Carbon monoxide toxicity: Difference between revisions
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=== Pathophysiology ===
=== Pathophysiology ===
*Hypoxia  
*[[Hypoxia]]
**Binding affinity of Hb for CO (carboxyhemoglobin) is 200x that of O2  
**Binding affinity of Hb for CO (carboxyhemoglobin) is 200x that of O2  
**Half-Life  
**Half-Life  
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*[[Lactic acidosis]]
*[[Lactic acidosis]]
**CO inhibits oxidative phosphorylation  
**CO inhibits oxidative phosphorylation  
*Hypotension  
*[[Hypotension]]
**CO induces NO2 and guanylate cyclase release --> vasodilation release
**CO induces NO2 and guanylate cyclase release --> vasodilation release


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**Focal neurologic deficit  
**Focal neurologic deficit  
*GI  
*GI  
**Vomiting  
**[[Vomiting]]
*Pulm  
*Pulm  
**Dyspnea/tachypnea  
**Dyspnea/tachypnea  
*Cardio  
*Cardio  
**Chest pain  
**[[Chest pain]]
**ECG changes/dysrhythmias  
**[[ECG]] changes/[[dysrhythmias]]
*Derm  
*Derm  
**Bullous skin lesions  
**[[Bullous skin lesions]]
**Classic finding of cherry red oral mucosa is rarely seen in living pts
**Classic finding of cherry red oral mucosa is rarely seen in living pts
***More likely seen in > 25% COHb levels
***More likely seen in > 25% COHb levels
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== Workup ==
== Workup ==
*VBG  
*[[VBG]]
**Co-oximetry analysis will provide carboxyhemoglobin level  
**Co-oximetry analysis will provide carboxyhemoglobin level  
**pH will be low secondary to metabolic acidosis caused by anaerobic metabolism and elevated lactate levels
**pH will be low secondary to metabolic acidosis caused by anaerobic metabolism and elevated lactate levels
*Lactate  
*Lactate  
*Chemistry  
*Chemistry  
*Troponin  
*[[Troponin]]
*Total CK (rhabdo)  
*Total CK ([[rhabdo]])  
*ECG  
*[[ECG]]
**May range from normal to STEMI (most common ST, then prolonged QT)
**May range from normal to STEMI (most common ST, then prolonged QT)
***Few of the pts w/ AMI from CO have occlusive lesions in their arteries  
***Few of the pts w/ AMI from CO have occlusive lesions in their arteries  
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*Pt must be stable prior to transport since response to acute medical conditions while undergoing hyperbaric therapy in a chamber is difficult.
*Pt must be stable prior to transport since response to acute medical conditions while undergoing hyperbaric therapy in a chamber is difficult.
*'''Indications (generally accepted guidelines):''' <ref>Practice Recommendations in the Diagnosis, Management and Prevention of Carbon Monoxide Poisoning. Hampson NB et al. Am J Respir Crit Care Med 2012 Oct 18</ref>
*'''Indications (generally accepted guidelines):''' <ref>Practice Recommendations in the Diagnosis, Management and Prevention of Carbon Monoxide Poisoning. Hampson NB et al. Am J Respir Crit Care Med 2012 Oct 18</ref>
**Syncope  
**[[Syncope]]
**Confusion/AMS  
**Confusion/[[AMS]]
**Seizure  
**[[Seizure]]
**Coma  
**Coma  
**Focal neuro deficit  
**Focal neuro deficit  
**Pregnancy w/ CoHb level >15%  
**Pregnancy w/ CoHb level >15%  
**Blood level >25%  
**Blood level >25%  
**Acute myocardial ischemia
**[[Acute myocardial ischemia]]


== Disposition ==
== Disposition ==
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**Discharge^
**Discharge^
*Mildly symptomatic  
*Mildly symptomatic  
**Headache, vomiting, elevated COHb level  
**[[Headache]], [[vomiting]], elevated COHb level  
**Discharge after 4hr obs and symptom resolution^  
**Discharge after 4hr obs and symptom resolution^  
*Severely symptomatic  
*Severely symptomatic  
**Ataxia, syncope, chest pain, neuro deficit, dyspnea, ECG changes, pregnant w/ COHb >15%  
**[[Ataxia]], [[syncope]], [[chest pain]], [[focal neuro deficit]], [[dyspnea]], [[ECG]] changes, pregnant w/ COHb >15%  
**Admit; discuss with hyperbaric specialist
**Admit; discuss with hyperbaric specialist


Revision as of 20:20, 2 February 2015

Background

  • Colorless, odorless gas
  • Most toxic component in smoke inhalation and major contributor to fire-related deaths
    • Can co-occur with Cyanide toxicity in industrial fires
  • Peak incidence in winter months

