smoke education supplement august 2006

8/14/2019 SMOKE Education Supplement August 2006

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PERCEPTIONS, MYTHS, AND MISUNDERSTANDINGSSMOKE

Photo: Steve Redick

Educational Supplement sponsored by theCyanide Poisoning Treatment Coalition


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REVOLUTION: a drastic and far-reachingchange in thinking and behavior.

Americans are, by and large,assaulted with a steady stream of so-called revolutions. Theres been noshortage of fitness and dietary revolu-tions over the years, each one offering unbelievable results with a money back guarantee. The ongoing technol-ogy revolution has promised increasedproductivity and more free time, whilethe computerized banking industry has almost rendered cash obsolete. And while each of these examples hashad an impact on daily life, they appearto be more evolutionary than revolu-tionary. Its gotten to the point whererevolution has become synonymous with benign terms like change, devel-opment, or progress. Unfortunately,such common usage of the term has watered down its meaning.

In reality, true revolutions areanything but benign.

Revolutions are fueled by a new way of thinking, risk taking, and thecourage to do things completely dif-ferently. Something the American fireservice is not entirely comfortable with. This is not to say that the fireservice is backward or unable toembrace new ideas. It is however,accurately characterized as 200 yearsof tradition unimpeded by progress.

Why all the talk of revolution?Because the fire service is on the eve

of one. A far-reaching and possibly tumultuous revolution that will chal-lenge everything we thought we knew about smoke - the constant companionof the firefighter.

Research conducted over the yearshas proven that smoke is bad - we allknow that. We all know that smokekills more people than flames and thatbreathing smoke isnt good. So why do we still go to fires and not wear ourSCBA? And Im not talking about wear-ing the tank with the mask dangling around your neck. After the fire isknocked down, why is it that firefightersdrop their SCBA and perform overhaul

in the smoldering debris, breathing allthose products of incomplete com-bustions? Why do we put so much effortinto rapid intervention teams, when thecurrent method of medically treating someone after the rescue is largely ineffective? Weve figured out a better way to rescue our own, but have not com-pleted the loop by providing an effectiveantidote to correct a potential cause of death in smoke inhalation victims -cyanide poisoning. Typically, whensomeone dies in a fire, its attributed tothe nebulous cause of smoke inhala-tion. In truth, its more complicatedthan that - we just havent been looking at it the right way. We havent really digest-ed the combustion chemistry to truly understand why the smoke is so nasty.Understanding the basics of combustionchemistry is the first step towardgaining a new respect for an old foe.

Its fitting that this smoke revolutionfinds its roots in a busy fire departmentlike Providence, Rhode Island - a key player in the American Revolution. Inthis supplement, Chief of DepartmentDavid Costa provides a detaileddescription of a series of fire incidentsthat are emerging as a shot heardround the world for the fire service.He describes an investigation thatreached an unexpected conclusion: alarge number of his firefighters wereexposed to cyanide - from the smoke -after fighting a series of structure fires.These firefighters were operating at the

same kind of fires occurring every day in each and every part of this country -the typical residential structure fire.

I encourage you to read aboutChief Costas journey. A journey thatevery Fire Chief hopes to avoid - onethat ends with a visit to a firefightersspouse, telling them that their lovedone has been injured on the job.

I hope youll take the time to readthe articles following Chief Costasforeword. Youll learn about combus-tion chemistry, better ways to manage your air while fighting fire, the signsand symptoms of smoke inhalation,and why current methods of treating

smoke inhalation victims may be futile.The last piece, written by Dr. Jean-LucFortin, offers a look inside a successfulresuscitation of a firefighter in Paris,France. The firefighter, overcome by smoke after getting lost inside a structurefire, is alive and well today because of aggressive pre-hospital care and anantidote for cyanide poisoning.

The bottom line is this - the fireservice needs to become better educatedabout smoke. Hopefully, an increasedlevel of knowledge will reinforce theimportance of respiratory protection onthe fireground, and the need to prop-erly manage your air supply. Its betterto avoid getting into trouble thanrelying on a rapid intervention team tocome in and find you! Unfortunately, alow air emergency does not come witha money back guarantee.

Smoke has become such a constantcompanion for us that we may havelost respect for it. According to Chief Costa, his department was shocked by the cyanide exposures. We haventcome up with a firm grasp of what willbe different, he says. Its too early totell. There is, however, a lot of lively discussion going on around thefirehouse coffee table.

And thats what we need to betterappreciate the immediate and long terms effects of breathing smoke - alively discussion. We also need a drasticmodification of our attitude towardsmoke. Most of all, its important to

keep an open mind about the researchand data presented here. You mightdiscover some solutions on the follow-ing pages, but more than anything, Ihope it raises some questions.

Rob Schnepp is the Chief of EMS and SpecialOperations for the Alameda County (CA) FireDepartment. He is the primary author of a textbook entitled Hazardous Materials:Regulations, Response & Site Operations,by Delmar Publishing, and is on the editorialadvisory board for Fire Engineering magazine.Rob is a member of the NFPA TechnicalCommittee on Hazardous Materials Response.

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READING SMOKE IS ONE THING - BREATHING ITIS COMPLETELY DIFFERENT

BY ROB SCHNEPP, Supplement Editor


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March 23, 2006 began like most daysin the City of Providence. I started theday by attending several meetingsdealing with the administrative issuesthat every chief of a fire departmentencounters. I did not know that thenext 24 hours would trigger a series of incidents that would thrust me into

the forefront of a nationwide debateover the testing and treatment of smoke inhalation victims and air man-agement at fireground operations.

The Providence Fire Department isa fully paid fire department with a uni-formed strength of 469 personnel. Weprotect the capital city of Rhode Island, which has a population of 173,618 in a20-square-mile area. The populationswells to approximately 300,000 onbusiness days.

At 10:31 AM on March 23, fire com-panies were dispatched to a structurefire in the south end of the city. They found a one-story restaurant with fireblazing from the cooking equipmentinto a concealed ceiling space and far-ther into a five-foot overhanging facadethat lined the exterior of the building at the roofline. Most of the suppressioneffort focused on an exterior attack in which firefighters used their air packsintermittently while opening the sof-fits to get at the bulk of the fire. Theoperations appeared routine, and firecompanies returned in service by 12:05PM. At 2:15 PM, one firefighter thatoperated at the fire was transported toRhode Island Hospital when he begantalking incoherently and experienceda headache, dizziness, shortness of breath, and coughing.

At 5:35 PM the same day, fire com-panies responded to a fire in a six-unitapartment building. The fire started ina rear bedroom of an apartment on thefirst floor. The fire was brought undercontrol at 6:07 PM, and no injuries were reported.

About 5:45 PM, I received a telephonecall at home from a dispatcher saying that a member that operated at therestaurant fire earlier in the day was atRhode Island Hospital and had beendiagnosed with high levels of cyanide in

his blood. The firefighter had receivedthe standard cyanide antidote kit.Having consulted with the fire-

fighter and his doctor, I decided thatevery firefighter who responded to therestaurant fire should be instructed toseek medical treatment if they experi-enced symptoms possibly indicative of cyanide poisoning. Sixteen firefighterssought medical treatment; 4 of the 16 were confirmed to have high levels of cyanide in their blood.

As I discussed the situation further with doctors, my officers, and fellow firefighters, there did not seem to be aclear answer to what could have

caused these poisonings, which wereunexpected for us. The feeling was thatthis must be an isolated incident andthat something unusual must havebeen present at the restaurant fire.

At approximately 2:30 AM on March24, 2006, I received a telephone call froma dispatcher that one of our firefighterscollapsed at the scene of a house fireand that cardiopulmonary resuscitation(CPR) was under way. The firefighter wastransported to Rhode Island Hospital, where he was successfully resuscitated. While treatment continued in theemergency room, a test for cyanideexposure was conducted. The testconfirmed that the firefighter had ahigh level of cyanide in his blood. Thestandard antidote was administered.

Having learned that we had positivetests for cyanide exposure at twoseparate incidents, we issued a directivethat every firefighter who respondedto any of the three structure fires in thepast 16 hours should be contacted.They were instructed to seek medicaltreatment if they experienced any

symptoms of cyanide poisoning.Including the initial 16 firefighters whoreceived medical attention, 28 soughtevaluation and treatment. Cyanideexposure was confirmed in 27 firefight-ers, 8 of whom were identified as having

high levels of cyanide in their blood.Exposure to cyanide from theproducts of combustion is much moreprevalent than many in the fire serviceare aware. A graduate of the ExecutiveFire Officer Program at the NationalFire Academy with a Bachelors Degreein Fire Science, I was disturbed that I was not aware that cyanide is pervasivein fire smoke. While every firefighter istaught the basic information about thedangers related to hydrogen cyanide

and other products of combustion, thedepth of our understanding pales incomparison to the information availablein medical journals.

Following the cyanide exposureincidents, I requested a Health HazardEvaluation by the National Instituteof Occupational Safety and Health(NIOSH), and I appointed a five-mem-ber team of fire department personnelto investigate fully the cause of ourfirefighters exposure. The fire depart-ment report has been issued, and Iexpect NIOSH to issue their report sometime in the fall. The recommendationsfrom the fire department investigationteam include awareness training forfirefighters and the medical community;deployment of cyanide detectionequipment; enhanced compliance withexisting mandatory mask regulations;physical training with self containedbreathing apparatus (SCBA); immediatedeployment of an Air Supply Unit toaid in air management; additionalcommand support for accountability and incident management; routinetesting for cyanide in smoke inhalationvictims; and additional research.

