carbon monoxide poisoning the silent killer

Carbon Monoxide Carbon Monoxide PoisoningPoisoning

The Silent KillerThe Silent KillerOtto F. Sabando DO FACOEPOtto F. Sabando DO FACOEP

Program DirectorProgram DirectorDept. Of Emergency MedicineDept. Of Emergency Medicine

St. Joseph’s Regional Medical CenterSt. Joseph’s Regional Medical CenterPaterson NJPaterson NJ

Case PresentationCase Presentation

A 18 y.o. male presents to the ED via A 18 y.o. male presents to the ED via ambulance for “wondering around ambulance for “wondering around the highway. He is acutely confused the highway. He is acutely confused and not focusing on questions. It is and not focusing on questions. It is winter and there was a traffic jam.winter and there was a traffic jam.

His PMH, SH, Medications, PSH and His PMH, SH, Medications, PSH and FH are unknown.FH are unknown.


What other questions can be asked from What other questions can be asked from the paramedic?the paramedic?

Physical ExamPhysical Exam His vital signs are T: 99 F oral, P110,His vital signs are T: 99 F oral, P110, RR: 20 BP: 120/80 SaO2: 98% RARR: 20 BP: 120/80 SaO2: 98% RA Physical exam: neuro: disoriented to Physical exam: neuro: disoriented to

time and place, not following time and place, not following commands.commands.


What is the What is the differential?differential? MeningitisMeningitis ToxicologyToxicology DKADKA Head injuryHead injury CVACVA UremiaUremia SeizureSeizure

Brain tumorBrain tumor Medication side effectMedication side effect Severe anemiaSevere anemia HypotensionHypotension MalingererMalingerer Normal and lost in the Normal and lost in the

BronxBronx OverdoseOverdose Post-ictal statePost-ictal state


Plan of carePlan of care Cardiac monitorCardiac monitor Finger stickFinger stick OXYGENOXYGEN RestraintsRestraints LabsLabs

CBC, CMP, ABG, U/A, Urine tox., blood c/s x2, CBC, CMP, ABG, U/A, Urine tox., blood c/s x2, ETOH, ASA, TylenolETOH, ASA, Tylenol

Other ancillary studiesOther ancillary studies


CXRCXR CT brainCT brain EKGEKG


What test will yield the best What test will yield the best information in what’s going on?information in what’s going on?

ABG ABG EKGEKG

Death by Raccoon!Death by Raccoon!

Raccoon causes carbon monoxide Raccoon causes carbon monoxide fatality in East Sandwichfatality in East Sandwich

By Ira Kantor By Ira Kantor Tuesday, December 23, 2008 - Updated Tuesday, December 23, 2008 - Updated 37d 4h ago37d 4h ago E-mail E-mail Printable Printable (7) Comments (7) Comments Text size Text size Share Share (5) Rate (5) Rate

A 62-year-old East Sandwich man was A 62-year-old East Sandwich man was found dead of carbon monoxide found dead of carbon monoxide poisoning in his home Sunday morning poisoning in his home Sunday morning after a raccoon crawled into his after a raccoon crawled into his chimney flue and blocked it, police and chimney flue and blocked it, police and fire officials said.fire officials said.

““He was of such a size that it was a He was of such a size that it was a complete blockage of the products of complete blockage of the products of combustion from the gas appliance,” combustion from the gas appliance,” said Sandwich Deputy Fire Chief Tom said Sandwich Deputy Fire Chief Tom Corriveau. “So there was nowhere for Corriveau. “So there was nowhere for them to go but back into the them to go but back into the residence.”residence.”

BackgroundBackground

EpidemiologyEpidemiology Leading cause of poisoning M&M in USLeading cause of poisoning M&M in US 20,000 cases reported to PCCs annually20,000 cases reported to PCCs annually

500-5000 deaths in US500-5000 deaths in US Half are suicidesHalf are suicides 1/3 from fires1/3 from fires

SourcesSources

Coal and woodCoal and wood Engine exhaustEngine exhaust Propane powered Propane powered

vehiclesvehicles

Methylene chlorideMethylene chloride Paint, varnish Paint, varnish

removersremovers

Home heatingHome heating Natural gas stovesNatural gas stoves Kerosene heatersKerosene heaters Clothes dryersClothes dryers Fire placesFire places

PathophysiologyPathophysiology

COHb leads to decrease oxygen COHb leads to decrease oxygen content in blood, shifts the O2-Hb content in blood, shifts the O2-Hb dissociation curve to the left.dissociation curve to the left.

