and Evacuation begins Stream - Warwick Ladder civilians from fire smoke producing 1:30 min Smoke Layer <12:00 min Water on Fire - Master cyanide. The recommendations includ- Near Floor Stream - Engine 2 ed educating firefighters about how <1:42 min People wedged in <16:00 min Water on Fire - Master fire smoke can produce high, deadly front doorway Stream - Engine 4 levels of hydrogen cyanide and how fast 20:00 min Water on Fire - Three fire smoke can quickly incapacitate Hand Lines - Front someone trying to escape a fire; edu- cating the medical community to 11:08 pm 12:08 am routinely test smoke inhalation victims

for cyanide; establishing and support- 5:21 min Request 15 more ing quick federal approval of safe Engine 4 on Scene Ambulances

cyanide antidotes (hydroxocobalamin) 4 Engines, 1 Ladder, & Implement Mass in the United States to treat firefighters Bat. Chief Dispatched Casualty Plan and civilian smoke inhalation victims; 0:59 min Police at Nightclub 14:00 min Fire Chief educating firefighters on the dangers Report Fire to Dispatch Responding 50:00 min of cyanide poisoning and requiring the 0:41 min Fire Alarm Sounds Request 12 Accounting Roll-Call use of protective measures; and acquir- Strobes Flash Ambulances

ing and deploying new technologies to 0:36 min Cell Phone Callers Activate Warwick Main Roof Collapse detect cyanide at fire scenes. Report Fire to 911 Fire Task Force TRAGEDY IN WEST WARWICK: THE RHODE ISLAND NIGHTCLUB FIRE Approximately 440 people were in the Despite the rapid and capable of the nightclub (footprint of approxi- Station nightclub in West Warwick, emergency response, which is credited mately 4500 square feet) and the date Rhode Island, that Friday night in with saving many lives, 100 people it was built. Given the similarity of February 2003 when a fire broke out in perished in the fire, and scores of the test conditions to conditions on the single-story, wood-frame building.8 others were seriously injured. The US the night of the fire, it is likely that The fire started just after 11 PM, when Department of Commerce’s National the experimental observations closely pyrotechnics used by Great White, the Institute of Standards and Technology reflect what happened on the night band performing that night, ignited (NIST), which is responsible for of the fire. polyurethane foam lining the walls of investigating building-related failures The results of the simulations the stage area. The blaze quickly leading to substantial loss of life, was under un-sprinklered conditions dra- spread to the ceiling and then ignited deployed on a fact-finding mission to matically demonstrate how quickly the wood paneling on its way to investigate the fire. conditions in the nightclub may have becoming a full-blown structural fire. The NIST conducted experiments become deadly. Within seconds of Figure 1 shows the timeline of the to simulate the spread of fire and ignition of the fire, concentrations of Rhode Island Nightclub Fire and of the smoke through the nightclub.8,10 The the toxic combustion products carbon emergency response, which was rapid experiments were conducted in a test monoxide and hydrogen cyanide and well-executed.8 In response to 911 room having dimensions and contain- soared and oxygen levels plummeted calls made approximately 35 seconds ing materials similar to those of the to create conditions incompatible and 1 minute after the fire ignited, four nightclub on the night of the fire. with sustaining life (Figure 2).10

5 CyaIns_FE_0608 7/17/06 9:45 AM Page 9

The striking differences in temper- highly toxic combustion product that Why this lack of awareness of the ature and in concentrations of oxygen, is formed during combustion of any importance of cyanide as a toxic carbon monoxide, and hydrogen material containing nitrogen3-that is combustion product? Researchers at the cyanide between the sprinklered con- to say, during combustion of almost Swedish National Testing and Research dition and the un-sprinklered condition any material found or used in the Institute (SNTRI), which has conducted support the judgment of on-the-scene construction of human dwellings. The pioneering work identifying toxicants firefighters who contended that the possibility that cyanide contributed to in fire smoke, suggest that the perva- lack of a sprinkler system cost many morbidity and mortality in the Rhode sive and relatively well recognized lives (Figure 2).10 Whereas temperature Island Nightclub Fire was not consid- hazard of carbon monoxide can blind and oxygen levels were maintained at ered by at least some of the health care researchers and clinicians to the possi- nearly ambient levels from the floor to providers administering to fire victims bility that other toxicants, too, can be approximately 1.4 meters above floor as illustrated by a case report published important in causing smoke inhalation level in the sprinklered condition, in the New England Journal of Medicine injury.5 In effect, cyanide has not been flashover conditions occurred approx- in 2004.11 The authors assessed and found because it has not been sought. imately 60 seconds after ignition in the treated a woman severely burned in un-sprinklered condition. These find- the Rhode Island Nightclub Fire for FIRE SMOKE RESEARCH FROM ings contributed to the NIST’s primary carbon monoxide poisoning but did THE SWEDISH NATIONAL TESTING recommendations that model codes not report evaluating her for toxicity AND RESEARCH INSTITUTE require sprinkler systems for all new arising from other combustion prod- As discussed in the introduction, data and existing nightclubs regardless of ucts including hydrogen cyanide. from studies conducted by the SNTRI size and that state and local authorities Furthermore, although the authors are consistent with NIST data in showing adopt this provision.8 discussed several aspects of managing that cyanide is a major combustion burn injury and smoke inhalation, product generated during burning of CYANIDE IN FIRE SMOKE they did not discuss cyanide toxicity materials commonly found in domes- INHALATION: A DEADLY TOXIC MIX despite the presence of several signs and tic structures. In one series of experi- Results of the NIST experiments are symptoms suggesting cyanide poison- ments, the SNTRI assessed the emission consistent with the possibility that an ing. The failure to consider cyanide as of hydrogen cyanide and carbon elevated level of hydrogen cyanide was a potential cause of fire-related morbidity monoxide under both non-flaming among the causes of incapacitation and mortality characterizes much of the (i.e., pyrolyzing) and flaming (i.e., fire) and death in the Rhode Island medical literature on the management conditions during burning of wool, Nightclub Fire. Hydrogen cyanide is a of smoke inhalation. nylon, synthetic rubber, melamine, and polyurethane foam.5 The results show that all of these substances liber- Figure 2. Temperature and oxygen, carbon monoxide, and hydrogen cyanide ated high quantities of cyanide when concentrations in an experiment simulating the Rhode Island Nightclub Fire.10 burned-particularly under pyrolyzing Temperature and gas concentrations were measured 1.4 meters above the floor and 1.6 meters away from the stage where the fire started. conditions characterized by low oxy- gen. Carbon monoxide was also emitted during the burning of these substances. Temperature Oxygen Noting that hydrogen cyanide is 800 25 approximately 35 times more toxic than Ceiling 700 Un-sprinklered carbon monoxide during acute exposure, 20 600 1.4 m above floor the authors emphasized the need for

º 500 Sprinklered 15 increased recognition of the contribu- Ceiling 1.4 m above floor Sprinklered 400 Un-sprinklered tion of cyanide to smoke toxicity.5 300 10 1.4 m above floor The SNTRI conducted other exper- Un-sprinklered

Temperature (Temperature C) 200 5 iments to identify factors that affect 1.4 m above floor Oxygen (volume %) 100 Sprinklered the amount of cyanide generated in a 0 0 3 0 50 100 150 200 0 50 100 150 200 fire. They developed combustion Time (s) Time (s) models that take into account the observations that oxygen content in Carbone Monoxide Hydrogen Cyanide the air near a fire is lower than that of 6 0.15 fresh air; that air in the fire contains 5 1.4 m above floor Un-sprinklered 1.4 m above floor Un-sprinklered combustion products that reduce the 4 0.1 efficiency of burning and result in

3 incomplete combustion; and that growth of a fire increases the contents 2 0.05 1.4 m above floor of combustion products in the air. Sprinklered 1.4 m above floor 1 Sprinklered Using these models, they identified

Hydrogen Cyanide (volume %) Hydrogen 0 Carbon Monoxide (volume %) 0 two conditions that increased the 0 50 100 150 200 0 50 100 150 200 Time (s) Time (s) probability of cyanide formation in a fire. First, recycling of combustion