The fire service has seen dramatictechnological advances and has gained

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FOREWORDDAVID D. COSTAChief of Department Providence Rhode Island Fire Department

The cyanide exposure incidents have brought aharsh reality to our department about the realdangers of our profession.


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incredible experience since I joinedthe fire service 30 years ago. Examples

include new and improved air packs,PASS devices, thermal imaging cameras,and the Fire Service Joint LaborManagement Wellness/Fitness Initiative.But do we take full advantage of theknowledge we have gained throughoutthe years to protect ourselves? Whatare the real ramifications and true costof our injuries?

Besides monetary costs such asmedical bills, overtime costs due tolost time, and pension costs for dis-ability, there are the pain and traumato the injured firefighters. There is alsoa cost to the firefighters family. Whatare the emotional scars that a spouse,a child, or a parent is left with when they live through their loved ones injury? Ihope I never have to inform anotherfirefighters spouse that a loved one isin grave condition because of smokeexposure or another job-related injury.

The cyanide-exposure incidentshave awakened our department to theharsh 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 promotesafety for every firefighter. This educa-tional supplement was developed toeducate the fire service on a deadly toxicant in fire smoke that has gonerelatively undetected and certainly unreported. I encourage every firefight-er to pass along the information in thissupplement and read the full report of the Investigation Committee into theCyanide Poisonings of ProvidenceFirefighters, available online athttp://www.rifirechiefs.com/ .

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Firefighters needto understand

and know thattodays fire smokeis more dangerousthen ever.


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Some parts of this manuscript were takenfrom the publication Cyanide, a UbiquitousProduct of Combustion in Modern Fires(DW Walsh), which appeared in fireEMS inMay 2005.

INTRODUCTION

A re American firefighters being poisoned unknowingly during the

performance of their fire suppressionand rescue duties? Recent findingssuggest that firefighters may in factfrequently be exposed, sometimesunknowingly, to a dangerous toxicant:cyanide.

How many times have firefightersseen their colleagues on building roofsventilating in heavy smoke or perform-ing overhaul functions in smoldering fire debris without self-contained

breathing apparati (SCBA)? The fact isthat firefighters perform unprotectedfireground operations all the time.Many fire departmental standards

inadvertently allow for these practices.NFPA 1404, Standard for Fire Service Respiratory Protection Training ,1 andNFPA 1500, Standard on Fire Department Occupational Safety and Health Program ,2 establish standards for pro-tecting firefighters when fire smokeand hazardous materials are present.However, the American fire servicestill allow firefighters to perform venti-lation and overhaul activities withoutSCBA or appropriate protection.

Current scientific research isprompting the American fire serviceleaders to look much more closely at allowable practices. In addition, fireservice experts are further asking fornew, stronger fireground air-manage-ment standards to protect firefighters.

Research in Sweden has identified

specific building materials that arevery dangerous when burning andproducing fire smoke. 3-5 In a study by the Swedish National Testing and

Research Institute (SNTRI), scientistsidentified fiberglass-based materialsas producing some of the highestlevels of cyanide in fire smoke. Useof fiberglass insulation in Americanbuilding construction is much highertoday than 30 years ago. Many firedepartments tactical overhaul andextinguishing operations have notbeen updated to address theseand other changes that make smokeincreasingly dangerous. For theirhealth and safety, firefighters need tounderstand that todays fire smokeis more dangerous then ever. Thedays of the smoke-eater cultureneeds to end.

THE PROVIDENCE

FIREFIGHTERS POISONING A recent case of cyanide poisoning of a firefighter occurred in early 2006during a structural house fire inProvidence, Rhode Island. 6,7 During thefire, a firefighter collapsed into cardiacarrest while operating the enginepumps outside the fire building. Thefirefighter of Engine 6 was resuscitatedat Rhode Island Hospital and wasfound to have hydrogen cyanide in hisblood. The firefighter had no memory of the fire.

Following the fire, the fire chief had the poisoning investigated. Ninety-one of the departments firefighters

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HYDROGEN CYANIDEIN FIRE SMOKE:AN UNRECOGNIZED THREAT TO THE AMERICAN FIREFIGHTER

BY DONALD W. WALSH, PhD, EMT-P President Cyanide Poisoning Treatment Coalition (CPTC) Assistant Deputy Fire Commissioner, Chicago Fire Department, Chicago, Illinois

P h

o t o:

S t ev eR

e d i c k

P h

o t o: T i m O l k


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responded to three fires in March of 2006. Of those 91, 28 sought medicaltreatment, and 27 had their blood testedfor cyanide. Eight of the firefighters,including the firefighter from Engine6, had high levels of cyanide in theirblood. The fire chief assembled a spe-cial task force to investigate the impactof cyanide in fire smoke. The task forceconcurred with experts who haveconcluded that hydrogen cyanide is amuch more significant threat to fire-fighters than previously understood:It would appear that the ProvidenceFire Department and Rhode IslandHospital may have run into the tip of avery large iceberg, 6 the task forcereport indicates.

The task force made 16 recom-

mendations to protect firefighters andcivilians from fire smoke producing cyanide. The recommendations includ-ed educating firefighters about how fire smoke can produce high, deadly levels of hydrogen cyanide and how fastfire smoke can quickly incapacitatesomeone trying to escape a fire; edu-cating the medical community toroutinely test smoke inhalation victimsfor cyanide; establishing and support-ing quick federal approval of safecyanide antidotes (hydroxocobalamin)in the United States to treat firefightersand civilian smoke inhalation victims;educating firefighters on the dangersof cyanide poisoning and requiring theuse of protective measures; and acquir-ing and deploying new technologies todetect cyanide at fire scenes.

TRAGEDY IN WEST WARWICK: THERHODE ISLAND NIGHTCLUB FIRE Approximately 440 people were in theStation nightclub in West Warwick,Rhode Island, that Friday night inFebruary 2003 when a fire broke out inthe single-story, wood-frame building. 8

The fire started just after 11 PM, whenpyrotechnics used by Great White, theband performing that night, ignitedpolyurethane foam lining the walls of the stage area. The blaze quickly spread to the ceiling and then ignitedthe wood paneling on its way tobecoming a full-blown structural fire.

Figure 1 shows the timeline of theRhode Island Nightclub Fire and of the

emergency response, which was rapidand well-executed. 8 In response to 911calls made approximately 35 secondsand 1 minute after the fire ignited, four

engine companies, a tower-ladder truck,a rescue unit, and a battalion chief weredispatched to the scene. The firstresponding engine unit arrived at thescene in less than 5 minutes afterreceipt of the 911 call and began sup-pressing the fire with water. Ambulanceunits and additional fire companies were dispatched, and a mass casualty plan was implemented. 9

Despite the rapid and capableemergency response, which is credited with saving many lives, 100 peopleperished in the fire, and scores of others were seriously injured. The USDepartment of Commerces NationalInstitute of Standards and Technology (NIST), which is responsible forinvestigating building-related failuresleading to substantial loss of life, wasdeployed on a fact-finding mission toinvestigate the fire.

The NIST conducted experimentsto simulate the spread of fire andsmoke through the nightclub. 8,10 The

experiments were conducted in a testroom having dimensions and contain-ing materials similar to those of thenightclub on the night of the fire.

The fire simulation experiments meas-ured temperature as well as concen-trations of various combustion gasesin both sprinklered and un-sprinkleredconditions. The un-sprinklered condi-tion reproduced that of the Stationnightclub, which did not have asprinkler system. Building codes didnot require the Station nightclub tohave a sprinkler system given the size

of the nightclub (footprint of approxi-mately 4500 square feet) and the dateit was built. Given the similarity of the test conditions to conditions onthe night of the fire, it is likely thatthe experimental observations closely reflect what happened on the nightof the fire.

The results of the simulationsunder un-sprinklered conditions dra-matically demonstrate how quickly conditions in the nightclub may havebecome deadly. Within seconds of ignition of the fire, concentrations of the toxic combustion products carbon

monoxide and hydrogen cyanidesoared and oxygen levels plummetedto create conditions incompatible with sustaining life (Figure 2). 10

5

Ignition of Foam0:00 min

Band stops playing Evacuation begins

0:30 min

Smoke Layer Near Floor

1:30 min

People wedged infront doorway


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The striking differences in temper-ature and in concentrations of oxygen,carbon monoxide, and hydrogencyanide between the sprinklered con-dition and the un-sprinklered conditionsupport the judgment of on-the-scenefirefighters who contended that thelack of a sprinkler system cost many lives (Figure 2). 10 Whereas temperatureand oxygen levels were maintained atnearly ambient levels from the floor toapproximately 1.4 meters above floorlevel in the sprinklered condition,flashover conditions occurred approx-imately 60 seconds after ignition in theun-sprinklered condition. These find-ings contributed to the NISTs primary recommendations that model codesrequire sprinkler systems for all new

and existing nightclubs regardless of size and that state and local authoritiesadopt this provision. 8

CYANIDE IN FIRE SMOKEINHALATION: A DEADLY TOXIC MIX Results of the NIST experiments areconsistent with the possibility that anelevated level of hydrogen cyanide wasamong the causes of incapacitationand death in the Rhode IslandNightclub Fire. Hydrogen cyanide is a

highly toxic combustion product thatis formed during combustion of any material containing nitrogen 3-that isto say, during combustion of almostany material found or used in theconstruction of human dwellings. Thepossibility that cyanide contributed tomorbidity and mortality in the RhodeIsland Nightclub Fire was not consid-ered by at least some of the health careproviders administering to fire victimsas illustrated by a case report publishedin the New England Journal of Medicine in 2004. 11 The authors assessed andtreated a woman severely burned inthe Rhode Island Nightclub Fire forcarbon monoxide poisoning but didnot report evaluating her for toxicity arising from other combustion prod-

ucts including hydrogen cyanide.Furthermore, although the authorsdiscussed several aspects of managing burn injury and smoke inhalation,they did not discuss cyanide toxicity despite the presence of several signs andsymptoms suggesting cyanide poison-ing. The failure to consider cyanide asa potential cause of fire-related morbidity and mortality characterizes much of themedical literature on the managementof smoke inhalation.

