Carbon monoxide exposure scenarios that may guide a clinical suspicion of severe poisoning
Abstract
Carbon monoxide accumulates in closed environments when there is unnoticed combustion. Signs of poisoning are non-specific, and thus circumstances around poisoning may constitute a diagnostic guide.
Objective: to strengthen the clinical capacities to suspect and confirm carbon monoxide poisoning.
Method: descriptive, transversal study of suspicious cases (patients with neurological or digestive symptoms for which an indoor combustion source is identified) who consulted at the Poisoning Center in 2017.
Results: 111 cases were included in the study, 52 of which occurred in 22 episodes of collective exposure. 37 patients were under 15 years old and the percentage of children identified in collective poisoning (23/37) was significantly greater than the one representing adults. 67 cases occurred in winter, minimum average temperature being 9.3°C. The combustion equipment most frequently involved in poisoning events were gas-fired water heaters in the first place, followed by gas stoves. The most frequent initial symptom was headache. Average COHb was 14.7%. Severe cases (45/111) were significantly corelated to carbon monoxide exposure from gas-fired water heaters.
Conclusions: the poisoning rate is low when compared to countries in a similar latitude, what suggests the possibility of under-diagnosis. Minimum environment temperature under 10°C, staying in spaces with combustion-based heating and the use of gas-fired water heaters were the typical poisoning scenarios. Headache is a key symptom to search for exposure. The diagnostic suspicion may be lower when it involves individual cases, mainly in children.
References
2) Nogué S, Dueñas A. Monóxido de carbono: un homicida invisible y silencioso. Med Clin (Barc) 2005; 124(8):300-1.
3) Wright J. Chronic and occult carbon monoxide poisoning: we don’t know what we’re missing. Emerg Med J 2002; 19(5):386-90.
4) Ashcroft J, Fraser E, Krishnamoorthy S, Westwood-Ruttledge S. Carbon monoxide poisoning. BMJ 2019; 365:l2299.
5) Buchelli H, Fernández R, Rubinos G, Martínez C, Rodríguez F, Pere Casan C. Niveles elevados de carboxihemoglobina: fuentes de exposición a monóxido de carbono. Arch Bronconeumol 2014; 50(11): 465-8.
6) García S. Guía de prevención, diagnóstico, tratamiento y vigilancia epidemiológica de las intoxicaciones por monóxido de carbono. 2ª ed. Buenos Aires: Ministerio de Salud de la Nación. Programa Nacional de Prevención y Control de las Intoxicaciones, 2014.
7) Satran D, Henry CR, Adkinson C, Nicholson CI, Bracha Y, Henry TD. Cardiovascular manifestations of moderate to severe carbon monoxide poisoning. J Am Coll Cardiol 2005; 45:1513-6.
8) Karaman S, Coskun A. Risk of late appearance of acute myocardial infarction after carbon monoxide (CO) intoxication. Rev Med Chile 2019; 147(9):1128-35.
9) Yurtseven S, Arslan A, Eryigit U, Gunaydin M, Tatli O, Ozsahin F, et al. Analysis of patients presenting to the emergency department with carbon monoxide intoxication. Turk J Emerg Med 2015; 15(4):159-62.
10) Weaver LK, Valentine KJ, Hopkins RO. Carbon monoxide poisoning: risk factors for cognitive sequelae and the role of hyperbaric oxygen. Am J Respir Crit Care Med 2007; 176(5):491-7.
11) Clarke S, Keshishian C, Murray V, Kafatos G, Ruggles R, Coultrip E. Screening for carbon monoxide exposure in selected patient groups attending rural and urban emergency departments in England: a prospective observational study. BMJ Open 2012; 2(6):e000877.
12) McCann L, Close R, Staines L, Weaver M, Cutter M, Leonardi G. Indoor carbon monoxide: a case study in England for detection and interventions to reduce population exposure. J Environ Public Health 2013:735952.