6 CyaIns_FE_0608 7/18/06 4:39 PM Page 10

products within a confined space 4 increased the formation of hydrogen Table 1. Materials and products investigated in the test program. cyanide. Second, lowered ventilation rate to the fire increased the formation Material Comment Usage

of hydrogen cyanide by 6 to 10 times Glass fibre insulation wool building insulation relative to conditions of higher ventila- Mineral fibre insulation wool building insulation tion rate. Carbon monoxide formation Wood deal board building construction Bitumen waterproofing membrane building construction was also increased under these two Polystyrene expanded polystyrene(EPS) packaging, insulation, etc conditions, which are particularly Nitrile rubber insulating material tubing insulation likely to apply to closed-structure fires. PVC flooring material surface lining Fluoropolymer pure pellet material cable base material Polyethylene halogen free, fire retarded pellets cable base material HYDROGEN CYANIDE AS AN FR4 laminate brominated laminate printed circuit board base material ESCAPE INHIBITOR Melamine laminate building construction Wool 92% wool, 8% polyamide lining, clothes Cyanide poisoning from fire smoke Particle Board laminate building base material can be directly lethal or, as the SNTRI PUR flexible foam furniture upholstering and other researchers emphasize, can PUR rigid foam building insulation PIR rigid foam-polyisocyanurate (modified PUR) building insulation indirectly cause death by incapacitat- Plywood laminate room surface lining 5,12 ing a fire victim. Hydrogen cyanide Carbon fibre laminate composite material, small and intermediate high performance vehicles, and other toxicants in sublethal con- scale experiments airplanes, etc

centrations appear to act as escape Cable products: 5,12 inhibitors in modern fires. Exposure Polyethylene cable halogen free, fire retardedcable data cable to low cyanide concentrations in a fire PVC cable fire retarted cable data cable Fluoropolymer cable high performance cable data cable can cause unconsciousness that make PVC + fluoropolymer cables 50% of each material data cable self-directed escape from the fire very Optical cable uses urethane acrylate based polymer optical signal transport difficult.5 The victim of cyanide-asso- Real-scale products: ciated incapacitation may continue Sofa PUR upholstering; full scale experiment furniture to inhale increasing amounts of Mattress PUR; large scale experiment furniture carbon monoxide and other noxious gases. Carbon monoxide poisoning may eventually be the direct cause of Figure 3. Total isocyanate concentrations in Cone calorimeter tests.4 death. However, as the carbon monoxide poisoning might not have occurred without cyanide-induced incapacitation, hydrogen cyanide arguably is the cause 6000

of death in this example. ) 3 3 5000 Glass fibre: 8010 lug/m u g /m l SISTERS OF CYANIDE: 4000 ISOCYANATES GENERATED DURING COMBUSTION 3000 Other findings from the SNTRI suggest 2000 that the impact of cyanide as isocyanates ( isocyanates Total should be considered in estimating the cyanide-associated hazards of fire 1000 smoke.4 Derived from cyanide and 0 hydrocarbons, isocyanates are com- A B C D E F G H I J K L M N O P Q R S T U V monly found in plastics and adhesives. They are generated during the thermal A. Glass fibre F. Polystyrene K. Melamine P. Fluoropolymer pellets U. PVC cable B. Mineral fibre G. Particle Board L. Nitrile Rubber Q. Polyethylene pellets V. Optical cable decomposition of urethanes and, it is C. PUR (flexible) H. Plywood M. Bitumen R. Polyethylene cable hypothesized, during the incomplete D. PUR (rigid) I. Wood N. FR4-laminat S. PVC + fluoropolymer cables E. PIR J. Wool O. PVC T. Fluoropolymer cable combustion of nitrogen-containing compounds.4 The SNTRI assessed the formation of isocyanates in small- scale combustion experiments involving The small-scale experiments that made them potentially more 18 standard materials used in building involved highly ventilated conditions dangerous to humans than the other (Table 1) and in large-scale experiments under which generation of large combustion products that were tested involving two domestic products (i.e., a quantities of dangerous combustion (Figure 3).4 The results suggest that sofa and a mattress). Other combustion products such as carbon monoxide elevated isocyanate levels in a fire can products including carbon monoxide, and hydrogen cyanide was neither result in life-threatening conditions sulfur dioxide, hydrogen fluoride, expected nor observed. In these small- even when hydrogen cyanide and hydrogen chloride, and hydrogen scale experiments, isocyanates were carbon monoxide remain at nondan- cyanide were also measured. found to be present at a concentration gerous levels.

7 CyaIns_FE_0608 7/17/06 9:46 AM Page 11

The large-scale experiments differed insurmountable. Effective management 7. Milkivits, Amanda, Task Force Urges from the small-scale experiments in of cyanide poisoning in a fire emergency Firefighting Precautions, Providence that combustion generated high con- is possible. The first responder’s aware- Journal, May 31, 2006. centrations of dangerous combustion ness that cyanide poisoning is highly 8. Grosshandler WL, Bryner N, products such as hydrogen cyanide probable in smoke inhalation victims of Madrzykowski D, et al. Draft report and carbon monoxide. Isocyanates closed space structure fires constitutes of the technical investigation of the were also present at high levels in these a first step in effective management of Station nightclub fire. US Department large-scale experiments. For example, smoke inhalation-associated cyanide of Commerce, Technology in a large-scale test in which a sofa poisoning. Specific measures to help Administration, National Institute in an enclosed room was ignited, iso- victims of smoke inhalation-associated of Standards and Technology. cyanates reached approximately 17% cyanide poisoning in the prehospital March 2005. of the concentration that is immedi- setting are discussed elsewhere in 9. Anonymous. At least 96 killed in ately dangerous to life and health this supplement. nightclub inferno. Available at (IDLH) and carbon monoxide reached www.cnn.com. CNN news report, 30% of the IDLH value during the test RECOMMENDATIONS TO THE 21 February 2003. Accessed 17 period. The authors concluded based AMERICAN FIRE SERVICE March 2005. on these results that the contribution 1. Increase education of firefighters 10. Madrzykowski D, Bryner NP, of isocyanates should be included and civilians about the risk of Grosshandler WL, et al. Fire spread in estimating the toxic effect of a cyanide poisoning from fire smoke. through a room with polyurethane gas mixture.4 2. Support blood testing for cyanide foam-covered walls. Interflam 2004. of firefighters and fire victims. International Interflam Conference, CONCLUSIONS 3. Support the use of safe cyanide 10th Proceedings; Volume 2; July Medical lab results of the Providence treatment antidotes (hydroxocobal- 5-7, 2004. Rhode Island firefighters identified amin) in the United States to treat 11. Sheridan RL, Schulz JT, Ryan CM, et high levels of hydrogen cyanide in firefighters and civilian smoke- al. Case 6-2004: A 35-year-old- their blood. The results cause signifi- inhalation victims. woman with extensive, deep burns cant changes in the operational fire 4. Submit to the NFPA scientific from a nightclub fire. New Engl J fighting practices and procedures. research to identify health and Med. 2004;350:810-821. The investigations cause the recom- safety issues related to mandatory 12. Peacock RD, Averill JD, Reneke PA, mendations for new cyanide detecting air management standards especially et al. Characteristics of fire scenarios systems, new cyanide medical testing during overhaul operations. in which sublethal effects of smoke protocols, new cyanide antidote treat- are important. Fire Technology. ments, and educational programs on REFERENCES 2004;40:127-147. the dangers of fire smoke. 1. NFPA 1404, Standard for Fire Service Results of fire modeling experiments Respiratory Protection Training, Photo: Tim Olk including simulations of the February National Fire Protection Association, 2003 Rhode Island Nightclub Fire Quincy, MA, 2002 Edition. suggest that cyanide is a ubiquitous 2. NFPA 1500, Standard on Fire toxicant in modern fires. Depending Department Occupational Safety on the fire conditions, hydrogen cyanide and Health Program, National Fire is formed as an intermediate combus- Protection Association, Quincy, tion product and/or an end product. MA, 2002 Edition. Isocyanates, too, are formed during 3. Tuovinen H, Blomqvist P. Modeling combustion and should be considered of hydrogen cyanide formation in in estimating cyanide-related hazards room fires. Brandforsk project 321- from fire smoke. The amount of cyanide 011. SP Swedish National Testing produced can vary from fire to fire and and Research Institute. SP Report from one location to another in a given 2003:10. Borås, Sweden, 2003. fire depending on factors such as the 4. Hertzberg T, Blomqvist P, Dalene composition of the burning material, M, et al. Particles and isocyanates the rate of burning, the absolute tem- from fires. Brandforsk project 324- perature, and ambient oxygen level. 021. SP Swedish National Testing Experience with the Rhode Island and Research Institute. SP Report Nightclub Fire, in which cyanide is 2003:05. Borås, Sweden, 2003. likely to have contributed to morbidity 5. SP Swedish National Testing and and mortality, and data from studies Research Institute. Formation of reviewed elsewhere in this supplement hydrogen cyanide in fires. SP show that cyanide can be rapidly Report 2000:27. Borås, Sweden, 2000. lethal-a daunting challenge for first 6. Providence Task Force Issues responders working to save lives. Recommendations on Cyanide, While daunting, the challenge is not Associated Press, May 30, 2006.

8 CyaIns_FE_0608 7/17/06 11:27 AM Page 12

weight, improve reliability, and enhance AIR MANAGEMENT ON overall effectiveness. Combined with better protective equipment, along THE FIREGROUND: with training and improvements in THE NEED - THE MANDATE - THE SOLUTION leadership, it should be expected that firefighter deaths rates on the fireground BY CAPTAIN MIKE GAGLIANO should be decreasing. Unfortunately, CAPTAIN CASEY PHILLIPS that is not the case as fireground deaths CAPTAIN PHIL JOSE are staying about the same in spite of a LIEUTENANT STEVE BERNOCCO decrease in actual fires. One factor All contributors to this article are from the Seattle Fire Department stands out that needs to be addressed: Firefighters that die in structures are dying in increasingly higher num- bers due to asphyxiation. Or, to put it in street terms When firefighters run out of air they breathe smoke. When firefighters breathe smoke they die.

