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It was a dream weddingƒa lovely bride with her handsome groom, a catered affair in a beautiful ballroom, with family and friends sharing the special day. Indeed, this became an unforgettable wedding, but for the wrong reason. An uninvited guest, carbon monoxide (CO), crashed this celebration by sneaking in through the building's ventilation system. While happy guests were laughing, dancing and eating in the luxuriously appointed second-floor reception hall, an improperly vented gas water heater in the basement was sending CO into nearby air ducts, dispersing the toxic gas throughout the building.
More than two hours into the reception, the groom's mother fainted. The 9-1-1 call for an unconscious victim prompted the response of FDNY ALS and BLS ambulances and an FDNY Certified First Responder (CFR) engine company. The engine company officer's CO detector registered more than 500 ppm of CO shortly after he entered the building. He immediately ordered the evacuation of the building, had hiscrew vent the building and changed the call to a hazmat assignment. The first arrivingEMS officer declared a mass casualty incident (MCI) and recognized the potential for several patients and the need to measure blood gases of all occupants in the building.
The groom's mother, a 42-year-old female, had a COHb reading of 10%, which, inconjunction with her loss of consciousness, elevated her risk for later developing neurologicsequelae. She was quickly transported, along with a 42-year-old male experiencing supraventricular tachycardia, shortness of breath,pedal edema, dizziness and nausea.
During the initial stage of this MCI, fire department and EMS officers workedcollaboratively, utilizingEMS and CFR companies to treat the patients. As the number of patients began to rise, other resources were deployed. The Logistical Supply Unit (LSU) stationed in theBorough of Queens arrived on scene within minutes of the first ambulances and set up twomultilators, each of which provided oxygen therapy to eight patients at a time.
The FDNY EMS Mobile Respiratory Therapy Unit (MRTU) arrived a short time later. The MRTU has 34 oxygen ports and is capable of delivering high-concentrationoxygen at each position for extended periods without replacing the onboard cylinders. For prolonged MCIs, the oxygen cylinders can be replaced as necessary without interrupting the oxygen supply.
The MRTU also served as warm shelter from the cold evening air as FDNY EMTs assessed and obtained COHb readings from 41 patients, utilizing handheldMasimo Rad-57 monitors.
COHb levels from 1Ï28% were present in the patients assessed. Interestingly, some of the patients presented with high COHb readings but no obvious signs of distress or CO poisoning, with onlyminor or no complaints of nausea. FDNY's protocol calls for all patients with COHb readings at and above 10% as requiring transport to the hospital.
In addition to these patients, there were a few others of obvious concern: two infants and several elderly patients with cardiac histories. Patients with underlying medical conditions, at the extremes of age or pregnant, were targeted for additional assessment, because their initial symptoms were alleviated by rapid evacuation and aggressive oxygen therapy.
Some of the patients with very low CO levels seemed to suffer more acutely from their exposure than those with higher readings.Acute symptoms relate to pre-exposure cardiovascular health and often to increased minute ventilation during the exposure. This commonly occurs from exercise (such as dancing) or the inherent increased minute volume of the young child and infant. Despite increased readings, a young, physically fit adult may have minimal symptoms.
Following evacuation, all patients received high-flow oxygen therapy via a non-rebreather mask to facilitate CO elimination and increase the amount of oxygen dissolved in the blood, promoting oxygenation of the tissues.
Treatment with high-flow oxygen was continued through transport for 28 patients taken to six different hospitals in Queens andManhattan. The remaining 13 patients refused transport following treatment and none had readings above 3% COHb when released with instructions to seek further medical care.
Carbon monoxide, known as the "silent killer," is the leading cause of poisoning death in theU.S., with more than 6,000 victims each year. Due to the coordinated response of FDNY and FDNY EMS, tragedy wasavoided for the bride and groom, as well as their wedding celebrants.
Deputy Chief Ann Fitton is a 24-year paramedic veteran of EMS inNew York City and is currently assigned to FDNY EMS field operations. Ann holds extensive credentials in EMS education and has published research in pediatric resuscitation andEMS educational methodologies. Contact her firstname.lastname@example.org.