Sources

  • Automotive exhaust
  • Propane-fueled heaters
  • Wood or coal-burning heaters
  • Structure fires
  • Gasoline-powered motors
  • Natural gas-powered heaters

Pathophysiology

  • Hypoxia
    • Binding affinity of Hb for CO (carboxyhemoglobin) is 200x that of O2
    • Half-Life
      • Room air: ~5hrs
      • 100% O2: ~1hr
      • HBO 2.5atm: 24min
  • Lactic acidosis
    • CO inhibits oxidative phosphorylation
  • Hypotension
    • CO induces NO2 and guanylate cyclase release --> vasodilation release

Clinical Features

Expected CNS Function by COHb%

  • 10-20% - confusion and agitation 2/2 mild hypoxia
  • 20-30% - progressive obtundation and nausea
  • >40% - almost always unconscious
  • >60% - survival is very rare

Diagnosis

  • Must have high clinical suspicion (esp in pts w/ coma, AMS, or anion gap acidosis)
    • Comatose pt removed from fire should be assumed to have CO poisoning
  • Carboxyhemoglobin Level
    • Interpretation must take into account time since exposure and O2 tx
    • Normal value in non-smokers is ~1%, normal value in smokers may be up to 10%
    • Symptoms and COHb levels do not always correlate well
  • Pulse oximetry is unreliable
    • CoHb registers the same as O2Hb so will have artificially high SpO2
    • O2 saturation gap reflects discordance of SpO2 by pulse oximeter vs by VBG

Workup

  • VBG
    • Co-oximetry analysis will provide carboxyhemoglobin level
    • pH will be low secondary to metabolic acidosis caused by anaerobic metabolism and elevated lactate levels
  • Lactate
  • Chemistry
  • Troponin
  • Total CK (rhabdo)
  • ECG
    • May range from normal to STEMI (most common ST, then prolonged QT)
      • Few of the pts w/ AMI from CO have occlusive lesions in their arteries
  • Head CT
    • Identified radiolographically within 12 hours of exposure
    • Bilateral hypodense lesions in the basal ganglia: globus pallidus, putamen, and caudate nuclei[1]

Treatment

  • If smoke inhalation, good pulmonary toilet is very important
  • NEVER use steroids in smoke inhalation injury; intubate early if concern for obstructing edema
  • O2 100% by NRB or ETT
    • Provide O2 until COHb value <10%
    • Early PEEP prevents progressive atelectasis and improves O2 diffusion
    • In general, COHb levels fall rapidly to < 10% within 30 min of 100% O2
    • Maintain 100% O2 for additional 2-3 hrs after < 10%, since anaerobic metabolism is occuring due to cytochrome oxidase poisoning[2]
      • Anaerobic metabolism universally seen with COHb > 40%
      • Monitor for return of aerobic metabolism with normal serum bicarbonate levels

Hyperbaric Therapy (HBO)

  • Decision to initiate HBO should be made in consultation w/ hyperbaric specialist
  • Controversial Outcomes regarding benefit[3]
    • Three HBO treatments within 24hrs reduced risk of cognitive sequelae 6 weeks and 12 months after CO poisoning[4]
    • While an Australian study showed not benefit and suggested worse outcomes in HBO therapy[5]
  • Pt must be stable prior to transport since response to acute medical conditions while undergoing hyperbaric therapy in a chamber is difficult.
  • Indications (generally accepted guidelines): [6]

Disposition

^If discharging patient- may need to alert local fire/police services to evaluate home/work before they return. Check with your local branch.

Source

  1. ↑ Lee, DC: Hydrocarbons, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 7. St. Louis, Mosby, Inc., 2010, (Ch) 156:p 2035-2038
  2. ↑ MetroHealth Medical Center Burn ICU Handbook (Not a policy manual), Cleveland, OH
  3. ↑ http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1116883/pdf/1083.pdf
  4. ↑ Weaver, L. et al. Hyperbaric Oxygen For Acute Carbon Monoxide Poisoning. NEJM. 2002:347(14):1057 http://emed.wustl.edu/Portals/2/Answer%20Key%20PDF/2012/January2012/SecondYear.pdf
  5. ↑ Scheinkestel C. et al. Med J Aust 1999; 170 (5): 203-210. Hyperbaric or normobaric oxygen for acute carbon monoxide poisoning: a randomised controlled clinical trial http://www.mja.com.au/journal/1999/170/5/hyperbaric-or-normobaric-oxygen-acute-carbon-monoxide-poisoning-randomised
  6. ↑ Practice Recommendations in the Diagnosis, Management and Prevention of Carbon Monoxide Poisoning. Hampson NB et al. Am J Respir Crit Care Med 2012 Oct 18
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