THE NEED The need for a progressive, compre- hensive air management program is obvious for one simple reason: Firefighters are running out of air on the fireground. The results of firefighters running out of air vary dramatically — increasing firefighter line-of-duty deaths, close calls, injuries and he modern fireground is one of the Unfortunately, the fire service increased cancer/respiratory disease T deadliest environments in the world. developed some bad habits when the rates that are directly linked to the It is a combination of forces and SCBA was first introduced. These bad smoke firefighters breathe when their factors that can kill, cripple, or maim habits have carried over into poor air air is depleted. in a matter of seconds. management practices. The fire serv- According to NFPA firefighter fatality On a daily basis, firefighters around ice is paying a steep price for these reports, between 1996 and 2003 there the world fight fires in this deadly behaviors. Numerous fireground deaths were 103 deaths directly attributed to arena armed with only some basic are attributed to firefighters running asphyxiation. These numbers did not tools - water, protective clothing, and out of air and dying of asphyxiation. take into account the direct contribu- air. These tools are extremely impor- Initially, SCBA were not worn by tion “running out of air” played in tant and the job of fighting fires could the majority of firefighters because deaths that were attributed to other not be done without them. It is air, they were deemed too bulky and time factors such as thermal insult, cardiac however, carried on the back of a fire- consuming to bother with. This was arrest, or collapse. fighter in a self contained breathing combined with tremendous peer The need for air management is apparatus (SCBA), which makes it pressure that insinuated you were a etched on fallen firefighter monuments possible to safely enter a fire building “weak” firefighter if you wasted the and get the job done. It is also air, or time it took to put on your breathing A “ROUTINE” HOUSE FIRE CAN the lack thereof, that is the primary apparatus. These assertions were PRODUCE ANY OF THE FOLLOWING cause of non-cardiac related death demonstrated to be incorrect and WITHIN SECONDS OF IGNITION: on fireground. unsafe; however, it is still a common practice in some departments to 1 Extreme Temperatures/ AIR MANAGEMENT routinely disregard wearing a self con- Thermal Insult 2 Poisonous/Asphyxiating The concept of Air Management revolves tained breathing apparatus. Atmospheres around the discipline of knowing how Most progressive and professional 3 Structural Collapse much air a firefighter has in their fire departments around the world are 4 Explosions SCBA, monitoring that air, and ensuring now mandating the use of the SCBA. 5 Entrapment it is being utilized to safely and effec- The SCBA continues to improve as 6 Electrical Shock tively accomplish the task at hand. newer technology seeks to decrease the

9 CyaIns_FE_0608 7/17/06 9:46 AM Page 13

across the country, and in the tragic fire suppression, rescue, and related “Know how much air is in your consequences line-of-duty deaths bring activities in a toxic, contaminated, SCBA, and manage that air so that you to the families and fire departments of or oxygen-deficient atmosphere or leave the IDLH environment BEFORE these fallen firefighters. environment. your low air warning alarm activates.” NFPA 1404 5.1.4* The authority For many fire departments, this is THE MANDATE having jurisdiction shall establish and going to be a significant change in how Besides the disturbing firefighter death enforce written Standard Operating fireground operations are performed. statistics, there are other mandated Procedures’s for training in the use The current practice is for firefighters changes coming to the American fire of respiratory protection equipment to operate until the activation of the service that focus directly on air and that training SHALL include low-air warning alarm and then begin management. the following: to exit the structure. This practice The most significant change is the NFPA 1404 A5.1.4(2) Individual air allows a firefighter to use 75% of the air new language in the National Fire management program. This program will in their SCBA for entry and work in the Protection Association (NFPA) 1404 develop the ability of an individual to IDLH environment leaving only 25% respiratory standard that will take manage his or her air consumption as for exit and no margin for error. effect in 2007. Beginning in January, part of a team during a work period. The new language in the NFPA NFPA 1404 will include the following The individual air management 1404 standard is going to be the meas- provisions: program should include the following ure used by the professional and legal directives: community to determine if a fire NFPA 1404 Chapter 1 Administration 1) Exit from an IDLH atmosphere department has taken the minimum 1.1* Scope. This standard shall contain should be before consumption of required action necessary to protect minimum requirements for the training reserve air supply begins. their firefighters from the exposure to component of the Respiratory Protection 2) Low air alarm is notification the IDLH environments. To that end, fire Program found in NFPA 1500, Standard individual is consuming their departments must train firefighters to on Fire Department Occupational Safety reserve air. manage their air. and Health Program. 3) Activation of the reserve air alarm 1.2*Purpose. The purpose of this is an immediate action item for WILL THE LAW BE ON YOUR SIDE? standard shall be to specify the mini- the individual and the team. This moves the discussion into the mum requirements for respiratory The NFPA 1404 Standard outlines that legal arena where departmental and protection training for the emergency fire department must train their members personal liabilities are factors that will response organization, including safe- to operate in accordance with the Rule have far reaching impact on the fire ty procedures for those involved in Of Air Management (ROAM) which states: service. Many firefighters are already dealing with the fallout from the real- ization that “giving your all” to the The fire service has seen dramatic changes since Benjamin Franklin citizens as a member of the fire service began building the American fire service. Despite all the changes, deaths does not necessarily correlate into on the fireground that are not related to heart attack or vehicle accidents being taken care of in return. still occur in the same ways they have for 200 years. These are: The preceding article on the dele- terious effects of smoke and its components highlights the toxic and • Smoke • Getting Lost or Separated carcinogenic nature of the modern fire • Thermal Insult • Running out of Air environment. Every firefighter is sub- • Structural Collapse jected to products of combustion as a normal course of doing their job. Exposure to products of combustion is “ Running out of Air” affects all other categories on the list: causing cancer in firefighters at levels “ No Air” in the toxic smoke environment of today leads to far above those found in the general rapid asphyxiation. population. It could be assumed “ No Air” during a thermal insult event will result in immediate that the willingness to take on these and fatal burns to the throat and lungs. risks would be met with an equal “ No Air” during a structural collapse means a lack of time responsibility of the employer to care for rescue and asphyxiation. for the individual who gets sick “ No Air” when lost or separated leads to panic and asphyxiation. because of them. That assumption “ No Air” requires the firefighter to breathe the products of is proving nightmarishly wrong for combustion - toxic smoke that is proven to be both poisonous many firefighters. and carcinogenic. Many states are adopting “ No Air” means that even if the firefighter survives the initial “Presumptive Legislation” that attempts assault on their respiratory system the toll on their wellness to address the right of firefighters to will be immeasurable. get medical care for cancer and other diseases that are a direct result of the job. The devil, as always, is in the

10 CyaIns_FE_0608 7/17/06 11:33 AM Page 14

details of just what is, and is not, and if they used the safety equipment require the purchase of expensive deemed “job-related.” In the state of provided them. Much like the current equipment, the addition of more Washington, for example, the follow- discussions that are ongoing in regard personnel, or the cessation of aggres- ing are considered valid “job-related” to vehicle accidents in which seatbelts sive fireground attack to implement. conditions under current presumptive are not worn, the proper use of The Rule of Air Management (ROAM) legislation: SCBAs and respiratory guidelines will is the simple means by which the be expected. Deviation from these fireground can be made safer, exposure • Primary Brain Cancer guidelines opens the firefighter up to to toxic/carcinogenic smoke can • Malignant Melanoma questions of personal liability. be greatly limited, and exposure to • Leukemia Finally, all of the above will certainly legal/liability issues can be decreased. • Non-Hodgkin’s Lymphoma result in court cases in which firefight- • Bladder Cancer ers, fire officers, and fire departments The Rule of Air Management says: • Ureter Cancer as a whole may be required to justify Know how much air you have in your • Kidney Cancer their actions. A case in Memphis, SCBA, and manage that air so that you Tennessee, is currently questioning why leave the hazardous environment before The Washington State Senate Ways a “30-Minute Bottle” did not last a your low-air warning alarm activates. and Means Committee specifically deceased firefighter 30 minutes. This is While this looks like a simple solu- amended the original list of diseases something all who’ve donned a mask tion, it is a radical change in behavior that provided more appropriate cover- can answer easily. Everyone in the fire for the fire service. Most firefighters age for firefighters. The original list service understands that the label have never checked their air before was dramatically slashed and elimi- “30 minute cylinder” is a misnomer. entry or during operations at structure nated the following cancers from the These cylinders have only enough air fires. Up until now, the standard list of “Presumptive” cancers: for firefighters to work 15-20 minutes indication for “time to exit” is when at best. Imagine explaining to the the low-air warning alarm activates. • Breast Cancer judge, or the widow, that “everyone The problem with this approach is that • Reproductive System Cancer knows” of the deficiency–yet no action it allows for no margin of error. • Central Nervous System Cancer was taken prior to the fatality. Those in • Skin Cancer charge must answer: The ROAM changes all that. • Lymphatic System Cancer 1) Why do they allow their firefighters By checking your air before entry, there • Digestive System Cancer to enter a structure fire without is a verification that nothing has gone • Hematological System Cancer breathing from an SCBA? wrong with the breathing apparatus • Urinary System Cancer 2) Why they routinely allow firefighters pack prior to interior smoke exposure. • Skeletal System Cancer to operate until their low-air A full bottle gives a baseline from which • Oral System Cancer warning alarm activates? the firefighter can build a good approach 3) Why aren’t they training, and to managing the air they have. A The Washington State Ways and operating, according to recognized Radio–Equipment–Air–Duties–Yes! Means Committee also included addi- minimum national standards? (R.E.A.D.Y.) Check (See Fire Engineering tional language that put limits on how The mandate for air management magazine June 2005 for more details) is long coverage would be in place. The answers these concerns. recommended prior to entry, to eliminate current system allows for 3 months of some of the key problem areas that are coverage for every year of employment THE SOLUTION killing and/or injuring firefighters. up to 60 months. In other words, a The solution for the air management A routine check of the air status by firefighter who has been subjected to problem is a simple one. It does not the individual and team leader during the hazardous smoke for a career of 30 years had better test positive for cancer within 5 years of retirement or they are not covered. They will get zero coverage despite the obvious links to the years “Know how much air you have in of service and high rates of cancer probability. There are additional vari- ables written in that allow further your SCBA, and manage that air questioning of whether the cancer is job related including smoking history, so that you leave the hazardous fitness, etc. There is a growing recognition that proper usage of equipment and follow- environment before your low-air ing of operating guidelines/policies will be scrutinized in the light of warning alarm activates.” personal liability. An injury or exposure will be judged based on how the fire- fighter operated during the emergency