CO bind to myoglobin leading to CO bind to myoglobin leading to myocardial and skeletal muscle myocardial and skeletal muscle hypoxiahypoxia

PathophysiologyPathophysiology

CO binds to cytochrome oxidase CO binds to cytochrome oxidase leads to impaired mitochondrial leads to impaired mitochondrial respirationrespiration

Lipid peroxidation in CNS leading to Lipid peroxidation in CNS leading to neurologic sequelaeneurologic sequelae

Clinical PresentationClinical Presentation

Nervous systemNervous system HAHA DizzinessDizziness NauseaNausea Blurred visionBlurred vision AMSAMS Ataxia Ataxia Seizures Seizures ComaComa

Cardiovascular Cardiovascular systemsystem Exert ional dyspneaExert ional dyspnea WeaknessWeakness AnginaAngina PalpitationsPalpitations HypotensionHypotension MIMI DysrhythmiasDysrhythmias

Clinical PresentationClinical Presentation

Respiratory systemRespiratory system ARDSARDS Pulmonary edemaPulmonary edema

Renal systemRenal system ARF secondary to ARF secondary to

ATN or ATN or rhabdomyolysisrhabdomyolysis

Dermal systemDermal system Bullae, cherry-red Bullae, cherry-red

colorcolor MusculoskeletalMusculoskeletal

Atraumatic Atraumatic rhabdomyolysisrhabdomyolysis

COHb levelsCOHb levels

Normal: 1-2%Normal: 1-2% COHb Level(%)COHb Level(%)

10-2010-20 3030

40-5040-50

60-7060-70

8080

Smokers: 5-10%Smokers: 5-10% SymptomsSymptoms

““flu-like” symptomsflu-like” symptoms Severe HA, impaired Severe HA, impaired

judgmentjudgment Confusion, LOC, Confusion, LOC,

minimal level for minimal level for lethality as per M.E.lethality as per M.E.

Cardiovascular collapse, Cardiovascular collapse, deathdeath

Rapidly fatalRapidly fatal


CO level is 30%CO level is 30% What do we do now?What do we do now?

Send the patient to hyperbaric Send the patient to hyperbaric chamber!chamber!

Indications for Hyperbaric Indications for Hyperbaric OxygenOxygen

Evidence of end organ damageEvidence of end organ damage LOC, Coma, seizures, visual symptomsLOC, Coma, seizures, visual symptoms MI, DysrhythmiasMI, Dysrhythmias Persistent symptoms after tx with 1 ATM Persistent symptoms after tx with 1 ATM

O2O2 COHb levelsCOHb levels

COHb > 25%COHb > 25% COHb > 15% in pregnant patientCOHb > 15% in pregnant patient


While waiting for transfer to HBO, While waiting for transfer to HBO, what is the half-life of CO if the pt. what is the half-life of CO if the pt. has been on 100% O2 at 1 ATM?has been on 100% O2 at 1 ATM?

90 min.90 min.

Half life of COHbHalf life of COHb

Room air (21%)Room air (21%) 100% at 1 ATM100% at 1 ATM 100% at 3 ATM100% at 3 ATM

2-7 hrs mean is 5 2-7 hrs mean is 5 hrshrs

36-137min mean is 36-137min mean is 60 min. 60 min.

4-86 min mean is 4-86 min mean is 40 min.40 min.