Why this lack of awareness of theimportance of cyanide as a toxiccombustion product? Researchers at theSwedish National Testing and ResearchInstitute (SNTRI), which has conductedpioneering work identifying toxicantsin fire smoke, suggest that the perva-sive and relatively well recognizedhazard of carbon monoxide can blindresearchers and clinicians to the possi-bility that other toxicants, too, can beimportant in causing smoke inhalationinjury. 5 In effect, cyanide has not been found because it has not been sought.

FIRE SMOKE RESEARCH FROM THE SWEDISH NATIONAL TESTING AND RESEARCH INSTITUTE As discussed in the introduction, data

from studies conducted by the SNTRIare consistent with NIST data in showing that cyanide is a major combustionproduct generated during burning of materials commonly found in domes-tic structures. In one series of experi-ments, the SNTRI assessed the emissionof hydrogen cyanide and carbonmonoxide under both non-flaming (i.e., pyrolyzing) and flaming (i.e., fire)conditions during burning of wool,nylon, synthetic rubber, melamine,and polyurethane foam. 5 The resultsshow that all of these substances liber-ated high quantities of cyanide whenburned-particularly under pyrolyzing conditions characterized by low oxy-gen. Carbon monoxide was also emittedduring the burning of these substances.Noting that hydrogen cyanide isapproximately 35 times more toxic thancarbon monoxide during acute exposure,the authors emphasized the need forincreased recognition of the contribu-tion of cyanide to smoke toxicity. 5

The SNTRI conducted other exper-iments to identify factors that affectthe amount of cyanide generated in afire. 3 They developed combustionmodels that take into account theobservations that oxygen content inthe air near a fire is lower than that of fresh air; that air in the fire containscombustion products that reduce theefficiency of burning and result inincomplete combustion; and thatgrowth of a fire increases the contentsof combustion products in the air.

Using these models, they identifiedtwo conditions that increased theprobability of cyanide formation in afire. First, recycling of combustion

6

Figure 2. Temperature and oxygen, carbon monoxide, and hydrogen cyanideconcentrations in an experiment simulating the Rhode Island Nightclub Fire. 10

Temperature and gas concentrations were measured 1.4 meters above thefloor and 1.6 meters away from the stage where the fire started.

Hydrogen Cyanide

Time (s)

1.4 m above floorSprinklered

1.4 m above floorUn-sprinklered

0.1

0.15

00 50 100 150 200

H y d r o g e n

C y a n

i d e

( v o

l u m e

% )

0.05

Carbone Monoxide

Time (s)


1

3

4

5

6

00 50 100 150 200

C a r b o n

M o n o x i

d e

( v o

l u m e

% )

2


Temperature

Time (s)

CeilingUn-sprinklered

1.4 m above floor

Un-sprinklered


CeilingSprinklered

100

200

300

400

500

600

300

700

800

00 50 100 150 200

T e m p e r a t u r e

( C )

Oxygen

Time (s)



5

15

20

25

00 50 100 150 200

O x y g

e n ( v o

l u m e

% )

10


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products within a confined spaceincreased the formation of hydrogencyanide. Second, lowered ventilationrate to the fire increased the formationof hydrogen cyanide by 6 to 10 timesrelative to conditions of higher ventila-tion rate. Carbon monoxide formation was also increased under these twoconditions, which are particularly likely to apply to closed-structure fires.

HYDROGEN CYANIDE AS ANESCAPE INHIBITORCyanide poisoning from fire smokecan be directly lethal or, as the SNTRIand other researchers emphasize, canindirectly cause death by incapacitat-ing a fire victim. 5,12 Hydrogen cyanideand other toxicants in sublethal con-

centrations appear to act as escapeinhibitors in modern fires. 5,12 Exposureto low cyanide concentrations in a firecan cause unconsciousness that makeself-directed escape from the fire very difficult. 5 The victim of cyanide-asso-ciated incapacitation may continueto inhale increasing amounts of carbon monoxide and other noxiousgases. Carbon monoxide poisoning may eventually be the direct cause of death. However, as the carbon monoxidepoisoning might not have occurred without cyanide-induced incapacitation,hydrogen cyanide arguably is the causeof death in this example.

SISTERS OF CYANIDE:ISOCYANATES GENERATEDDURING COMBUSTIONOther findings from the SNTRI suggestthat the impact of cyanide as isocyanatesshould be considered in estimating the cyanide-associated hazards of firesmoke. 4 Derived from cyanide andhydrocarbons, isocyanates are com-monly found in plastics and adhesives.They are generated during the thermaldecomposition of urethanes and, it ishypothesized, during the incompletecombustion of nitrogen-containing compounds. 4 The SNTRI assessed theformation of isocyanates in small-scale combustion experiments involving 18 standard materials used in building (Table 1) and in large-scale experimentsinvolving two domestic products (i.e., asofa and a mattress). Other combustion

products including carbon monoxide,sulfur dioxide, hydrogen fluoride,hydrogen chloride, and hydrogencyanide were also measured.

The small-scale experimentsinvolved highly ventilated conditionsunder which generation of largequantities of dangerous combustionproducts such as carbon monoxide

and hydrogen cyanide was neitherexpected nor observed. In these small-scale experiments, isocyanates werefound to be present at a concentration

that made them potentially moredangerous to humans than the othercombustion products that were tested(Figure 3). 4 The results suggest thatelevated isocyanate levels in a fire can

result in life-threatening conditionseven when hydrogen cyanide andcarbon monoxide remain at nondan-gerous levels.

7

6000

5000

4000

3000

2000

1000

0

A B C D E F G H I J K L M N O PQ R S T U V

A. Glass fibr e B. Miner al fibr eC. PUR (flexible)D. PUR (r ig id)E. PIR

F. Polysty r eneG. Par ticle Boar dH. PlywoodI. Wood

J. Wool

K. Melamine L. Nitr ile Rubber M. BitumenN. FR4-laminatO. PVC

P. Fluor opolymer pelletsQ. Polyethylene pelletsR. Polyethylene cableS. PVC + fluor opolymer cables

T. Fluor opolymer cable

U. PVC cable V. Optical cable

T o t a l i s o c y a n a

t e s

( l u g / m

3 )

Glass fibr e: 8010 lug /m3

Figure 3. Total isocyanate concentrations in Cone calorimeter tests. 4

Table 1. Materials and products investigated in the test program. 4

Material Comment Usage

Glass fibre insulation wool building insulationMineral fibre insulation wool building insulationWood deal board building constructionBitumen waterproofing membrane building constructionPolystyrene expanded polystyrene(EPS) packaging, insulation, etcNitrile rubber insulating material tubing insulationPVC flooring material surface lining Fluoropolymer pure pellet material cable base materialPolyethylene halogen free, fire retarded pellets cable base materialFR4 laminate brominated laminate printed circuit board base materialMelamine laminate building constructionWool 92% wool, 8% polyamide lining, clothesParticle Board laminate building base materialPUR flexible foam furniture upholstering PUR rigid foam building insulationPIR rigid foam-polyisocyanurate (modified PUR) building insulationPlywood laminate room surface lining Carbon fibre laminate composite material, small and intermediate high performance vehicles,

scale experiments airplanes, etc

Cable products:Polyethylene cable halogen free, fire retardedcable data cablePVC cable fire retarted cable data cableFluoropolymer cable high performance cable data cablePVC + fluoropolymer cables 50% of each material data cableOptical cable uses urethane acrylate based polymer optical signal transport

Real-scale products:Sofa PUR upholstering; full scale experiment furnitureMattress PUR; large scale experiment furniture


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The large-scale experiments differedfrom the small-scale experiments inthat combustion generated high con-centrations of dangerous combustionproducts such as hydrogen cyanideand carbon monoxide. Isocyanates were also present at high levels in theselarge-scale experiments. For example,in a large-scale test in which a sofain an enclosed room was ignited, iso-cyanates reached approximately 17%of the concentration that is immedi-ately dangerous to life and health(IDLH) and carbon monoxide reached30% of the IDLH value during the testperiod. The authors concluded basedon these results that the contributionof isocyanates should be includedin estimating the toxic effect of a

gas mixture.4

CONCLUSIONSMedical lab results of the ProvidenceRhode Island firefighters identifiedhigh levels of hydrogen cyanide intheir blood. The results cause signifi-cant changes in the operational firefighting practices and procedures.The investigations cause the recom-mendations for new cyanide detecting systems, new cyanide medical testing protocols, new cyanide antidote treat-ments, and educational programs onthe dangers of fire smoke.