11 CyaIns_FE_0608 7/17/06 9:47 AM Page 15

the operation is the second critical component of the ROAM. While this FIRE OVERHAUL, REHAB, AND A seems like an obvious thing to do, most firefighters have never done it. This COMPREHENSIVE RESPIRATORY check serves two purposes. The first is PROTECTION PROGRAM an obvious reminder of where the crew stands as far as air level is concerned, and gives a good indicator of when to BY CAPTAIN PHIL JOSE make the “time to exit” decision. The LIEUTENANT STEVE BERNOCCO second is an increase in situational CAPTAIN MIKE GAGLIANO awareness that keeps the team from CAPTAIN CASEY PHILLIPS getting tunnel vision while performing All contributors to this article are from the Seattle Fire Department their task. The air gauge check provides a brief break in the action that allows the team leader to not only monitor air, but also check condition changes and sta- tus of crew members. Finally, the ROAM requires the team to exit the structure before the low air warning alarm activates. The final 25% of the bottle is the emergency reserve air, and should only be utilized when something has gone wrong for the firefighter or the crew. Unfortunately, firefighters routinely use this “emergency reserve” for the incident itself. This has caused numerous firefighters to run out of air and suffer exposures to products of combustion. By exiting the structure with the emergency reserve intact, fire- fighters allows themselves a margin of error for an unexpected collapse, dis- orientation, or other problem. It also gives the Rapid Intervention Team time to make entry and affect rescue if nec- essary. This is the model used by SCUBA divers who regard their emer- gency air as sacred. Just as our lungs were not designed to breathe water, nei- ther were they meant to endure smoke. Firefighters who stay in the haz- fter firefighters extinguish a structure amount of smoke and fire during ardous environment until their low air A fire, they typically re-enter the build- overhaul, they are not being signifi- warning alarm activates are betting ing to conduct overhaul activities. cantly exposed to the products of their life that nothing will go wrong on During overhaul, firefighters often combustion. Science has proved this the way out. This is a gamble that open up and look in the walls, ceilings, notion to be false. Firefighters are, in firefighters can no longer afford to take. attics, and any other void space where fact, routinely breathing toxic gases The Rule of Air Management is the these still-burning embers might be and being exposed to dangerous car- future of the fire service. It can be com- located. To accomplish the strenuous cinogens in the post-fire environment. bined with any technological or per- task of overhaul, firefighters use These products may include hydrogen sonnel advance, but it does not rely on thermal imaging cameras (TICs), and cyanide (HCN), aldehydes, benzene, them. Technology can be relied on only other tools such as axes, chainsaws, nitrogen dioxide (NO2), sulfur dioxide so far, as it always is subject to failure. and pike poles to search for hidden (SO2), polynuclear aromatic hydrocar- Shrinking staffing levels and human fire after the main body of the fire has bons (PNA), and other substances. error make air management, at the been extinguished. Recent scientific studies show that strategic level, a secondary option at During overhaul, there may be the post-fire environment may be more best. The simple reality of the fireground little or no smoke, so most firefighters dangerous than firefighters realize. is that an individual firefighter’s air is remove the face piece of their SCBA Based on that concept, all fire depart- their responsibility to manage. The (self contained breathing apparatus) ments should have an overhaul policy ROAM ensures that this happens and and work in the environment without that requires firefighters to wear will save the lives of firefighters who any respiratory protection. Firefighters respiratory protection throughout the use it. falsely believe that due to the reduced overhaul phase of the fire.

12 CyaIns_FE_0608 7/17/06 9:47 AM Page 16

OVERHAUL AND RESPIRATORY PROTECTION In their excellent study of firefighter exposure during fire overhaul, authors Bolstad-Johnson, et al, found that con- taminants in the “overhaul atmosphere exceeded occupational exposure limits and could therefore result in adverse health effects in firefighters without respiratory protection.” In this impor- tant study, the authors found that in many fires, concentrations of acrolein, CO, formaldehyde, and gluteralde- hyde exceeded exposure limits set by the Occupational Safety and Health Administration (OSHA). They also found that concentrations of coal tar pitch volatiles (PNAs) exceeded the OSHA and NIOSH limits. In other words, the post-fire environment, though there is little or no smoke pres- ent, is extremely toxic and dangerous to firefighters. The authors conclude that respiratory protection should be worn by firefighters during overhaul activities, and that the SCBA is a far better choice of respiratory protection than full-face air purifying respirators, become educated about their SCBA. in overall safety, there is a cost to the which provide only limited protection They must understand the limitations wearer. A complete self contained to the firefighters as compared to the of the SCBA and how it functions. breathing apparatus can easily add in positive pressure SCBA. They must be fitted with the proper excess of 25 pounds to the firefighter. Many fire departments allow fire- face-piece. They must be properly In addition, the backpack carrying fighters to take off their SCBA during trained on how to use it under normal system compresses the thoracic cavity overhaul if carbon monoxide (CO) operating conditions, and how to and restricts the ability of the respira- readings are below acceptable levels. handle a low air emergency. All of tory muscles to function normally. However, CO levels have no correla- this is mandated by NFPA 1404, Each 1 kg increase in the weight of the tion to irritants, other toxic gases, or Standard for Fire Service Respiratory SCBA ensemble has related impacts carcinogens that are present in the Protection Training. on the respiratory rate, heart rate, and post-fire environment. The current air The SCBA is widely recognized in energy expended. This increases the monitors/gas detectors used by most the fire service as the biggest single workload of the firefighter thereby fire departments do not monitor these improvement for firefighter safety and increasing the rate of metabolic heat carcinogens and toxic gases - gases like health. By providing a reliable supply that is produced simply through the hydrogen cyanide, which is proving to of uncontaminated air for the fire- effort of breathing. be one of the most deadly compounds fighter operating in a highly dangerous Additionally, a comprehensive in the fire and post-fire environment. and contaminated environment, the respiratory protection program must To that end, the practice of allow- SCBA allows firefighters to work for ensure that firefighters wear and ing firefighters to take off their SCBA extended periods while protecting use their SCBA while fighting fire. during overhaul should stop. Because their respiratory system. SCBA have Unfortunately, there are many fire of this uneducated and dangerous improved over the years and now departments around the US that either practice, too many firefighters are represent a relatively lightweight and do not mandate or do not enforce the being injured, contracting various reliable piece of equipment that policy that every firefighter must wear kinds of cancers, and suffering from firefighters should use at all times. and use their SCBA during fires. respiratory illnesses. Exposure to products of combustion is Another component of a compre- Having firefighters wear their an unnecessary and therefore unac- hensive respiratory protection program SCBA during fire overhaul, however, is ceptable risk for firefighters in the should require firefighters to manage just one piece of a comprehensive modern era. In addition, improved air their air supply, ensuring they maintain respiratory protection program. management techniques and an effec- a supply of emergency reserve air in tive work/rest interval while operating case they run into trouble. Ideally, this RESPIRATORY PROTECTION in SCBA and maintaining an appropri- reserve air must only be used in case PROGRAM AND AIR MANAGEMENT ate margin for safety. And while a the firefighter encounters an unfore- First and foremost, firefighters must SCBA will provide a significant increase seen emergency - it should not be

