The Bergen County Fire Chiefs Association is hosting a Smoke Symposium on November 6, 2010.

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At a recent incident 2 City firefighters were taken to Lakeland Hospital with the possibility of Hydrogen Cyanide (HCN) exposure.  A policy was in place to avoid this issue which was not followed.  One of the reasons I’m sure was the size of the fire. We were on the smallest kitchen fire you could ever have.  Very little smoke and the fire only left the stove and exposed the cabinet directly above.  I don’t even think the ceiling was sooted up.   It was one of those fires that we would have had cleaned up and been back at the station in a few minutes in days past.   With that established we have been running a HCN detector with Niles Township for close to a year.  We typically run the unit though with a CO monitor after knockdown to make sure air quality is good enough to remove our masks.  In this case we found High levels of CO over 100 ppm and HCN near 50 ppm in the building.  With the IDLH of HCN being around 4 and the fire being out for 10-15 minutes already you can see where we were confused.  We already had a Gas Powered Honda PPV fan in the front door ventilating so we gave it more time and sent a few guys in packs to the second floor to begin to strategically open windows.  The two guys who had been on initial attack and following had removed their masks were seeing all this from outside and reported feeling a little nauseous.  They were checked out by SMCAS and as a precaution transported to Lakeland to be checked out.  Again there was absolutely no visible smo ke in the structure at the time they removed their masks.  They were later released with no ill effects. We learned while still on the scene that when the fan was started in this case the choke was left partially on.  You couldn’t tell as the fan was not sputtering and appeared to be running normally.  With the readings not really coming down with close to 30 minutes of continuous ventilation already under our belt, we decided to put one of our electrical fans in the doorway in a PPV configuration to see if we could get the property ventilated.  The levels slowly began to go down on the first and second floor but we were still finding pockets of higher readings.  I opened up a small bathroom that had been closed from the start and got a quick reading of over 20 ppm.  This home approximately of 2500 square feet had a basement with a secondary stair with Bilco doors.   This door had been opened early on yet the door to the basement had been closed.  As everyone who has vented a house knows this didn&rsq uo;t let air from either operation push into the basement.  We were still getting readings of HCN near 40 ppm down there.  Once we made sure that we had the door open and an exhaust from the basement it took around 10 minutes to get the area  totally cleared out allowing us to clear the scene.  This would have been one of those events that we would have cleared in 20 minutes and gave back to the family to occupy prior to using our HCN Detector. 

As you can expect we had a lot of questions resulting from this call.  To try to get a better idea of what had happened we took our fan down to our training building to run a few tests.  First, we took readings of both CO and HCN and got 0’s.  We then ran the fan in a PPV configuration into the space at full throttle for 15 minutes and took readings.  We got really no readings on HCN and 17 ppm on the CO meter.   We then ran the same fan at about half choke at full throttle for 15 minutes.  Following this time we took a second set of readings.  The HCN was up to 21, which is 5 times the IDLH number and the CO was at 96 which is also above what is acceptable for any length of time.   Our monitors were located approximately 15 feet inside the multi room structure, one room past the room the fans were directly charging.  We had one window open at the back side of the space with good air f low from the vent. 

In closing I have been doing this job for over 25 years.  I have choked on my fair share of smoke over that time.  I was even taught to breath off the nozzle in my early years.   Since we began using this detector it has really opened my eyes to the prevalence and pervasiveness of this gas.  It doesn’t seem to be very predictable to date.  All I can tell you is that we have been breathing it more than we thought over the years. 

  Wear Your Air & Use It! 

Last night we had a fire in a warehouse full of welders, cardboard and rubber hose.  Literally tons of hose.  The fire went defensive early.  The fire was in the early evening hours and a temperature inversion and increasing relative humidity caused the smoke from the fire to lay low in the area.  We immediately put our monitoring devices to work and discovered readings as high as 26ppm of HCN around the exterior of the structure.  Fortunately our safety officers had those working in or near the smoke plume “on air.”  As the inversion settled even more the plume began to move across a major portion of the city.  Out hazmat team deployed their “area Raes” to determine if there was any HCN or other toxics.  Those readings were negative.  Only the smell of burning rubber. 

I used my knowledge from the CPTC to ensure that we kept our firefighters safe as well as the community.  Keep up the good work.  Our culture here at the PFA is very in tune to what the CPTC is doing and we definitely have a culture of wearing our air.  

Have the Courage to be Safe!

Tom DeMint

Battalion Chief

Poudre Fire Authority

According to news accounts, 33 firefighters were treated or hospitalized for smoke inhalation during the month of July, for a total of 156 firefighters treated or hospitalized for smoke inhalation since January 1.  As of July 30, 2010 first responders treated or transported 1179 civilians for smoke inhalation and 450 civilians died from smoke inhalation.