Results of fire modeling experimentsincluding simulations of the February 2003 Rhode Island Nightclub Firesuggest that cyanide is a ubiquitoustoxicant in modern fires. Depending on the fire conditions, hydrogen cyanideis formed as an intermediate combus-tion product and/or an end product.Isocyanates, too, are formed during combustion and should be consideredin estimating cyanide-related hazardsfrom fire smoke. The amount of cyanideproduced can vary from fire to fire andfrom one location to another in a givenfire depending on factors such as thecomposition of the burning material,the rate of burning, the absolute tem-perature, and ambient oxygen level.

Experience with the Rhode IslandNightclub Fire, in which cyanide islikely to have contributed to morbidity and mortality, and data from studiesreviewed elsewhere in this supplement

show that cyanide can be rapidly lethal-a daunting challenge for firstresponders working to save lives. While daunting, the challenge is not

insurmountable. Effective managementof cyanide poisoning in a fire emergency is possible. The first responders aware-ness that cyanide poisoning is highly probable in smoke inhalation victims of closed space structure fires constitutesa first step in effective management of smoke inhalation-associated cyanidepoisoning. Specific measures to helpvictims of smoke inhalation-associatedcyanide poisoning in the prehospitalsetting are discussed elsewhere inthis supplement.

RECOMMENDATIONS TO THE AMERICAN FIRE SERVICE1. Increase education of firefighters

and civilians about the risk of cyanide poisoning from fire smoke.

2. Support blood testing for cyanideof firefighters and fire victims.3. Support the use of safe cyanide

treatment antidotes (hydroxocobal-amin) in the United States to treatfirefighters and civilian smoke-inhalation victims.

4. Submit to the NFPA scientificresearch to identify health andsafety issues related to mandatory air management standards especially during overhaul operations.

REFERENCES1. NFPA 1404, Standard for Fire Service

Respiratory Protection Training,National Fire Protection Association,Quincy, MA, 2002 Edition.

2. NFPA 1500, Standard on FireDepartment Occupational Safety and Health Program, National FireProtection Association, Quincy,MA, 2002 Edition.

3. Tuovinen H, Blomqvist P. Modeling of hydrogen cyanide formation inroom fires. Brandforsk project 321-011. SP Swedish National Testing and Research Institute. SP Report2003:10. Bors, Sweden, 2003.

4. Hertzberg T, Blomqvist P, DaleneM, et al. Particles and isocyanatesfrom fires. Brandforsk project 324-021. SP Swedish National Testing and Research Institute. SP Report2003:05. Bors, Sweden, 2003.

5. SP Swedish National Testing andResearch Institute. Formation of hydrogen cyanide in fires. SP

Report 2000:27. Bors, Sweden, 2000.6. Providence Task Force IssuesRecommendations on Cyanide, Associated Press, May 30, 2006.

7. Milkivits, Amanda, Task Force UrgesFirefighting Precautions, ProvidenceJournal, May 31, 2006.

8. Grosshandler WL, Bryner N,Madrzykowski D, et al. Draft reportof the technical investigation of theStation nightclub fire. US Departmentof Commerce, Technology Administration, National Instituteof Standards and Technology.March 2005.

9. Anonymous. At least 96 killed innightclub inferno. Available at www.cnn.com. CNN news report,21 February 2003. Accessed 17March 2005.

10. Madrzykowski D, Bryner NP,Grosshandler WL, et al. Fire spreadthrough a room with polyurethane

foam-covered walls. Interflam 2004.International Interflam Conference,10th Proceedings; Volume 2; July 5-7, 2004.

11. Sheridan RL, Schulz JT, Ryan CM, etal. Case 6-2004: A 35-year-old- woman with extensive, deep burnsfrom a nightclub fire. New Engl JMed. 2004;350:810-821.

12. Peacock RD, Averill JD, Reneke PA,et al. Characteristics of fire scenariosin which sublethal effects of smokeare important. Fire Technology.2004;40:127-147.

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T he modern fireground is one of thedeadliest environments in the world.It is a combination of forces andfactors that can kill, cripple, or maimin a matter of seconds.

On a daily basis, firefighters aroundthe world fight fires in this deadly arena armed with only some basictools - water, protective clothing, andair. These tools are extremely impor-tant and the job of fighting fires couldnot be done without them. It is air,however, carried on the back of a fire-fighter in a self contained breathing apparatus (SCBA), which makes itpossible to safely enter a fire building and get the job done. It is also air, orthe lack thereof, that is the primary cause of non-cardiac related deathon fireground.

AIR MANAGEMENT The concept of Air Management revolvesaround the discipline of knowing how

much air a firefighter has in theirSCBA, monitoring that air, and ensuring it is being utilized to safely and effec-tively accomplish the task at hand.

Unfortunately, the fire servicedeveloped some bad habits when theSCBA was first introduced. These badhabits have carried over into poor airmanagement practices. The fire serv-ice is paying a steep price for thesebehaviors. Numerous fireground deathsare attributed to firefighters running out of air and dying of asphyxiation.

Initially, SCBA were not worn by the majority of firefighters becausethey were deemed too bulky and timeconsuming to bother with. This wascombined with tremendous peerpressure that insinuated you were aweak firefighter if you wasted thetime it took to put on your breathing apparatus. These assertions weredemonstrated to be incorrect andunsafe; however, it is still a commonpractice in some departments toroutinely disregard wearing a self con-tained breathing apparatus.

Most progressive and professional

fire departments around the world arenow mandating the use of the SCBA.The SCBA continues to improve asnewer technology seeks to decrease the

weight, improve reliability, and enhanceoverall effectiveness. Combined withbetter protective equipment, along with training and improvements inleadership, it should be expected thatfirefighter deaths rates on the firegroundshould be decreasing. Unfortunately,that is not the case as fireground deathsare staying about the same in spite of adecrease in actual fires. One factorstands out that needs to be addressed:

Firefighters that die in structuresare dying in increasingly higher num-bers due to asphyxiation. Or, to put itin street terms

THE NEEDThe need for a progressive, compre-hensive air management program isobvious for one simple reason:Firefighters are running out of air onthe fireground. The results of firefightersrunning out of air vary dramatically increasing firefighter line-of-duty deaths, close calls, injuries andincreased cancer/respiratory diseaserates that are directly linked to thesmoke firefighters breathe when theirair is depleted.

According to NFPA firefighter fatality reports, between 1996 and 2003 there were 103 deaths directly attributed toasphyxiation. These numbers did nottake into account the direct contribu-tion running out of air played indeaths that were attributed to otherfactors such as thermal insult, cardiacarrest, or collapse.

The need for air management isetched on fallen firefighter monuments

AIR MANAGEMENT ONTHE FIREGROUND:THE NEED -THE MANDATE -THE SOLUTION

9

A ROUTINE HOUSE FIRE CANPRODUCE ANY OF THE FOLLOWINGWITHIN SECONDS OF IGNITION:

1 Extreme Temperatures/Thermal Insult

2 Poisonous/AsphyxiatingAtmospheres

3 Structural Collapse4 Explosions5 Entrapment6 Electrical Shock

BY CAPTAIN MIKE GAGLIANO

CAPTAIN CASEY PHILLIPS

CAPTAIN PHIL JOSE

LIEUTENANT STEVE BERNOCCO

All contributors to this article are from the Seattle Fire Department

When firefighters run outof air they breathe smoke.When firefighters breathe

smoke they die.


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10

across the country, and in the tragicconsequences line-of-duty deaths bring to the families and fire departments of these fallen firefighters.

THE MANDATEBesides the disturbing firefighter deathstatistics, there are other mandatedchanges coming to the American fireservice that focus directly on airmanagement.

The most significant change is thenew language in the National FireProtection Association (NFPA) 1404respiratory standard that will takeeffect in 2007. Beginning in January,NFPA 1404 will include the following provisions:

NFPA 1404 Chapter 1 Administration1.1* Scope. This standard shall containminimum requirements for the training component of the Respiratory ProtectionProgram found in NFPA 1500, Standardon Fire Department Occupational Safety and Health Program.

1.2*Purpose. The purpose of thisstandard shall be to specify the mini-mum requirements for respiratory protection training for the emergency response organization, including safe-ty procedures for those involved in

fire suppression, rescue, and relatedactivities in a toxic, contaminated,or oxygen-deficient atmosphere orenvironment.

NFPA 1404 5.1.4* The authority having jurisdiction shall establish andenforce written Standard Operating Proceduress for training in the useof respiratory protection equipmentand that training SHALL includethe following:

NFPA 1404 A5.1.4(2) Individual airmanagement program. This program willdevelop the ability of an individual tomanage his or her air consumption aspart of a team during a work period.The individual air managementprogram should include the following directives:

1) Exit from an IDLH atmosphereshould be before consumption of reserve air supply begins.

2) Low air alarm is notification theindividual is consuming theirreserve air.

3) Activation of the reserve air alarmis an immediate action item forthe individual and the team.

The NFPA 1404 Standard outlines thatfire department must train their membersto operate in accordance with the RuleOf Air Management (ROAM) which states:

Know how much air is in yourSCBA, and manage that air so that youleave the IDLH environment BEFORE your low air warning alarm activates.

For many fire departments, this isgoing to be a significant change in how fireground operations are performed.The current practice is for firefightersto operate until the activation of thelow-air warning alarm and then beginto exit the structure. This practiceallows a firefighter to use 75% of the airin their SCBA for entry and work in theIDLH environment leaving only 25%for exit and no margin for error.