13 CyaIns_FE_0608 7/17/06 9:47 AM Page 17

used as part of the working air for multiple units working together should before beginning to exit. Firefighters fighting the fire. do overhaul. This provides firefighters who use the ROAM recognize that the The commercial and recreational with regular rest breaks - a concept time to exit is before the low air alarm SCUBA diving industry has used the consistent with following safe activates. Without adhering to the concept of air management for work-rest intervals. ROAM, Company Officers should decades. Every SCUBA diver knows Company Officers and Incident follow the recommended practice of that they never breathe into their Commanders must take all of the using only one “45-minute” cylinder emergency reserve air unless they run above into account when determining before rotating to a designated reha- into trouble underwater. In fact, dive when crews must rotate through an bilitation area. Any use of a “60-minute” masters expect every diver to return to assignment and move toward rehabili- cylinder should be followed by an the dive boat with their reserve air in tation (rehab). Current recommended assignment to the formal rehab area. tact. If they do not, and they had no practice identifies work-to-rest inter- Formal incident scene rehabilitation emergency, those divers are deemed vals in terms of “30-minute” cylinder is a tactical level function normally unsafe, and are not allowed to dive rotations for interior operations and assigned as a division, group, or sector. again for that day or that company. time-based 20-minute work cycles for The rehab supervisor should be trained Currently, the American fire service outside operations. Company officers in all the functions and responsibilities does not enforce such stringent penal- or crew leaders should perform self- inherent to the position and should ties for utilizing emergency supplies of rehab after one “30-minute” cylinder understand how rehab operates with- air. It is commonplace to see firefight- use or 20-minutes of intense work. in the Incident Management System ers working past the low-air warning This rehabilitation process is informal (IMS) and the standard operating whistle or bell, failing to have any air and is most often conducted and procedures (SOP’s) of the department. in reserve. supervised by the company officer Rehabilitation areas should be far The last step of a comprehensive during the SCBA cylinder exchange enough from a working incident to respiratory protection program is a at the apparatus. The recommended provide protection from the products comprehensive fire overhaul policy; a work-to-rest interval includes 10 min- of combustion and from apparatus policy requiring firefighters to wear and utes of rest for each “30-minute” cylin- exhaust. They should also be close use their SCBA during fire overhaul. der work cycle. Incident Commanders enough so ready access can be made between the incident scene and the rehab area. Rehab should also provide An overhaul policy must have a few important pieces to make it work. appropriate protection from the envi- ronment, whether this includes hot or cold weather. Companies should be able • First, there should be an air support unit on scene. Fire crews will be to re-supply and stage firefighting equip- breathing through many SCBA cylinders during overhaul, so the air unit ment before entering the rehab area. must be there to refill or replace empty cylinders in a timely fashion. Departmental SOP’s or trained observations of company officers may • Next, firefighters should follow the ROAM (see the preceding article dictate when and how units are entitled “Air Management on the Fireground: The Need - The Mandate - assigned to rehabilitation. Minimum The Solution” for more details on the ROAM) concept during fire overhaul. standards for rehabilitation programs should include: • Finally, firefighters should ensure they are out of the hazardous environment before their low-air warning alarm activates. Again, this • Identified work-to-rest intervals gives firefighters a safety margin should they become trapped or lost before company level rehab are listed in the structure. below and should require a 10- minute company rehab including rest, hydration, and an evaluation Since overhaul is can be more must be able to forecast incidents of the company’s readiness for physically demanding than extin- where rehab will be needed beyond re-assignment at the completion of guishing the initial fire, there should the company level and establish a the 10-minute rehab be more firefighters on scene to share formal rehab area early. • One “30-minute” cylinder without in the overhaul workload. Overhaul Industry accepted standards for air management operations should also include the “30-minute” cylinder work interval • One “45-minute” cylinder following mandatory rest breaks for firefighters, may also be extended to the “45- the ROAM providing personnel time to cool off minute” cylinder if air management is • 20 minutes of intense work and hydrate. Safe work-rest intervals practiced in accordance with the Rule • Identified work-to-rest intervals should be observed, since overheating, Of Air Management (ROAM). Firefighters before assignment to the rehabilit- dehydration, and fatigue will all who follow the ROAM will have work tion area be working against the firefighters cycles that closely match those of • Two “30-minute” cylinders without performing overhaul. The practice of firefighters operating in “30-minute” following the ROAM including a 10- leaving one unit on scene to perform cylinders while working in the hazard minute rest and hydration period fire overhaul should be discontinued - area until the low-air alarm activates between cylinders

14 CyaIns_FE_0608 7/17/06 9:48 AM Page 18

• Two “45-minute” cylinders following the ROAM including a 10-minute SMOKE ASSOCIATED rest and hydration period between cylinders CYANIDE EXPOSURE: • One “45-minute” cylinder or “60- THE IMPORTANCE OF PROMPT RECOGNITION AND minute” cylinder work cycle without PROTOCOLS FOR PREHOSPITAL TREATMENT following the ROAM • One “30-minute” cylinder without BY JAMES AUGUSTINE, MD AND DONALD W. WALSH, PhD, EMT-P following the ROAM or One “45- minute” cylinder following the James Augustine, MD, is an emergency physician from Atlanta and the Director of Clinical ROAM after having rotated through Operations for EMP Management. He serves as Medical Director for the Atlanta Fire Department, rehab previously. This requirement which includes operations at Atlanta Hartsfield Jackson International Airport, and is on the recognizes the cumulative impact of Clinical Faculty in the Department of Emergency Medicine at Emory University. He has served repeated work-rest intervals over 25 years as a firefighter and EMT-A. the course of an incident and promotes coordinated company rotations and Donald W. Walsh, PhD, EMT-P is the Assistant Deputy Fire Commissioner for the Chicago incident accountability Fire Department’s Emergency Medical Services Division. Dr. Walsh is also President of the Cyanide • In addition to the work-rest interval Poisoning Treatment Coalition. Dr. Walsh is a Fellow of the Chicago Institute of Medicine, and considerations, any SOP should Adjunct Faculty at the US Department of Homeland Security’s National Fire Academy. include the following for assignment to rehab • The company officer recognizes the company needs to move to the rehab area at any time • The incident commander assigns the company to rehab

Once units are assigned to report to rehab they should report to the rehab supervisor for check in and recording of their arrival time. Personal Protective Equipment (PPE) should be removed and SCBA should be re-supplied with full cylinders. The company should then be given an initial medical screen- ing by assigned EMS personnel in accordance with department SOP’s. This initial evaluation should include:

• Symptoms of dehydration • Heat/Cold stress • Physical exhaustion • Cardiopulmonary abnormalities • Emotional/mental stress or exhaustion FINAL THOUGHTS Fire overhaul is necessary to assure INTRODUCTION CONTEXT that the fire is out and will not rekindle. he preceding articles cover the Both citizens and firefighters die as a However, the post-fire environment is T toxic composition of smoke, means result of inhalation of products of dangerous due to irritants, toxic gases, of improving firefighting operations combustion from fire. Cyanide may and carcinogens in the atmosphere. to reduce smoke toxicity, and the need contribute significantly to these deaths. Firefighters must wear their SCBA dur- for effective interventions to reduce Hydrogen cyanide, a toxic product of ing this overhaul phase of firefighting smoke-related toxicity. This article combustion of common nitrogen and to protect them from breathing in these describes the signs and symptoms carbon-containing substances, is likely harmful compounds. Fire departments of cyanide exposure, and discusses to be generated under the conditions must adopt a comprehensive respira- the importance of a comprehensive of high temperature and low oxygen tory protection program that mandates smoke inhalation assessment and that characterize closed-space structure the wearing and use of SCBA during all treatment protocol for improving out- fires. Research on victims of smoke phases of the fire and adheres to safe comes in smoke-associated cyanide inhalation indicates that cyanide poi- and effective air management practices. poisoning. soning may be an important agent of