13) Oliu G, Nogué S, Miró Ó. Intoxicación por monóxido de carbono: claves fisiopatológicas para un buen tratamiento. Emergencias 2010; 22: 451-9.
14) Pose D, Negrin A, Laborde A. Intoxicaciones por monóxido de carbono. En: Leonardis D, Sehabiague G, Prego J, Bello O. Pediatría, urgencias y emergencias. Montevideo: Bibliomédica, 2009:1081-8.
15) Rose J, Wang L, Xu Q, McTiernan C, Shiva S, Tejero J, et al. Carbon monoxide poisoning: pathogenesis, management, and future directions of therapy. Am J Respir Crit Care Med 2017; 195(5):596-606.
16) Díaz M, Crapanzano G, Cabrerizo S, Aichele C, Deurtiaga A, Vallejos Y. Intoxicación masiva con monóxido de carbono: puesta al día a partir de un caso. Arch Argent Pediatr 2017; 115(1):76-81.
17) Donati S, Gainnier M, Chibane-Donati O. Intoxicación por monóxido de carbono. EMC-Anest-Reanim 2005; 31(2):1-17.
18) Vázquez M, Álvarez C, Cruz A, López M. Intoxicaciones inadvertidas por monóxido de carbono: una epidemia oculta. Rev Toxicol 2015; 32:98]101.
19) Lin CH, Su WH, Chen YC, Feng PH, Shen WC, Ong JR. Treatment with normobaric or hyperbaric oxygen and its effect on neuropsychometric dysfunction after carbon monoxide poisoning: a systematic review and meta-analysis of randomized controlled trials. Medicine (Baltimore) 2018; 97(39):e12456.
20) Sethuraman KN, Dougla TM, Bostick BB, Comer AC, Myers B, Rosenthal RE. Clinical characteristics of pediatric patients with carbon monoxide poisoning. Pediatr Emerg Care 2017; 36(4):178-81.
21) Uruguay. Ministerio de Industria, Energía y Minería. Dirección Nacional de Energía. Características del sector residencial, datos 2013. Encuesta de consumo. Planificación, estadística y balance. Disponible en: https://www.miem. gub.uy/energia/encuesta-sobre-consumo-y-usos-de-la-energia-en-el-sector-residencial-datos-2013 [Consulta: 25 junio 2020].
22) Instituto Uruguayo de Meteorología. El invierno: año 2015. Montevideo, 2015 Disponible en: https://www.inumet.gub.uy/reportes/dcd/invierno.pdf [Consulta: 21 junio 2020].
23) Instituto Uruguayo de Meteorología. Tendencias Climáticas Agosto-Setiembre-Octubre 2017.Montevideo, 2017. Disponible en: https://www.inumet.gub.uy/index.php/clima/tendencias-climaticas/tendencias-climaticas-agosto-setiembre-octubre-2017 [Consulta: 21 junio 2020].
24) Hampson NB, Hampson LA. Characteristics of headache associated with acute carbon monoxide poisoning. Headache 2002; 42(3):220-3.
25) Chiew AL, Buckley NA. Carbon monoxide poisoning in the 21st century. Crit Care 2014; 18:221.
26) Köthe L, Radke J. Carboxyhemoglobin concentration in carbon monoxide poisoning. Critical appraisal of the predictive value. Anaesthesist 2010; 59(6):529-34.
27) Jones S, Horton A, Brunt H, Shankar G. Preventing carbon monoxide poisoning. BMJ 2019; 366:l4613.
28) Keles A, Demircan A, Kurtoglu G. Carbon monoxide poisoning: how many patients do we miss? Eur J Emerg Med 2008, 15:154-7.
29) Penney D, Benignus V, Kephalopoulos S, Kotzias D, Kleinman M, Verrier A. Carbon monoxide. En: WHO Guidelines for indoor air quality. Selected pollutants. Geneva: WHO, 2010.
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