The new language in the NFPA 1404 standard is going to be the meas-ure used by the professional and legalcommunity to determine if a fire

department has taken the minimumrequired action necessary to protecttheir firefighters from the exposure toIDLH environments. To that end, firedepartments must train firefighters tomanage their air.

WILL THE LAW BE ON YOUR SIDE?This moves the discussion into thelegal arena where departmental andpersonal liabilities are factors that willhave far reaching impact on the fireservice. Many firefighters are already dealing with the fallout from the real-ization that giving your all to thecitizens as a member of the fire servicedoes not necessarily correlate intobeing taken care of in return.

The preceding article on the dele-terious effects of smoke and itscomponents highlights the toxic andcarcinogenic nature of the modern fireenvironment. Every firefighter is subjected to products of combustion as anormal course of doing their job.Exposure to products of combustion iscausing cancer in firefighters at levelsfar above those found in the generalpopulation. It could be assumedthat the willingness to take on theserisks would be met with an equalresponsibility of the employer to carefor the individual who gets sick because of them. That assumptionis proving nightmarishly wrong formany firefighters.

Many states are adopting Presumptive Legislation that attempts

to address the right of firefighters toget medical care for cancer and otherdiseases that are a direct result of the job. The devil, as always, is in the

The fire service has seen dramatic changes since Benjamin Franklinbegan building the American fire service. Despite all the changes, deathson the fireground that are not related to heart attack or vehicle accidentsstill occur in the same ways they have for 200 years. These are:

Smoke Thermal Insult Structural Collapse

Running out of Air affects all other categories on the list:

No Air in the toxic smoke environment of today leads torapid asphyxiation.

No Air during a thermal insult event will result in immediateand fatal burns to the throat and lungs.

No Air during a structural collapse means a lack of timefor rescue and asphyxiation.

No Air when lost or separated leads to panic and asphyxiation. No Air requires the firefighter to breathe the products of

combustion - toxic smoke that is proven to be both poisonousand carcinogenic.

No Air means that even if the firefighter survives the initial

assault on their respiratory system the toll on their wellnesswill be immeasurable.

Getting Lost or Separated Running out of Air


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details of just what is, and is not,deemed job-related. In the state of Washington, for example, the follow-ing are considered valid job-relatedconditions under current presumptivelegislation:

Primary Brain Cancer Malignant Melanoma Leukemia Non-Hodgkins Lymphoma Bladder Cancer Ureter Cancer Kidney Cancer

The Washington State Senate Waysand Means Committee specifically amended the original list of diseasesthat provided more appropriate cover-

age for firefighters. The original list was dramatically slashed and elimi-nated the following cancers from thelist of Presumptive cancers:

Breast Cancer Reproductive System Cancer Central Nervous System Cancer Skin Cancer Lymphatic System Cancer Digestive System Cancer Hematological System Cancer Urinary System Cancer Skeletal System Cancer Oral System Cancer

The Washington State Ways andMeans Committee also included addi-tional language that put limits on how long coverage would be in place. Thecurrent system allows for 3 months of coverage for every year of employmentup to 60 months. In other words, afirefighter who has been subjected tothe hazardous smoke for a career of 30 years had better test positive for cancer within 5 years of retirement or they arenot covered. They will get zero coveragedespite the obvious links to the yearsof service and high rates of cancerprobability. There are additional vari-ables written in that allow furtherquestioning of whether the cancer is job related including smoking history,fitness, etc.

There is a growing recognition thatproper usage of equipment and follow-ing of operating guidelines/policies

will be scrutinized in the light of personal liability. An injury or exposure will be judged based on how the fire-fighter operated during the emergency

and if they used the safety equipmentprovided them. Much like the currentdiscussions that are ongoing in regardto vehicle accidents in which seatbeltsare not worn, the proper use of SCBAs and respiratory guidelines willbe expected. Deviation from theseguidelines opens the firefighter up toquestions of personal liability.

Finally, all of the above will certainly result in court cases in which firefight-ers, fire officers, and fire departmentsas a whole may be required to justify their actions. A case in Memphis,Tennessee, is currently questioning why a 30-Minute Bottle did not last adeceased firefighter 30 minutes. This issomething all whove donned a mask can answer easily. Everyone in the fire

service understands that the label30 minute cylinder is a misnomer.These cylinders have only enough airfor firefighters to work 15-20 minutesat best. Imagine explaining to the judge, or the widow, that everyoneknows of the deficiencyyet no action was taken prior to the fatality. Those incharge must answer:1) Why do they allow their firefighters

to enter a structure fire withoutbreathing from an SCBA?

2) Why they routinely allow firefightersto operate until their low-air warning alarm activates?

3) Why arent they training, andoperating, according to recognizedminimum national standards?

The mandate for air managementanswers these concerns.

THE SOLUTIONThe solution for the air managementproblem is a simple one. It does not

require the purchase of expensiveequipment, the addition of morepersonnel, or the cessation of aggres-sive fireground attack to implement.The Rule of Air Management (ROAM)is the simple means by which thefireground can be made safer, exposureto toxic/carcinogenic smoke canbe greatly limited, and exposure tolegal/liability issues can be decreased.

The Rule of Air Management says:Know how much air you have in yourSCBA, and manage that air so that youleave the hazardous environment before your low-air warning alarm activates.

While this looks like a simple solu-tion, it is a radical change in behaviorfor the fire service. Most firefighters

have never checked their air beforeentry or during operations at structurefires. Up until now, the standardindication for time to exit is whenthe low-air warning alarm activates.The problem with this approach is thatit allows for no margin of error.

The ROAM changes all that.By checking your air before entry, thereis a verification that nothing has gone wrong with the breathing apparatuspack prior to interior smoke exposure. A full bottle gives a baseline from whichthe firefighter can build a good approachto managing the air they have. A RadioEquipmentAirDutiesYes!(R.E.A.D.Y.) Check (See Fire Engineering magazine June 2005 for more details) isrecommended prior to entry, to eliminatesome of the key problem areas that arekilling and/or injuring firefighters.

A routine check of the air status by the individual and team leader during

Know how much air you have inyour SCBA, and manage that airso that you leave the hazardousenvironment before your low-air

warning alarm activates.

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the operation is the second criticalcomponent of the ROAM. While thisseems like an obvious thing to do, mostfirefighters have never done it. Thischeck serves two purposes. The first isan obvious reminder of where the crew stands as far as air level is concerned,and gives a good indicator of when tomake the time to exit decision. Thesecond is an increase in situationalawareness that keeps the team fromgetting tunnel vision while performing their task. The air gauge check providesa brief break in the action that allows theteam leader to not only monitor air, butalso check condition changes and sta-tus of crew members.

Finally, the ROAM requires theteam to exit the structure before the

low air warning alarm activates. Thefinal 25% of the bottle is the emergency reserve air, and should only be utilized when something has gone wrong for thefirefighter or the crew. Unfortunately,firefighters routinely use this emergency reserve for the incident itself. This hascaused numerous firefighters to run outof air and suffer exposures to productsof 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 alsogives the Rapid Intervention Team timeto 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-ardous environment until their low air warning alarm activates are betting their life that nothing will go wrong onthe way out. This is a gamble thatfirefighters can no longer afford to take.

The Rule of Air Management is thefuture of the fire service. It can be com-bined with any technological or per-sonnel advance, but it does not rely onthem. Technology can be relied on only so far, as it always is subject to failure.Shrinking staffing levels and humanerror make air management, at thestrategic level, a secondary option atbest. The simple reality of the firegroundis that an individual firefighters air is

their responsibility to manage. TheROAM ensures that this happens and will save the lives of firefighters whouse it.

A fter firefighters extinguish a structurefire, they typically re-enter the build-ing to conduct overhaul activities.

During overhaul, firefighters oftenopen up and look in the walls, ceilings,attics, and any other void space wherethese still-burning embers might belocated. To accomplish the strenuoustask of overhaul, firefighters usethermal imaging cameras (TICs), andother tools such as axes, chainsaws,and pike poles to search for hiddenfire after the main body of the fire hasbeen extinguished.

During overhaul, there may belittle or no smoke, so most firefightersremove the face piece of their SCBA

(self contained breathing apparatus)and work in the environment withoutany respiratory protection. Firefightersfalsely believe that due to the reduced

amount of smoke and fire during overhaul, they are not being signifi-cantly exposed to the products of combustion. Science has proved thisnotion to be false. Firefighters are, infact, routinely breathing toxic gasesand being exposed to dangerous car-cinogens in the post-fire environment.These products may include hydrogencyanide (HCN), aldehydes, benzene,nitrogen dioxide (NO2), sulfur dioxide(SO2), polynuclear aromatic hydrocar-bons (PNA), and other substances.

Recent scientific studies show thatthe post-fire environment may be moredangerous than firefighters realize.Based on that concept, all fire depart-

ments should have an overhaul policy that requires firefighters to wearrespiratory protection throughout theoverhaul phase of the fire.