15 CyaIns_FE_0608 7/17/06 9:48 AM Page 19

death, particularly for victims in manifestations include headache, breath may have an almond-like odor closed-space fires. For example, stud- anxiety, blurry vision, and loss of attributed to excretion of small ies that simulated the nightclub fire in judgment. As cyanide accumulates amounts of cyanide in the breath. Rhode Island found rapid buildup of further, signs and symptoms of poi- However, many people lack the ability heat, carbon monoxide, and cyanide soning reflect the effects of oxygen to smell this odor, so the prehospital to levels incompatible with survival. deprivation on the heart and brain. provider’s failure to detect an almond Studies in Paris have also been illumi- Later manifestations of exposure are odor does not reflect the absence of nating regarding the role of cyanide in cardiac arrhythmias, seizure, coma, cyanide poisoning. fire death. The blood cyanide levels and death. The time between exposure Even at the hospital, rapid meas- from 66 fire victims who survived and and incapacitation or death is typical- urements of cyanide are not available. 43 fire victims who died in fires in the ly minutes, but varies depending on Therefore, assessment and treatment environs of Paris were compared with the concentration of cyanide and rely primarily on clinical judgment. those from 114 control individuals other toxicants. Many toxicants affect Hospital laboratory findings that may who had not been exposed to cyanide. oxygen utilization. The presence of indicate a strong possibility of cyanide Mean blood cyanide concentrations in multiple toxicants in fire smoke can be poisoning include: both groups of fire victims substantial- particularly hazardous. ly exceeded those in the control indi- • Metabolic acidosis viduals. Cyanide concentrations in fatal- RECOGNIZING ACUTE CYANIDE • Elevated plasma lactate concen- ities were more than three times high- POISONING tions caused by the accumulation er than concentrations in smoke Currently, there is no diagnostic test to of lactic acid, a byproduct of inhalation victims who survived. confirm cyanide poisoning within the anaerobic metabolism Blood cyanide exceeded levels that are short time available for initiating • Elevated oxygen content of venous potentially lethal (i.e., 1 mg/L) in the potentially lifesaving intervention. blood caused by failure of cyanide- group of victims with fatal outcomes Transcutaneous monitors such as poisoned cells to extract oxygen but not in the group that survived. those used to detect carbon monoxide from arterial blood Co-exposure to carbon monoxide and poisoning might some day be avail- • Minimal elevation of carbon mono- cyanide was frequent. Elevated levels able to quantify the level of cyanide ide by blood tests or use of the of both compounds were found in attached to hemoglobin; however, transcutaneous monitor many victims. such an assessment tool is not currently Cyanide poisoning can be treated available. Therefore, in the prehospital It can be difficult to differentiate effectively if it is recognized promptly setting, acute cyanide poisoning must the effects of cyanide and carbon and if intervention is initiated imme- be diagnosed presumptively. Cyanide monoxide poisoning. The classic diately. In this context, it is important poisoning should be suspected in any symptoms of poisoning with each that prehospital providers recognize person exposed to smoke in a closed- agent are outlined in Tables 1 and 2. signs and symptoms of cyanide space fire. Detection of carbon monoxide poi- poisoning and have smoke inhalation The concurrent presence of soning can be accomplished with the evaluation and treatment protocols hypotension increases confidence in transcutaneous carbon monoxide in place. the diagnosis of cyanide poisoning. meter. The assessment for cyanide A few cyanide-poisoned victims have poisoning in the smoke inhalation MECHANISMS AND a pinkish to cherry-red complexion victim remains a matter of clinical MANIFESTATIONS OF caused by the (abnormal) high oxy- assessment by the astute emergency CYANIDE TOXICITY genation of venous blood. The victim’s provider. Cyanide causes human toxicity by deactivating the mechanisms allowing Table 1. Manifestations of Cyanide Poisoning cells to utilize oxygen. Because cyanide- poisoned cells are unable to use oxygen, they transition from aerobic Early Indications of Exposure to Low Inhaled Concentrations metabolism to anaerobic metabolism and generate toxic byproducts such as • Drowsiness • Headache lactic acid. The buildup of toxic • Impaired judgment • Dyspnea byproducts of anaerobic metabolism • Anxiety • Tachypnea ultimately breaks down the cell. • Vertigo • Tachycardia Organs such as the heart and brain, which rely on a substantial, continuous Inhalation of Moderate to High Concentrations supply of oxygen, are quickly affected by cyanide poisoning. • Markedly altered level • Respiratory depression or arrest Exposure to smaller concentra- of consciousness • Cardiac dysrhythmia tions can initially cause respiratory • Smell of almonds on breath • Hypotension activation (manifested by hyperpnea (sometimes undetectable) • Cardiovascular collapse and tachycardia) in an attempt to • Seizure compensate for lack of oxygen. Early

16 CyaIns_FE_0608 7/19/06 11:04 AM Page 20

management. The key elements of Table 2. Manifestations of Carbon Monoxide Poisoning evaluation include:

• Mental status Low Inhaled Concentrations • Any concurrent burn • Fatigue • Headache • Any concurrent severe or • Difficulty with balance • Palpitations critical injury • Degree of respiratory distress • Ability to oxygenate Manifestations of Exposure to Moderate to High Concentrations The patient’s airway, breathing, and • Altered level of consciousness • Seizure mental status are evaluated as part of • Severe headache • Respiratory arrest the primary assessment. Compromise • Syncope • Cardiac dysrhythmia of any of these elements makes the • Nausea and vomiting • Shock and death patient a “red category” triage victim and makes rapid treatment a priority. The patient requires support of airway, BASIC AND ADVANCED LIFE sideration, so a patient with more than breathing, and supplemental oxygen. SUPPORT FOR THE SMOKE 10% full-thickness burns, respiratory The patient that has sustained INHALATION VICTIM burns, or more than 27% partial-thick- burn injury or other severe or critical Basic life support care for the smoke ness burns are preferentially taken to traumatic injury should be given inhalation victim includes removing the adult or pediatric burn treatment treatment specific for those elements. the victim from the source of exposure; hospital. Not all hospitals are prepared In addition, the inhalation treatment providing cardiopulmonary support, and equipped to manage minor burns, protocol should be initiated. warmth, and fluids; administering moderate inhalation, and cyanide poi- A pulse oximeter reading can assist 100% oxygen; and assuring appropriate soning. When in doubt, on-line medical in the evaluation of the patient’s overall ventilation. Nebulizer treatment with control should be contacted and their ability to perfuse the body with oxygen. a bronchodilator may be given for assistance requested in determining In the presence of carbon monoxide wheezing. The suspicion of acute the correct destination hospital. inhalation, the pulse oximeter alone cyanide poisoning should prompt the can produce an incorrect reading as the prehospital provider to initiate antidote PROTOCOLS FOR PREHOSPITAL machine does not assess the percent therapy. The use of antidotes is ASSESSMENT AND TREATMENT OF of hemoglobin affected by carbon discussed in the next article written by THE SMOKE INHALATION VICTIM monoxide or cyanide. A reading below J.L.Fortin. Smoke-associated poisoning with 90% reflects ineffective breathing, Advanced life support care includes cyanide and other toxicants can rapidly direct injury to the airway or lungs, or anticonvulsants for seizures. The motor culminate in death. To ensure that severe underlying lung disease (or activity associated with seizures can smoke inhalation victims are efficiently some combination of these elements). aggravate acidosis. Victims with heart evaluated and intervention is promptly When available, the carbon monoxide disease may develop significant dys- provided, it is essential to have proto- oximeter detects the level of carbon rhythmias, so antiarrhythmics should cols in place for prehospital assessment monoxide attached to the victim’s be administered to stabilize cardiovas- and treatment of victims of smoke hemoglobin. A detector reading exceed- cular function. Shock is treated with inhalation. The following sample proto- ing 12% reflects moderate carbon fluids and prevention of hypothermia. col can be adapted to department- or monoxide inhalation, and one exceeding If the victim has indications of severe facility-specific needs and capabilities: 25% reflects severe inhalation. acidosis, sodium bicarbonate may Smoke and other toxic products be administered to reverse this state Indications cause direct irritation of the airway and improve the effectiveness of The protocol applies to the patient and lungs, and treatment should other therapies. who has been trapped or rescued from reduce this irritation. Any injury to the a closed space structure fire. The pres- airway or lungs causes impaired abili- TRANSPORTATION ence of soot in the nose and/or mouth ty to oxygenate and ventilate, and CONSIDERATIONS in the unconscious patient may be a treatment should supplement oxygen Some communities have hospitals strong indicator of cyanide poisoning. delivery and carbon dioxide removal. equipped to manage burn patients, The protocol applies regardless of and/or to provide hyperbaric oxygen whether a concurrent injury or burn is Emergency Treatment and Transportation treatment. In those communities, local present. Smoke inhalation can be a 1) Perform a primary survey to medical control protocols typically pre- dangerous medical condition requiring evaluate airway, breathing, mental scribe the transportation of victims expedient evaluation and treatment! status, and the presence of burns with burns and those with suspected or other injuries. If possible, carbon monoxide poisoning. Most Patient Evaluation obtain a history regarding the local protocols consider significant The patient should be removed to patient’s underlying heart or burns as the priority treatment con- an area safe for their evaluation and lung problems.