The CPTC and the Wayne Township FD will host a two-day Smoke Symposium October 16-17, 2010 in Indianapolis, Indiana.  The session includes one day of classroom and one day of hands-on training. 

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Masimo has identified very strong Federal Funding for Fire and EMS agencies with a total population (based on latest Census Data) of 20,000 or less.

If you are in a district with less than 20,000 and are nterested in funding RAD 57 CO Oximeters contact information is below.  This program requires minimal effort for the department and in most cases matching funds will be small.  

This program is currently open and is funded on a first come, first serve basis.  The good news is that you find out rather quickly whether you are funded, unlike the AFG where the waiting period is approx 9-13 months. The other good part regarding this grant is that it has twice the amount of dollars this year versus 2009.

Rural, Tribal or communities with lower overall income based on population and revenue will have the highest chance of success with this grant.  If you are interested in Masimo's assistance with this program, please contact pmullins@masimo.com.

The CPTC is exhibiting at the Indiana Emergency Response conference in Indianapolis August 12-13 and also at Rescue International August 27-28.  During both conferences the CPTC will offer lifetime memberships for $25.00 - one-half the cost of the current membership fee.  Those who join during the conference will be entered into a drawing for a ToxiRAE II single gas HCN monitor (the drawing will take place in Chicago on August 28).  This is an excellent opportunity for departments exploring HCN monitoring to start the process absolutely FREE!  Membership benfefits include access to the CPTC Training Room, the latest research relative to the toxic smoke environment, and immediate access to fire service and medical experts to assist departments with developing air management and medical protocols.  

Stop by and see us!   

Submitted by Capt. Jason Krusen, Columbia SCFD: 

We ran this call today (8/6/2010):

Do not be fooled by complacency or bad habits.  No matter how much smoke there is -  it is dangerous.  The photos were taken at small kitchen fire that was actually extinguished before the arrival of the first due units.  An elderly occupant that was unable to escape the structure was trapped on the second division in a bedroom.  The ladder company quickly threw a ladder to the second division and brought the occupant down the ladder.  The moderate smoke condition was ventilated and readings were taken using the HCN meter.  At the time metering began the first division had a fair amount of natural ventilation that had occurred, so readings did not exceed 7ppm which is just about the department's action level of 5ppm.  The second division saw higher numbers that were as high as 22ppm.  These readings were taken once the fans were started and after natural ventilation had a chance to remove some of the smoke.  Imagine what the levels were while the elderly occupant was waiting to be rescued.  By looking at the photos it is hard to imagine numbers this high.  This is only stresses the importance of utilizing SCBA and monitoring before removing it. Do not commit into the dangerous smoke filled environment because it doesn't look that bad, because looks are deceiving.

J.C. Sipes,

 I think we all fell your pain.  Just like trying to teach a new skill to seasoned paramedics.  Seasoned Firefighters have done it that way so long there is no other way.  Overhaul is probably the time FF's get exposded the most and over the longest time period.  Most FF's write off mild exposures to CO and HCN to fatigue and being under conditioned.  I spent the past year reviewing signs and symptoms of HCN exposure and CO.  Some of our department of over 1000 career and volunteers are getting it.  We do have the Cyanokits available on 4 Rescue units.  In our area only 1 hospital out of 12 has the Cyanokit.  The ER physician still do not regularly consult with a toxicologist for FF post exposure.  That is another topic all together.  Our plan is contiuned education and focus on retaining SCBA until the job is completed including overhaul.

Press Release from FDA 

For Immediate Release: July 22, 2010
Media Inquiries: Elaine Gansz Bobo, 301-796-7567, elaine.bobo@fda.hhs.gov
Consumer Inquiries: 888-INFO-FDA

Federal Government Seizes Cyanide Antidote Kits from California Company
FDA says Keystone kits are unapproved new drugs, and have not been proven safe and effective

At the request of the U.S. Food and Drug Administration, U.S. Marshals today seized $39,000 worth of products labeled as cyanide antidote kits from Keystone Pharmaceuticals in Laguna Hills, California. The seizure warrant was issued by the U.S. District Court for the Central District of California.

Marketed for use in cases of cyanide poisoning, Keystone distributes the kits primarily to hospitals in the United States and Canada. The products contain a Sodium Thiosulfate injection and a Sodium Nitrite injection in vials, along with components such as needles, tubing, and a syringe.

Most commonly, cyanide exposure occurs through inhaling smoke in residential fires, or through inhaling cyanide fumes during industrial accidents.

The cyanide antidote kits distributed by Keystone are unapproved new drugs under the Federal Food, Drug and Cosmetic Act and are therefore not permitted to be introduced into interstate commerce. The products have not been proven safe and effective for their intended use. 