FIRE OVERHAUL, REHAB, AND ACOMPREHENSIVE RESPIRATORYPROTECTION PROGRAMBY CAPTAIN PHIL JOSELIEUTENANT STEVE BERNOCCO

CAPTAIN MIKE GAGLIANO

CAPTAIN CASEY PHILLIPS

All contributors to this article are from the Seattle Fire Department


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OVERHAUL ANDRESPIRATORY PROTECTIONIn their excellent study of firefighterexposure during fire overhaul, authorsBolstad-Johnson, et al, found that con-taminants in the overhaul atmosphereexceeded occupational exposure limitsand could therefore result in adversehealth effects in firefighters withoutrespiratory protection. In this impor-tant study, the authors found that inmany fires, concentrations of acrolein,CO, formaldehyde, and gluteralde-hyde exceeded exposure limits set by the Occupational Safety and Health Administration (OSHA). They alsofound that concentrations of coal tarpitch volatiles (PNAs) exceeded theOSHA and NIOSH limits. In other

words, the post-fire environment,though there is little or no smoke pres-ent, is extremely toxic and dangerousto firefighters. The authors concludethat respiratory protection should be worn by firefighters during overhaulactivities, and that the SCBA is a farbetter choice of respiratory protectionthan full-face air purifying respirators, which provide only limited protectionto the firefighters as compared to thepositive pressure SCBA.

Many fire departments allow fire-fighters to take off their SCBA during overhaul if carbon monoxide (CO)readings are below acceptable levels.However, CO levels have no correla-tion to irritants, other toxic gases, orcarcinogens that are present in thepost-fire environment. The current airmonitors/gas detectors used by mostfire departments do not monitor thesecarcinogens and toxic gases - gases likehydrogen cyanide, which is proving tobe one of the most deadly compoundsin the fire and post-fire environment.

To that end, the practice of allow-ing firefighters to take off their SCBA during overhaul should stop. Becauseof this uneducated and dangerouspractice, too many firefighters arebeing injured, contracting variouskinds of cancers, and suffering fromrespiratory illnesses.

Having firefighters wear theirSCBA during fire overhaul, however, is just one piece of a comprehensiverespiratory protection program.

RESPIRATORY PROTECTIONPROGRAM AND AIR MANAGEMENT First and foremost, firefighters must

become educated about their SCBA.They must understand the limitationsof the SCBA and how it functions.They must be fitted with the properface-piece. They must be properly trained on how to use it under normaloperating conditions, and how tohandle a low air emergency. All of this is mandated by NFPA 1404,Standard for Fire Service Respiratory Protection Training .

The SCBA is widely recognized inthe fire service as the biggest singleimprovement for firefighter safety andhealth. By providing a reliable supply of uncontaminated air for the fire-fighter operating in a highly dangerousand contaminated environment, theSCBA allows firefighters to work forextended periods while protecting their respiratory system. SCBA haveimproved over the years and now represent a relatively lightweight andreliable piece of equipment thatfirefighters should use at all times.Exposure to products of combustion isan unnecessary and therefore unac-ceptable risk for firefighters in themodern era. In addition, improved airmanagement techniques and an effec-

tive work/rest interval while operating in SCBA and maintaining an appropri-ate margin for safety. And while aSCBA will provide a significant increase

in overall safety, there is a cost to the wearer. A complete self containedbreathing apparatus can easily add inexcess of 25 pounds to the firefighter.In addition, the backpack carrying system compresses the thoracic cavity and restricts the ability of the respira-tory muscles to function normally.Each 1 kg increase in the weight of theSCBA ensemble has related impactson the respiratory rate, heart rate, andenergy expended. This increases the workload of the firefighter thereby increasing the rate of metabolic heatthat is produced simply through theeffort of breathing.

Additionally, a comprehensiverespiratory protection program mustensure that firefighters wear anduse their SCBA while fighting fire.Unfortunately, there are many firedepartments around the US that eitherdo not mandate or do not enforce thepolicy that every firefighter must wearand use their SCBA during fires.

Another component of a compre-hensive respiratory protection programshould require firefighters to managetheir air supply, ensuring they maintaina supply of emergency reserve air in

case they run into trouble. Ideally, thisreserve air must only be used in casethe firefighter encounters an unfore-seen emergency - it should not be

13


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used as part of the working air forfighting the fire.

The commercial and recreationalSCUBA diving industry has used theconcept of air management fordecades. Every SCUBA diver knowsthat they never breathe into theiremergency reserve air unless they runinto trouble underwater. In fact, divemasters expect every diver to return tothe dive boat with their reserve air intact. If they do not, and they had noemergency, those divers are deemedunsafe, and are not allowed to diveagain for that day or that company.Currently, the American fire servicedoes not enforce such stringent penal-ties for utilizing emergency supplies of air. It is commonplace to see firefight-

ers working past the low-air warning whistle or bell, failing to have any airin reserve.

The last step of a comprehensiverespiratory protection program is acomprehensive fire overhaul policy; apolicy requiring firefighters to wear anduse their SCBA during fire overhaul.

Since overhaul is can be morephysically demanding than extin-guishing the initial fire, there shouldbe more firefighters on scene to sharein the overhaul workload. Overhauloperations should also includemandatory rest breaks for firefighters,providing personnel time to cool off and hydrate. Safe work-rest intervalsshould be observed, since overheating,dehydration, and fatigue will all

be working against the firefightersperforming overhaul. The practice of leaving one unit on scene to performfire overhaul should be discontinued -

multiple units working together shoulddo overhaul. This provides firefighters with regular rest breaks - a conceptconsistent with following safe work-rest intervals.

Company Officers and IncidentCommanders must take all of theabove into account when determining when crews must rotate through anassignment and move toward rehabili-tation (rehab). Current recommendedpractice identifies work-to-rest inter-vals in terms of 30-minute cylinderrotations for interior operations andtime-based 20-minute work cycles foroutside operations. Company officersor crew leaders should perform self-rehab after one 30-minute cylinderuse or 20-minutes of intense work.

This rehabilitation process is informaland is most often conducted andsupervised by the company officerduring the SCBA cylinder exchangeat the apparatus. The recommended work-to-rest interval includes 10 min-utes of rest for each 30-minute cylin-der work cycle. Incident Commanders

must be able to forecast incidents where rehab will be needed beyondthe company level and establish aformal rehab area early.

Industry accepted standards forthe 30-minute cylinder work intervalmay also be extended to the 45-minute cylinder if air management ispracticed in accordance with the RuleOf Air Management (ROAM). Firefighters who follow the ROAM will have work

cycles that closely match those of firefighters operating in 30-minutecylinders while working in the hazardarea until the low-air alarm activates

before beginning to exit. Firefighters who use the ROAM recognize that thetime to exit is before the low air alarmactivates. Without adhering to theROAM, Company Officers shouldfollow the recommended practice of using only one 45-minute cylinderbefore rotating to a designated reha-bilitation area. Any use of a 60-minutecylinder should be followed by anassignment to the formal rehab area.

Formal incident scene rehabilitationis a tactical level function normally assigned as a division, group, or sector.The rehab supervisor should be trainedin all the functions and responsibilitiesinherent to the position and shouldunderstand how rehab operates with-in the Incident Management System

(IMS) and the standard operating procedures (SOPs) of the department.Rehabilitation areas should be farenough from a working incident toprovide protection from the productsof combustion and from apparatusexhaust. They should also be closeenough so ready access can be madebetween the incident scene and therehab area. Rehab should also provideappropriate protection from the envi-ronment, whether this includes hot orcold weather. Companies should be ableto re-supply and stage firefighting equip-ment before entering the rehab area.

Departmental SOPs or trainedobservations of company officers may dictate when and how units areassigned to rehabilitation. Minimumstandards for rehabilitation programsshould include:

Identified work-to-rest intervalsbefore company level rehab are listedbelow and should require a 10-minute company rehab including rest, hydration, and an evaluationof the companys readiness forre-assignment at the completion of the 10-minute rehab

One 30-minute cylinder withoutair management

One 45-minute cylinder following the ROAM

20 minutes of intense work Identified work-to-rest intervals

before assignment to the rehabilit-tion area

Two 30-minute cylinders withoutfollowing the ROAM including a 10-minute rest and hydration periodbetween cylinders

An overhaul policy must have a few important pieces to make it work.

First, there should be an air support unit on scene. Fire crews will bebreathing through many SCBA cylinders during overhaul, so the air unitmust be there to refill or replace empty cylinders in a timely fashion.

Next, firefighters should follow the ROAM (see the preceding articleentitled Air Management on the Fireground: The Need - The Mandate -The Solution for more details on the ROAM) concept during fire overhaul.

Finally, firefighters should ensure they are out of the hazardousenvironment before their low-air warning alarm activates. Again, thisgives firefighters a safety margin should they become trapped or lostin the structure.


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Two 45-minute cylinders following the ROAM including a 10-minuterest and hydration period betweencylinders

One 45-minute cylinder or 60-minute cylinder work cycle withoutfollowing the ROAM

One 30-minute cylinder withoutfollowing the ROAM or One 45-minute cylinder following theROAM after having rotated throughrehab previously. This requirementrecognizes the cumulative impact of repeated work-rest intervals overthe course of an incident and promotescoordinated company rotations andincident accountability

In addition to the work-rest intervalconsiderations, any SOP should

include the following for assignmentto rehab The company officer recognizes the

company needs to move to the rehabarea at any time

The incident commander assignsthe company to rehab

Once units are assigned to report torehab they should report to the rehabsupervisor for check in and recording of their arrival time. Personal ProtectiveEquipment (PPE) should be removedand SCBA should be re-supplied withfull cylinders. The company shouldthen be given an initial medical screen-ing by assigned EMS personnel inaccordance with department SOPs.This initial evaluation should include:

Symptoms of dehydration Heat/Cold stress Physical exhaustion Cardiopulmonary abnormalities Emotional/mental stress

or exhaustion

FINAL THOUGHTSFire overhaul is necessary to assurethat the fire is out and will not rekindle.However, the post-fire environment isdangerous due to irritants, toxic gases,and carcinogens in the atmosphere.Firefighters must wear their SCBA dur-ing this overhaul phase of firefighting to protect them from breathing in theseharmful compounds. Fire departmentsmust adopt a comprehensive respira-

tory protection program that mandatesthe wearing and use of SCBA during allphases of the fire and adheres to safeand effective air management practices.