17 CyaIns_FE_0608 7/17/06 9:48 AM Page 21

2) Evaluate the patient’s oxygenation Place 2 ampules of albuterol in the BIBLIOGRAPHY (listed chronologically) by pulse oximeter, and listen to the cup, fill the rest of the cup with • Hall A, Rumack BH. Clinical toxicology lungs for any abnormal sounds, saline, and allow the patients to of cyanide. Ann Emerg Med. particularly wheezing. When avai- self-administer the mixture by mask. 1986;15:1067-1074. able, obtain a carbon monoxide 9) Victims with mild to moderate • Jones J, McMullen MJ, Dougherty oximeter reading. Victims with smoke inhalation may be treated J. Toxic smoke inhalation: cyanide carbon monoxide levels exceeding and released. To allow the victim to poisoning in fire victims. Am J Emerg 25% should be preferentially release himself or herself from Med. 1987;5:317-321. transported to the appropriate care, the following conditions must • Silverman SH, Purdue GF, Hunt JL, et receiving hospital. be met: al. Cyanide toxicity in burned 3) Evaluate for potential cyanide a. Mental status unimpaired or back patients. J Trauma. 1988;28:171-176. toxicity. The patient should be to baseline for that individual (with • Kulig K. Cyanide antidotes and evaluated for the presence of soot verification by a friend or family fire toxicology. N Engl J Med. in the nose or mouth, and/or an member) 1991;325:1801-1802. altered mental status, hypotension b. No signs of respiratory distress • Baud F, Barriot P, Toffis V, et al. or shock, flushed skin, and seizures. with a pulse oximeter reading Elevated blood cyanide concentrations These patients may be candidates above 92% in victims of smoke inhalation. for treatment with a cyanide antidote c. Lungs clear on auscultation N Engl J Med. 1991;325:1761-1766. Contact on-line medical control. d. No other significant burn or • Agency for Toxic Substances and 4) Treat any burn or traumatic injury. traumatic injury Disease Registry. US Department of The spine should be immobilized 10)Victims with more severe smoke Health and Human Services, Public if indicated. If there is no indication inhalation are transported to the Health Service. Cyanide toxicity. Am for immobilization, allow the victim hospital. Fam Phys. 1993;48:107-114. to find his/her position of comfort. a. For patients requiring hospital • Houeto P, Hoffman JR, Imbert M, et al. Significant inhalation will cause removal, appropriate treatment Relation of blood cyanide to plasma violent coughing and at times should occur in conjunction with

vomiting, so the victim should be the transport agency, and the Photo: Steve Redick placed in a protective position or patient should be turned over for in the position of comfort. further assessment and interventions. 5) If the airway is compromised or b. Symptoms of carbon monoxide injured, the patient should undergo poisoning require the crews to endotracheal intubation. If unsuc- consider removal of the patient to cessful, a secondary device can a hospital that has a hyperbaric be inserted. oxygen treatment capability. 6) Provide supplemental oxygen. Evidence of carbon monoxide Most victims with an inhalation poisoning includes impaired mental injury do not tolerate dry oxygen; status, neurologic compromise therefore, the oxygen line should including seizures, and a carbon have a nebulizer placed in-line with a monoxide reading over 25%. full container of saline as soon as c. Major burn injuries get precedent possible. If mental status permits, in the determination of a receiving allow the patient to self-administer facility. A significant burn injury the oxygen by holding the mask and (generally, any burn over 10% full sitting in a position of comfort. thickness, a respiratory burn, or a 7) If any wheezing is present on lung burn over 25% partial thickness) evaluation or if the patient has a requires transport to the appropriate history of asthma or wheezing, adult or pediatric burn center. administer nebulized albuterol. The nebulizer should have 2.5 mL CONCLUSIONS of Albuterol placed in it and then Both prompt recognition of acute be filled with normal saline. The cyanide poisoning and immediate patient should continue use of the initiation of care are necessary for nebulized albuterol and saline effective treatment. The fire profes- until it is dry. sional often provides the first line 8) If there are a large number of of medical care for victims of smoke- victims and an oxygen distributor associated cyanide poisoning in the manifold is available, place the prehospital setting. By recognizing victims in the same area, set up cyanide poisoning and efficiently the manifold with an appropriate initiating corrective measures according number of oxygen masks, and to protocol, the fire professional can obtain the large nebulizer cup. save lives.

18 CyaIns_FE_0608 7/17/06 9:49 AM Page 22

cyanocobalamin concentration after a fixed dose of hydroxocobalamin in ACUTE CYANIDE POISONING: cyanide poisoning. Lancet. 1995; A PARIS FIREFIGHTER RECOVERS FROM SEVERE 346:605-608. SMOKE INHALATION • Borron SW, Vicaut E, Ruttimann M, et al. Biological tolerance of hydroxocobalamin in fire victims BY J.L. FORTIN, Emergency and Intensive Care, Military Hospital Legouest, Metz, France intoxicated by cyanide. Intensive S. WAROUX, Emergency Medical Service, Fire Brigade, Paris, France Care Medicine. 1997;23:S181. A-M ARVIS, Emergency Medical Service, Fire Brigade, Paris, France • Lee-Chiong TL. Smoke inhalation JP. GIOCANTI, SAMU 25, J. Minjoz Hospital, Besançon, France injury. Postgrad Med. 1999;105:55-62. C. FUILLA, Emergency Medical Service, Fire Brigade, Paris, France • Ferrari LA, Arado MG, Giannuzzi L, D. WALSH, Medical Service, Chicago Fire Department, Chicago, USA et al. Hydrogen cyanide and carbon M. RUTTIMANN, Emergency and Intensive Care, Military Hospital Legouest, Metz, France monoxide in blood of convicted M. ECKSTEIN, Medical Service, Los Angeles Fire Department, USA dead in a polyurethane combustion: a proposition for the data analysis. Forensic Sci Int. 2001;121:140-143. • Sauer SW, Keim ME. Hydroxocobalamin: improved public health readiness for cyanide disasters. Ann Emerg Med. 2001;37:635-641. • Moriya F, Hashimoto Y. Potential for error when assessing blood cyanide concentrations in fire victims. J Forensic Sci. 2001;46:1421-1425. • Calafat AM, Stanfill SB. Rapid quantitation of cyanide in whole blood by automated headspace gas chromatography. J Chromatogr B Analyt Technol Biomed Life Sci. 2002; 772:131-137. • Alarie Y. Toxicity of fire smoke. Crit Rev Toxicol. 2002;32:259-289. • Koschel MJ. Where there’s smoke, there may be cyanide. Am J Nurs. 2002;102:39-42. • Borron SW, Baud FJ. Toxicity, cyanide. February 2003. Available at www.emedicine.com/emerg/topic11 .htm. Accessed 16 May 2006. • Mégarbane B, Delahaye A, Goldgran-Tolédano D, et al. Antidotal treatment of cyanide poisoning. J Chin Med Assoc. 2003;66:193-203. Photo: Rob Schnepp • Gill JR, Goldfeder LB, Stajic M. The happy land homicides: 87 deaths EDITORS FOREWORD due to smoke inhalation. J Forensic he following case study chronicles During the last several years, fire- Sci. 2003;48:161-163. T the exposure and subsequent treat- fighters in the United States have spent • Madrzykowski D. The Station ment of a Paris firefighter suffering countless hours on rapid-intervention Nightclub Fire: Simulation of fire from smoke inhalation. It underscores training. Today, almost every fire and smoke movement in laboratory a common exposure scenario for department in this country has incor- reconstruction. NIST, US Department firefighters the world over: getting lost porated the concept of “backing up” of Commerce. National Construction or trapped inside a structure fire and interior firefighters with a group of Safety Team Investigation. June 23, running out of air. The outcome in this rescuers outside the structure, tasked 2004. case was favorable. However, the case solely with the mission of locating and • Eckstein M, Maniscalco P. Focus on illustrates the need in the US prehospital rescuing firefighters who become Smoke Inhalation-the most common arena for a safe and effective antidote trapped, disoriented, or lost inside the cause of acute cyanide poisoning. to counteract the effects of hydrogen fire building. While the training and Prehosp Disaster Med. 2006:21: cyanide, one of the most deadly equipment used for rapid intervention s49-55. fire gases. and/or firefighter rescue helps in

19 CyaIns_FE_0608 7/17/06 9:49 AM Page 23

removing the downed firefighter from study focused on two subsets of Paris Fire Brigade. This case report the toxic environment, they do not victims: 29 patients found in cardiac describes a Paris firefighter who counteract the toxic and potentially arrest and 15 hemodynamically unsta- suffered acute cyanide poising and lethal effects of smoke inhalation. To ble patients. The patient population was treated with hydroxocobalamin that end, the medical management of ranged in age from 21 to 38 years. Of with a favorable outcome. the 29 patient sfound in cardiac arrest,