Mechanism of HBOMechanism of HBO

Decreases half-life Decreases half-life of COHbof COHb

Displaces CO from Displaces CO from myoglobin and myoglobin and cytochrome cytochrome oxidase in tissuesoxidase in tissues

Increases O2 Increases O2 content of bloodcontent of blood

Evidence Base Medicine for Evidence Base Medicine for HBOHBO

Choi HS: Delayed neurologic Choi HS: Delayed neurologic sequelae in CO intoxication.Arch sequelae in CO intoxication.Arch Neurol 1983;40:433-435Neurol 1983;40:433-435 Without HBOWithout HBO 12% persistent CNS signs or symptoms12% persistent CNS signs or symptoms 12% delayed neurologic sequelae12% delayed neurologic sequelae 2%death2%death


Delayed Neurologic sequelaeDelayed Neurologic sequelae Resolution:Resolution:

Mild: 100% within 2 monthsMild: 100% within 2 months Severe: 75% within 1 year (average 3-6 Severe: 75% within 1 year (average 3-6

months)months) Elderly most susceptibleElderly most susceptible


Goulon M, Barios M et al: CO Goulon M, Barios M et al: CO intoxication and treatment with intoxication and treatment with hyperbaric oxygen. Journal of hyperbaric oxygen. Journal of Hyperbaric Medicine 1986;1:23Hyperbaric Medicine 1986;1:23 HBO within 6hrs mortality decreased HBO within 6hrs mortality decreased

from 30% to 13.5%from 30% to 13.5% Delayed neurologic sequalae (DNS): Delayed neurologic sequalae (DNS):

30% to 5.5%30% to 5.5%


Scheinkestel CD, Bailey M, Myles PS et al: Scheinkestel CD, Bailey M, Myles PS et al: Hyperbaric or normobaric oxygen for acute Hyperbaric or normobaric oxygen for acute CO poisoning: a randomized controlled CO poisoning: a randomized controlled clinical trial. Med J Aust 1999; 170:203-210clinical trial. Med J Aust 1999; 170:203-210 Found no benefitFound no benefit 100% O2 for three days by facemask then HBO 100% O2 for three days by facemask then HBO

treatmenttreatment Most of the patients were suicidalMost of the patients were suicidal Follow up was only 46%Follow up was only 46%


Weaver LK, Hopkins RO, Chan KJ, et Weaver LK, Hopkins RO, Chan KJ, et al. Hyperbaric oxygen for acute CO al. Hyperbaric oxygen for acute CO poisoning. N Engl J Med poisoning. N Engl J Med 2002;347:1057-672002;347:1057-67 Reduced the risk of DNS 6 weeks and 1 Reduced the risk of DNS 6 weeks and 1

year after acute CO poisoningyear after acute CO poisoning

HBO TreatmentHBO Treatment

Patient’s must Patient’s must receive treatment receive treatment within 6 hrs.within 6 hrs.

ED ManagementED Management

Remove from exposureRemove from exposure 100% O2 by mask100% O2 by mask COHb levels: venous or arterialCOHb levels: venous or arterial Pulse oximetryPulse oximetry Assess end organ damage.Assess end organ damage.

Special CasesSpecial Cases

Family that may walk in with “flu-Family that may walk in with “flu-like” symptoms that get better like” symptoms that get better during the day and worse at night.during the day and worse at night. Ask about where they live and what kind Ask about where they live and what kind

of heating system they have.of heating system they have. Ask if any pets are sick at home with Ask if any pets are sick at home with

unknown etiology.unknown etiology.

Methylene ChlorideMethylene Chloride

Easily absorbed Easily absorbed through the skin as through the skin as well as inhalationwell as inhalation Metabolized in the Metabolized in the

liver to COliver to CO Half life prolonged Half life prolonged

to 13 hrs. to 13 hrs.

Prevention and EducationPrevention and Education

Yearly inspections of boilerYearly inspections of boiler Check cars exhaust systemsCheck cars exhaust systems Check ventilation ducts of fire placesCheck ventilation ducts of fire places Clean snow from exhaust systemClean snow from exhaust system

Prevention and EducationPrevention and Education

CO monitorsCO monitors Standard in new houses in NJStandard in new houses in NJ Cost $25-$50Cost $25-$50

Fire detectorsFire detectors Mandatory in housesMandatory in houses Cost $15!Cost $15!

Questions?Questions?

carbon monoxide poisoning the silent killer

Documents

carbon monoxide fatality

minimal level

gas appliance

impaired judgmentconfusion

sandwich deputy

yearold east sandwich

hyperbaric chamber

abg ekgdeath