INTRODUCTION

T he preceding articles cover thetoxic composition of smoke, meansof improving firefighting operationsto reduce smoke toxicity, and the needfor effective interventions to reducesmoke-related toxicity. This articledescribes the signs and symptomsof cyanide exposure, and discussesthe importance of a comprehensive

smoke inhalation assessment andtreatment protocol for improving out-comes in smoke-associated cyanidepoisoning.

CONTEXT Both citizens and firefighters die as aresult of inhalation of products of combustion from fire. Cyanide may contribute significantly to these deaths.Hydrogen cyanide, a toxic product of combustion of common nitrogen andcarbon-containing substances, is likely to be generated under the conditionsof high temperature and low oxygen

that characterize closed-space structurefires. Research on victims of smokeinhalation indicates that cyanide poi-soning may be an important agent of

15

SMOKE ASSOCIATEDCYANIDE EXPOSURE:THE IMPORTANCE OF PROMPT RECOGNITION ANDPROTOCOLS FOR PREHOSPITAL TREATMENT

BY JAMES AUGUSTINE, MD AND DONALD W. WALSH, PhD, EMT-P

James Augustine, MD , is an emergency physician from Atlanta and the Director of Clinical Operations for EMP Management. He serves as Medical Director for the Atlanta Fire Department,which includes operations at Atlanta Hartsfield Jackson International Airport, and is on the Clinical Faculty in the Department of Emergency Medicine at Emory University. He has served 25 years as a firefighter and EMT-A.

Donald W. Walsh, PhD , EMT-P is the Assistant Deputy Fire Commissioner for the Chicago Fire Departments Emergency Medical Services Division. Dr. Walsh is also President of the Cyanide Poisoning Treatment Coalition. Dr. Walsh is a Fellow of the Chicago Institute of Medicine, and Adjunct Faculty at the US Department of Homeland Securitys National Fire Academy.


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death, particularly for victims inclosed-space fires. For example, stud-ies that simulated the nightclub fire inRhode Island found rapid buildup of heat, carbon monoxide, and cyanideto levels incompatible with survival.Studies in Paris have also been illumi-nating regarding the role of cyanide infire death. The blood cyanide levelsfrom 66 fire victims who survived and43 fire victims who died in fires in theenvirons of Paris were compared withthose from 114 control individuals who had not been exposed to cyanide.Mean blood cyanide concentrations inboth groups of fire victims substantial-ly exceeded those in the control indi-viduals. Cyanide concentrations in fatal-ities were more than three times high-

er than concentrations in smokeinhalation victims who survived.Blood cyanide exceeded levels that arepotentially lethal (i.e., 1 mg/L) in thegroup of victims with fatal outcomesbut not in the group that survived.Co-exposure to carbon monoxide andcyanide was frequent. Elevated levelsof both compounds were found inmany victims.

Cyanide poisoning can be treatedeffectively if it is recognized promptly and if intervention is initiated imme-diately. In this context, it is importantthat prehospital providers recognizesigns and symptoms of cyanidepoisoning and have smoke inhalationevaluation and treatment protocolsin place.

MECHANISMS ANDMANIFESTATIONS OF CYANIDE TOXICITY Cyanide causes human toxicity by deactivating the mechanisms allowing cells to utilize oxygen. Because cyanide-poisoned cells are unable to useoxygen, they transition from aerobicmetabolism to anaerobic metabolismand generate toxic byproducts such aslactic acid. The buildup of toxicbyproducts of anaerobic metabolismultimately breaks down the cell.Organs such as the heart and brain, which rely on a substantial, continuoussupply of oxygen, are quickly affectedby cyanide poisoning.

Exposure to smaller concentra-

tions can initially cause respiratory activation (manifested by hyperpneaand tachycardia) in an attempt tocompensate for lack of oxygen. Early

manifestations include headache,anxiety, blurry vision, and loss of judgment. As cyanide accumulatesfurther, signs and symptoms of poi-soning reflect the effects of oxygendeprivation on the heart and brain.Later manifestations of exposure arecardiac arrhythmias, seizure, coma,and death. The time between exposureand incapacitation or death is typical-ly minutes, but varies depending onthe concentration of cyanide andother toxicants. Many toxicants affectoxygen utilization. The presence of multiple toxicants in fire smoke can beparticularly hazardous.

RECOGNIZING ACUTE CYANIDEPOISONING

Currently, there is no diagnostic test toconfirm cyanide poisoning within theshort time available for initiating potentially lifesaving intervention.Transcutaneous monitors such asthose used to detect carbon monoxidepoisoning might some day be avail-able to quantify the level of cyanideattached to hemoglobin; however,such an assessment tool is not currently available. Therefore, in the prehospitalsetting, acute cyanide poisoning mustbe diagnosed presumptively. Cyanidepoisoning should be suspected in any person exposed to smoke in a closed-space fire.

The concurrent presence of hypotension increases confidence inthe diagnosis of cyanide poisoning. A few cyanide-poisoned victims havea pinkish to cherry-red complexioncaused by the (abnormal) high oxy-genation of venous blood. The victims

breath may have an almond-like odorattributed to excretion of smallamounts of cyanide in the breath.However, many people lack the ability to smell this odor, so the prehospitalproviders failure to detect an almondodor does not reflect the absence of cyanide poisoning.

Even at the hospital, rapid meas-urements of cyanide are not available.Therefore, assessment and treatmentrely primarily on clinical judgment.Hospital laboratory findings that may indicate a strong possibility of cyanidepoisoning include:

Metabolic acidosis Elevated plasma lactate concen-

tions caused by the accumulation

of lactic acid, a byproduct of anaerobic metabolism Elevated oxygen content of venous

blood caused by failure of cyanide-poisoned cells to extract oxygenfrom arterial blood

Minimal elevation of carbon mono-ide by blood tests or use of thetranscutaneous monitor

It can be difficult to differentiatethe effects of cyanide and carbonmonoxide poisoning. The classicsymptoms of poisoning with eachagent are outlined in Tables 1 and 2.Detection of carbon monoxide poi-soning can be accomplished with thetranscutaneous carbon monoxidemeter. The assessment for cyanidepoisoning in the smoke inhalationvictim remains a matter of clinicalassessment by the astute emergency provider.

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Table 1. Manifestations of Cyanide Poisoning

Early Indications of Exposure to Low Inhaled Concentrations

Inhalation of Moderate to High Concentrations

Markedly altered levelof consciousness

Smell of almonds on breath(sometimes undetectable)

Seizure

Respiratory depression or arrest Cardiac dysrhythmia

Hypotension Cardiovascular collapse

Drowsiness Impaired judgment Anxiety Vertigo

Headache Dyspnea Tachypnea Tachycardia


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BASIC AND ADVANCED LIFESUPPORT FOR THE SMOKE

INHALATION VICTIMBasic life support care for the smokeinhalation victim includes removing the victim from the source of exposure;providing cardiopulmonary support, warmth, and fluids; administering 100% oxygen; and assuring appropriateventilation. Nebulizer treatment witha bronchodilator may be given for wheezing. The suspicion of acutecyanide poisoning should prompt theprehospital provider to initiate antidotetherapy. The use of antidotes isdiscussed in the next article written by J.L.Fortin.

Advanced life support care includesanticonvulsants for seizures. The motoractivity associated with seizures canaggravate acidosis. Victims with heartdisease may develop significant dys-rhythmias, so antiarrhythmics shouldbe administered to stabilize cardiovas-cular function. Shock is treated withfluids and prevention of hypothermia.If the victim has indications of severeacidosis, sodium bicarbonate may be administered to reverse this stateand improve the effectiveness of other therapies.

TRANSPORTATIONCONSIDERATIONSSome communities have hospitalsequipped to manage burn patients,and/or to provide hyperbaric oxygentreatment. In those communities, localmedical control protocols typically pre-scribe the transportation of victims

with burns and those with suspectedcarbon monoxide poisoning. Mostlocal protocols consider significantburns as the priority treatment con-

sideration, so a patient with more than10% full-thickness burns, respiratory

burns, or more than 27% partial-thick-ness burns are preferentially taken tothe adult or pediatric burn treatmenthospital. Not all hospitals are preparedand equipped to manage minor burns,moderate inhalation, and cyanide poi-soning. When in doubt, on-line medicalcontrol should be contacted and theirassistance requested in determining the correct destination hospital.

PROTOCOLS FOR PREHOSPITAL ASSESSMENT AND TREATMENT OF

THE SMOKE INHALATION VICTIMSmoke-associated poisoning withcyanide and other toxicants can rapidly culminate in death. To ensure thatsmoke inhalation victims are efficiently evaluated and intervention is promptly provided, it is essential to have proto-cols in place for prehospital assessmentand treatment of victims of smokeinhalation. The following sample proto-col can be adapted to department- orfacility-specific needs and capabilities:

IndicationsThe protocol applies to the patient who has been trapped or rescued froma closed space structure fire. The pres-ence of soot in the nose and/or mouthin the unconscious patient may be astrong indicator of cyanide poisoning.The protocol applies regardless of whether a concurrent injury or burn ispresent. Smoke inhalation can be adangerous medical condition requiring expedient evaluation and treatment!