Photo: Rob Schnepp 18 recovered for a survival rate of CASE REPORT 62.1%. The average time between Prehospital phase administration of antidote and recovery A 31-year-old firefighter responded to of spontaneous cardiac activity was the scene of a store fire on January 6, 19.3 minutes. Four patients recovered 2006. The firefighter, who carried a self- without sequelae. In the subgroup of contained breathing apparatus, was 15 patients hemodynamically unstable trapped in the fire, and the air in his before the Cyanokit® was adminis- unit ran out. After some delay, he was tered, 12 patients (80%) showed found unconscious at about 11:40 AM. hemodynamic improvement, defined When he was rescued, he was seen as systemic arterial blood pressure by the doctor on board the rescue exceeding 90 mmHg. The average time ambulance at about 12:04 PM (In Paris, to hemodynamic improvement was some rescue ambulances are staffed 49.2 minutes from the beginning of by paramedics and a physician). The antidote infusion and 28.8 minutes patient was initially unconscious from the end of infusion. (Glasgow score = 3) and bradypneic smoke inhalation victims must be In France, Cyanokit® comes with (respiratory rate less than 10 per minute, more fully addressed by the American 2 vials of hydroxocobalamin (each with a blood pressure of 110/70) with fire service. This case study sheds light containing 2.5 g of red powder). The elevated blood pressure (110/70 mmHg), on possible means of improving care powder is reconstituted with 100 mL of tachycardia (120 bpm), and arterial for smoke inhalation victims. normal saline per vial, infused into the hypoxia (93% with administration of 15 The US Food and Drug patient over 15 minutes. liters oxygen/minute). The first elec- Administration is evaluating hydroxo- * Fortin J-L. Use of Hydroxocobalamin in fire trocardiogram showed no signs other cobalamin as an antidote for acute victims by “The Brigade De Sapeurs Pompiers than sinus tachycardia. There was no cyanide poisoning. Hydroxocobalamin, De Paris” from 1998-2003. Presentation at myocardial repolarization disorder. a precursor to vitamin B12, is a relatively The Second World Congress on Chemical, Initial management consisted of benign substance with minimal side Biological and Radiological Terrorism, endotracheal intubation after anesthe- effects, properties that make it well September, 2003. sia (40 mg Ethomidate and 100 mg suited for use in the prehospital setting. Celocurine injected intravenously). Its mechanism of action is simple: INTRODUCTION Endotracheal intubation revealed hydroxocobalamin binds to cyanide to In France, patients suspected of hav- massive inhalation of smoke from the form vitamin B12 (cyanocobalamin), ing acute cyanide poisoning from fire with a substantial quantity of soot a non-toxic compound excreted in sources such as smoke inhalation or in the oropharynx. Maintenance anes- the urine. ingestion of cyanide salts are treated with thesia was done with Midazolam 7 Hydroxocobalamin (Cyanokit®) is hydroxocobalamin (Cyanokit®)(1,2,3,4). mg/hour and Sufentanyl 15µg/hour. The used by the Paris (France) Fire Brigade This antidote has been used in prehos- patient was administered 10 g hydrox- as a prehospital antidote to treat pital care by various French emer- ocobalamin (Cyanokit®). The following suspected cyanide poisoning from gency medical services, particularly Table shows clinical parameters after smoke inhalation and other sources of the emergency medical service of the hydroxocobalamin administration: cyanide exposure. Cyanokit® can be administered to a smoke inhalation Clinical parameters after hydroxocobalamin administration patient without first verifying the presence of cyanide in the body and with little fear of making the patient worse. The Paris Fire Brigade routinely 12:15 PM 12:30 PM 12:40 PM 1:00 PM administers Cyanokit® to smoke Glasgow 3333 inhalation patients and has collected compelling data regarding its effec- Pulse 110 110 74 72 tiveness. From 1998 through 2002, the Blood pressure 120/80 110/70 110/60 120/80 Paris Fire Brigade retrospectively evaluated the prehospital use of SpO2 93% 96% 97% 97% hydroxocobalamin.* During this time, 81 victims (41 males and 40 females) Cyanokit® 5g 5g were treated for suspected cyanide poisoning from smoke inhalation. The

20 CyaIns_FE_0608 7/17/06 9:49 AM Page 24

Photo: Rob Schnepp CONCLUSION Thermal Burns and smoke inhalation are major occupational hazards for any firefighter. This case illustrates the importance of having an antidote on hand for rapid administration at the fire or accident scene. It is desirable for fire and emergency services to have a cyanide antidote in their pharmacopoeia. BIBLIOGRAPHY 1) J.L. FORTIN, M. RUTTIMANN, L. DOMANSKI, J.J. KOWALSKI Hydroxocobalamine Use: Experience of 81 cases from the medical emergency department “Brigade de sapeurs-pompiers de Paris” Hospital Phase No respiratory distress was observed. Fire Rescue Med International The patient was admitted to the inten- Pulmonary auscultation revealed rales Congress, Las Vegas, 26-28 April 2004 sive care unit (ICU) of the Val-de-Grâce at both bases and productive coughing 2) J.L. FORTIN, M. RUTTIMANN, L. military hospital at 1:10 PM, or 1 hour continued with blackish expectoration. DOMANSKI, J.J. KOWALSKI after the start of prehospital treat- However, the patient did not need oxygen. Hydroxocobalamine for smoke ment. When he arrived at the ICU, the The patient was apyretic with inhalation associated cyanide patient was intubated, with artificial white cells 14,000 /mm3. C-reactive poisoning: 8 years of experience in ventilation (FiO2 = 100%). Sedation protein was high at about 130. Burns the Paris Fire Brigade National with Midazolam and Sufentanyl was were dressed with Flammazine® and Association of Emergency Medical continued. Opening of the eyes and compresses. In an attempt to prevent Services Physicians, Tucson, mobility of all four limbs after pain posttraumatic stress disorder in this January 19-21, 2006 stimulation was noted. Blood pressure firefighter, a psychiatric session was 3) M. RUTTIMANN, J.L. FORTIN, was normal. A superficial second- conducted. Two days later, the patient MEURGEY F., L.DOMANSKI, J.J. degree burn of the left knee and calf was moved from the ICU to the KOWALSKI was noted. Medical Department. Gestion medicale des intoxications The first laboratory tests showed par les fumees d’incendie en milieu metabolic acidosis with pH 7.20 asso- DISCUSSION souterrain [Medical management of ciated with hypercapnia (PCO2=51.7 Early administration of hydroxocobal- smoke poisoning in an underground mmHg). There was no hypoxia: the amin, even before arrival at the setting] La revue des Samu - 2003: pO2 was 527 mm Hg (FiO2 = 100%). hospital, gave favorable results for 87-92. Carboxyhemoglobin was 7.8%. Lactates this firefighter who fell victim to 4) JL. FORTIN, M. RUTTIMANN, L. were 3 mmol/l. The initial lab tests severe cyanide intoxication from DOMANSKI, J.J. KOWALSKI showed no myocardial dysfunction smoke inhalation. Hydroxocobalamin L’utilisation pre-hospitalière de with the troponin level at 0.03. There administration was based on circum- l’hydroxocobalamine chez les was muscular rhabdomyolysis with stantial evidence of cyanide poisoning victimes d’incendie est elle efficace? elevated creatinine phosphokinase (fire, enclosed setting) and clinical [Is the prehospital use of hydroxo- (CPK = 1629 UI/l) and myoglobin at observation (coma, bradypnea). Because cobalamine in fire victims effective?] 5421 UI/l. No other lab tests were of the urgency of the situation, it was not Brûlures 2004 ; 4: 226-9 abnormal. The second electrocardio- possible to draw blood to test lactates5 5) F. BAUD,SW. BORRON, B. gram, done on arrival in the ICU, and get prehospital lab confirmation MEGARBANE et al. showed sinus rhythm with no conduc- before administering the hydroxocobal- Value of lactic acidosis in the tion or repolarization disorders. amin or subsequent lab confirmation assessment of the severity of acute The patient was given a hyperbaric by measuring blood cyanides. cyanide poisoning. Crit Care Med oxygen session at 2.5 ATA for 1 hour. This case report suggests that 2002; 30:2044-50 Bronchial fibroscopy, done after the hydroxocobalamin administration must 6) C. RENARD, J.L. FORTIN, F. BAUD hyperbaric chamber, showed substantial be rapid - done by the first aid or para- Terrorisme chimique et cyanures - inhalation of smoke with soot present medical team based on clinical or cir- Menace terroriste approche throughout the tracheobronchial tree. cumstantial criteria. Hydroxocobalamin, medicale [Chemical terrorism and On Day 2 (January 7, 2006), sedation which is a vitamin B12 derivative, has cyanides - medical approach to was withdrawn. The patient woke up no major adverse effects at the doses terrorist threat] Ed John Libbey quickly, and the breathing tube was normally in use6. The risk of acute Eurotext 2005, p353-359 removed. The level of consciousness cyanide poisoning is exceptional for a was normal (Glasgow = 15), and there firefighter and should be borne in was no sensory or motor deficit. mind by fire and emergency services.

21 CyaIns_FE_0608 7/18/06 4:39 PM Page 1

he Cyanide Poisoning Treatment Coalition is a T 501(c)(3) non-profit made up of organizations and individuals who have direct involvement with the identification and treatment of cyanide exposure. Currently, there are few resources that raise aware- ness and educate professionals about the potential danger of cyanide exposure. Through joint strategic initiatives to focus the required attention and resources on the issues, the members of the CPTC aim to increase awareness surrounding the dangers of cyanide exposure. For more information on cyanide poisoning, how to obtain a CPTC membership application or become a sponsor, please visit the Coalition website at www.cyanidepoisoning.org.

Copyright 2007 CPTC (TX 6-545-166)

EMD Pharmaceuticals is the founding sponsor of the CPTC.