The kits also are misbranded because their labeling does not contain adequate directions for their use. Additionally, the seized products are adulterated because they were manufactured under conditions not in compliance with current Good Manufacturing Practice (cGMP) to assure that they meet the identity, quality, and purity standards they claim to possess.

“The FDA is taking this action because Keystone has refused to take these unapproved products off the market,” said Michael Chappell, the FDA’s acting associate commissioner for regulatory affairs. “This action is a significant step in protecting the public health.”

In October 2008, the FDA issued a warning letter to Keystone’s contract manufacturer, PrimaPharm of San Diego. That letter identified numerous cGMP violations and informed PrimaPharm that the Keystone Sodium Thiosulfate Injection and the Keystone Sodium Nitrite Injection were unapproved new drugs. The FDA also twice warned Keystone verbally that it should not distribute the unapproved drugs in the cyanide antidote kits.

After an FDA inspection of PrimaPharm between August and September 2009 found continuing cGMP violations, the contract manufacturer said it would no longer accept orders from Keystone to manufacture the injections or kits.

An FDA inspection of Keystone between September and October 2009 revealed that the firm had continued to distribute the unapproved drugs in the cyanide antidote kits still in inventory and did not intend to stop. Keystone was given numerous opportunities to come into compliance, but the company failed to cease distributing the unapproved new drugs.

The FDA advises hospitals or organizations that purchased these products to return the unapproved products to Keystone.

To date, the agency has not received reports of adverse reactions linked to the Keystone cyanide antidote products.

• FDA Warning Letter
• FDA Inspections, Compliance Enforcement, and Criminal Investigations

Patient Number 1
58 year-old male
No medical history other than smoking
No shortness of breath but occasional coughing
Face covered with heavy black soot
No other injury noted
Vitals:  160/90, pulse 100, respiration 20
Pulse Ox- 97%,  RAD 57 CO of 12%
Treatment:  Oxygen via mask, IV Re-seal.
Administered 5G of Hydroxocobalamin
Transported to Helen Ellis Hospital, Tarpon Springs

Patient Number 2
57 year-old female
No medical history other than smoking
No shortness of breath but occasional coughing
Some mild confusion
Face covered with heavy black soot
First and second degree burns to right hand and wrist
Hair around her face significantly burned
No other injury noted
Vitals:  140/96, pulse 90, respiration 20
Pulse Ox- 99%, RAD 57 CO of 18%
Treatment:  Oxygen via mask, IV Re-seal x two.
Administered 5G of Hydroxocobalamin
Administered Morphine for pain management   of burns
Transported to Helen Ellis Hospital, Tarpon Springs

According to news accounts, between April 1 and June 1, 69 firefighters were reported as transported for treatment of smoke inhalation.  Since January 1, firefighters have transported or treated 1,609 civilians for smoke inhalation; 415 civilians have died from smoke inhalation and 123 firefighters have been transported for smoke inhalation. 

Whispering Palms Incident  

Suicide attempt by Hibachi

On Monday June 7th, 2010 units responded to Whispering Palms Apartments located at 13211 Wilcox Rd in Largo, Florida.  This was a request from LPD for a male patient with possible carbon monoxide inhalation. LPD requested a down-graded response.

This apartment building is two-story residential, classified as unprotected ordinary construction. Basically, a concrete foundation with wood-frame walls. The estimated area for the entire building is 12,000 square feet. Very typical of apartments in our City, the building contained 8 units. Two units upstairs and two downstairs, with a breeze-way separating the living units into 4 on each side. The incident occurred in the upstairs apartment.

The Lieutenant reports finding a male patient who has tried to commit suicide at approximately 0800 hrs. He lit a small hibachi grill in the bathroom of his apartment.  (The patient reports he got the idea off the internet).  However, at approximately 0900 hrs., he got scared and called friends. The following is an excerpt from the Lt's IDLH report:

Engine 39 responded emergency and arrived on the scene of a 2-story apartment building. The victim, along with 2 friends, was found inside. E39 immediately initiated air monitoring with the 4-gas monitor and obtained gas levels of zero, and an O2 level of 20.9. E39 crew simultaneously began treatment of the male patient. The charcoal grill had been moved by the patient, prior to everyone's arrival, to a small outside porch, it was still smoldering. Natural ventilation was also initiated.

The friends on the scene reported that it took them some time to get to the patients home, stating they arrived around 1100 hrs. The friend noted it was hard for her to breathe inside the apartment, so they convinced the patient to leave the building with them. They actually left the premises and returned.

The suicidal male patient may have had an approximate exposure time of 5 hours. The involved bathroom was stark white and showed no heat signatures or signs of extension.  He was treated and transported to a local hospital.  The patient was given full ALS treatment, including administration of the Cyanokit due to secondary events, patient appearance, behavior and length of exposure. 