Patient EvaluationThe patient should be removed toan area safe for their evaluation and

management. The key elements of evaluation include:

Mental status Any concurrent burn Any concurrent severe or

critical injury Degree of respiratory distress Ability to oxygenate

The patients airway, breathing, andmental status are evaluated as part of the primary assessment. Compromiseof any of these elements makes thepatient a red category triage victimand makes rapid treatment a priority.The patient requires support of airway,breathing, and supplemental oxygen.

The patient that has sustained

burn injury or other severe or criticaltraumatic injury should be giventreatment specific for those elements.In addition, the inhalation treatmentprotocol should be initiated.

A pulse oximeter reading can assistin the evaluation of the patients overallability to perfuse the body with oxygen.In the presence of carbon monoxideinhalation, the pulse oximeter alonecan produce an incorrect reading as themachine does not assess the percentof hemoglobin affected by carbonmonoxide or cyanide. A reading below 90% reflects ineffective breathing,direct injury to the airway or lungs, orsevere underlying lung disease (orsome combination of these elements). When available, the carbon monoxideoximeter detects the level of carbonmonoxide attached to the victimshemoglobin. A detector reading exceed-ing 12% reflects moderate carbonmonoxide inhalation, and one exceeding 25% reflects severe inhalation.

Smoke and other toxic productscause direct irritation of the airway and lungs, and treatment shouldreduce this irritation. Any injury to theairway or lungs causes impaired abili-ty to oxygenate and ventilate, andtreatment should supplement oxygendelivery and carbon dioxide removal.

Emergency Treatment and Transportation1) Perform a primary survey to

evaluate airway, breathing, mentalstatus, and the presence of burns

or other injuries. If possible,obtain a history regarding thepatients underlying heart orlung problems.

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Table 2. Manifestations of Carbon Monoxide Poisoning

Low Inhaled Concentrations

Manifestations of Exposure to Moderate to High Concentrations

Altered level of consciousness Severe headache Syncope Nausea and vomiting

Seizure Respiratory arrest Cardiac dysrhythmia Shock and death

Fatigue Difficulty with balance

Headache Palpitations


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2) Evaluate the patients oxygenationby pulse oximeter, and listen to thelungs for any abnormal sounds,particularly wheezing. When avai-able, obtain a carbon monoxideoximeter reading. Victims withcarbon monoxide levels exceeding 25% should be preferentially transported to the appropriatereceiving hospital.

3) Evaluate for potential cyanidetoxicity. The patient should beevaluated for the presence of sootin the nose or mouth, and/or analtered mental status, hypotensionor shock, flushed skin, and seizures.These patients may be candidatesfor treatment with a cyanide antidoteContact on-line medical control.

4) Treat any burn or traumatic injury.The spine should be immobilizedif indicated. If there is no indicationfor immobilization, allow the victimto find his/her position of comfort.Significant inhalation will causeviolent coughing and at timesvomiting, so the victim should beplaced in a protective position orin the position of comfort.

5) If the airway is compromised orinjured, the patient should undergoendotracheal intubation. If unsuc-cessful, a secondary device canbe inserted.

6) Provide supplemental oxygen.Most victims with an inhalationinjury do not tolerate dry oxygen;therefore, the oxygen line shouldhave a nebulizer placed in-line with afull container of saline as soon aspossible. If mental status permits,allow the patient to self-administerthe oxygen by holding the mask andsitting in a position of comfort.

7) If any wheezing is present on lung evaluation or if the patient has ahistory of asthma or wheezing,administer nebulized albuterol.The nebulizer should have 2.5 mLof Albuterol placed in it and thenbe filled with normal saline. Thepatient should continue use of thenebulized albuterol and salineuntil it is dry.

8) If there are a large number of victims and an oxygen distributormanifold is available, place the

victims in the same area, set upthe manifold with an appropriatenumber of oxygen masks, andobtain the large nebulizer cup.

Place 2 ampules of albuterol in thecup, fill the rest of the cup withsaline, and allow the patients toself-administer the mixture by mask.

9) Victims with mild to moderatesmoke inhalation may be treatedand released. To allow the victim torelease himself or herself fromcare, the following conditions mustbe met:

a. Mental status unimpaired or back to baseline for that individual (withverification by a friend or family member)

b. No signs of respiratory distress with a pulse oximeter reading above 92%

c. Lungs clear on auscultationd. No other significant burn or

traumatic injury 10) Victims with more severe smokeinhalation are transported to thehospital.

a . For patients requiring hospitalremoval, appropriate treatmentshould occur in conjunction withthe transport agency, and thepatient should be turned over forfurther assessment and interventions.

b. Symptoms of carbon monoxidepoisoning require the crews toconsider removal of the patient toa hospital that has a hyperbaricoxygen treatment capability.Evidence of carbon monoxidepoisoning includes impaired mentalstatus, neurologic compromiseincluding seizures, and a carbonmonoxide reading over 25%.

c. Major burn injuries get precedentin the determination of a receiving facility. A significant burn injury (generally, any burn over 10% fullthickness, a respiratory burn, or aburn over 25% partial thickness)requires transport to the appropriateadult or pediatric burn center.

CONCLUSIONSBoth prompt recognition of acutecyanide poisoning and immediateinitiation of care are necessary foreffective treatment. The fire profes-sional often provides the first lineof medical care for victims of smoke-associated cyanide poisoning in theprehospital setting. By recognizing

cyanide poisoning and efficiently initiating corrective measures according to protocol, the fire professional cansave lives.

BIBLIOGRAPHY (listed chronologically) Hall A, Rumack BH. Clinical toxicology

of cyanide. Ann Emerg Med.1986;15:1067-1074.

Jones J, McMullen MJ, Dougherty J. Toxic smoke inhalation: cyanidepoisoning in fire victims. Am J Emerg Med. 1987;5:317-321.

Silverman SH, Purdue GF, Hunt JL, etal. Cyanide toxicity in burnedpatients. J Trauma. 1988;28:171-176.

Kulig K. Cyanide antidotes andfire toxicology. N Engl J Med.1991;325:1801-1802.

Baud F, Barriot P, Toffis V, et al.Elevated blood cyanide concentrationsin victims of smoke inhalation.N Engl J Med. 1991;325:1761-1766.

Agency for Toxic Substances and

Disease Registry. US Department of Health and Human Services, PublicHealth Service. Cyanide toxicity. AmFam Phys. 1993;48:107-114.

Houeto P, Hoffman JR, Imbert M, et al.Relation of blood cyanide to plasma

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cyanocobalamin concentration aftera fixed dose of hydroxocobalamin incyanide poisoning. Lancet. 1995;346:605-608.

Borron SW, Vicaut E, Ruttimann M,et al. Biological tolerance of hydroxocobalamin in fire victimsintoxicated by cyanide. IntensiveCare Medicine. 1997;23:S181.

Lee-Chiong TL. Smoke inhalationinjury. Postgrad Med. 1999;105:55-62.

Ferrari LA, Arado MG, Giannuzzi L,et al. Hydrogen cyanide and carbonmonoxide in blood of convicteddead 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 cyanideconcentrations in fire victims. JForensic Sci. 2001;46:1421-1425.

Calafat AM, Stanfill SB. Rapidquantitation of cyanide in wholeblood by automated headspace gaschromatography. J Chromatogr B Analyt Technol Biomed Life Sci.2002; 772:131-137.

Alarie Y. Toxicity of fire smoke. CritRev Toxicol. 2002;32:259-289.

Koschel MJ. Where theres 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.

Mgarbane B, Delahaye A,Goldgran-Toldano D, et al. Antidotal treatment of cyanidepoisoning. J Chin Med Assoc.2003;66:193-203.

Gill JR, Goldfeder LB, Stajic M. Thehappy land homicides: 87 deathsdue to smoke inhalation. J ForensicSci. 2003;48:161-163.

Madrzykowski D. The StationNightclub Fire: Simulation of fireand smoke movement in laboratory reconstruction. NIST, US Departmentof Commerce. National ConstructionSafety Team Investigation. June 23,2004.

Eckstein M, Maniscalco P. Focus on

Smoke Inhalation-the most commoncause of acute cyanide poisoning.Prehosp Disaster Med. 2006:21:s49-55.

EDITORS FOREWORD

T he following case study chroniclesthe exposure and subsequent treat-ment of a Paris firefighter suffering from smoke inhalation. It underscoresa common exposure scenario forfirefighters the world over: getting lostor trapped inside a structure fire andrunning out of air. The outcome in thiscase was favorable. However, the caseillustrates the need in the US prehospital

arena for a safe and effective antidoteto counteract the effects of hydrogencyanide, one of the most deadly fire gases.

During the last several years, fire-fighters in the United States have spentcountless hours on rapid-interventiontraining. Today, almost every firedepartment in this country has incor-porated the concept of backing upinterior firefighters with a group of rescuers outside the structure, taskedsolely with the mission of locating andrescuing firefighters who become

trapped, disoriented, or lost inside thefire building. While the training andequipment used for rapid interve

smoke education supplement august 2006

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