Extensive air monitoring of all units in the vicinity was conducted.  CO levels were found in the downstairs apartment and the downstairs adjacent apartment.  All occupants were evacuated and 4 additional patients were evaluated and released.  

59 y/o male sat in the house several hours with the grill.  He called a friend and told her he wanted to kill himself.   She got him to leave the apartment for a while and talk.  They returned to the apartment and the friend became ill  from the toxins in the air.

The patient had poor skin color
Vitals 170/100 
90 HR
Odd behavior
Denies CP or SOB
GCS 15
CO level from Rad 57     4
O2 Sat 99%

Treatment:
O2, 12, lead, Rad 57, IV and Cyanokit 2.5mg.  The hospital elected not to give the second dose (2.5mg)

Bystander (Friend of patient who sat in the apartment with him)
She complained of

Head ache
Agitation
Vitals 168/110
92 Hr
98 O2 sat
Rad 57  5
(no history of hypertension)

She agreed to go to the hospital by POV

3 other patients evaluated (residents of the apartment below)
All person without complaints/signed refusals

Submitted by:

Chief Otto Sandelben

Chief Shelby Willis

Health and Safety Officers for Largo Fire Rescue

Largo, Florida

Cyanide Poisoning Treatment Coalition Awarded $394,000 Department of Homeland Security Grant to Protect Firefighters from Hydrogen Cyanide in Modern Day Fire Smoke

Indianapolis – July 1, 2010 –   Since January 1, 2010 the CPTC has tracked 1,100 civilians treated for smoke inhalation, 413 smoke inhalation deaths, and 125 firefighters who were transported for smoke inhalation treatment. Contrary to popular belief, whether a civilian or a firefighter, smoke inhalation isn’t a minor injury – it’s deadly.

Annually thousands of civilians die from smoke inhalation because they don’t wear air masks to prevent smoke exposure from a fire they never thought would strike.  On the other hand, firefighters are exposed to smoke by profession – not accidentally.  According to Kevin Reilly, president of the CPTC and Ridgewood NJ firefighter, “Firefighters have self contained breathing apparatus (SCBA) to prevent smoke inhalation, but many firefighters don’t use air when they should, and are therefore exposed to what we call, The Toxic Twins, CO and HCN, which work synergistically to kill.” 

Acute and chronic smoke exposure caused by firefighters not wearing and using air is more than likely the cause of heart attacks, diseases and illnesses which now plague the profession.  In a message to fire service leaders Capt. Mike Gagliano, Seattle Fire Department said, “I can think of no greater hypocrisy than fire service leaders berating politicians for not caring about firefighters until one of us dies, while exhibiting the exact same behavior when they look the other way and ignore shoddy air management practices in the hope that nothing goes wrong inside the fire.  Hope is not a plan.  Air management is.”

Fire smoke myths and misunderstandings will also be corrected. “I recently heard a firefighter state that smoke color is indicative of the presence of hydrogen cyanide,” said Rob Schnepp, Chief of Special Operations for the Alamenda County (CA) Fire Department.  “That is absolutely not true.  HCN and CO are colorless gases.  The last thing we need in the fire service is misinformation. Determining whether HCN is or is not present on the fireground cannot be based on the color of smoke.  This training program guarantees firefighters will receive accurate research and information from qualified and respected HCN and fire industry experts,” said Schnepp.

First responders will also learn about the Cyanokit™ or Hydroxocobalamin, an effective and safe antidote for acute cyanide poisoning from fire smoke. In fact, it has saved the lives of several firefighters and civilians in the last two years. “Clearly, this will be the most comprehensive live saving and behavior changing HCN training program that exists.  In addition, as more first responders learn how to treat smoke inhalation with the Cyanokit™, we anticipate a reduction in the number of civilian smoke inhalation deaths,” said Shawn Longerich, executive director.   The program will officially launch at FDIC in March, 2011.

Dr. Alan Hall addresses the question relative to HCN and the thyroid:

"There are basically two scenarios here.  If the body has enough sulfane sulfur available for endogenous rhodanese cyanide detoxicification, this produces thiocyanate.  Thiocyanate looks to the thyroid like iodine (due to the similarities in physical-chemical properties), so the thryoid takes it up and tries to make thyroid hormones out of it.  Naturally, this doesn't work and results in hypothyroidism, and the hormonal feedback loops when hypothyroidism is present cause the thyroid gland to enlarge as it would in patients with dietary iodine deficiency."

Can smoke color be an indicator for high level of toxins?

Absolutely NOT.  According to Dr. Alan Hall, world renowned for his research, knowledge and expertise on the topic of HCN and other toxins:

"As both CO gas and HCN in the vapor phase are colorless, the color of the smoke is of no use whatsoever in determining whether or not dangerous levels of either toxicant are present.  The more dense the smoke, most likely the greater concentration of soot, but I think you can't say more than that."