Carbon Monoxide Intoxication underrecognised
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- Adelia Martin
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1 Carbon Monoxide Intoxication underrecognised but deadly L intoxication au monoxyde de carbone: une affection mortelle trop souvent méconnue Koolstofmonoxidevergiftiging: vaak miskend en levensgevaarlijk Dr Peter Germonpre Medical Director, Centre for Hyperbaric Oxygen Therapy Military Hospital Brussels Tel medhyper@mil.be Introduction - disclaimer Hyperbaric Oxygen Treatment centre Transfer for patients based on Algorhitm for CO intoxication ( Availability of hyperbaric chamber Interests: Minimise delays before definitive treatment Optimise first aid Overview How big is the problem? Why is it under-recognised? Lack of knowledge of physics Wrong assumptions (social context) Interpretation of symptoms - physiopathology Why is it a serious health risk? Death Overtreatment Undertreatment / prevention How big is the problem? Epidemiological data sources Register for Carbon Monoxide, Annual Report(s) European Registries Uncertainties Definition of CO intoxication (ICD classification) Underreporting? Chronic intoxication (almost) never reported Sequelae vague, variable, not systematically reported (courtesy: Dr M. Fortuyn, Poison Centre) Reporting sources Annually: between victims hospitalised Some (many?) not registered? people killed ( /100,000) (slowly) downward trend (prevention?) Age of victims - young and old similar Approximately 55% of cases reported from hospitals with Centres for Hyperbaric Oxygen (hyperbaric or normobaric oxygen) 1
2 CO intoxication is widely under-recognised Physics of Carbon Monoxide Production by incomplete combustion of carbon chains Gas / Fuel / Coal / Wood... Example: propane gas Complete combustion C 3 H O 2 4 H 2 O + 3 CO 2 Incomplete combustion C 3 H O 2 4 H 2 O + 2 CO + 1 CO 2 2
3 CO production in closed environments: as O2 is consumed, CO production is faster and faster [CO] ppm Causes of carbon monoxide production Insufficient oxygen to flame Pipes - apparatus Environment Insufficient exhaust gas evacuation Pipes Environment Chemical reactions (PM) Time (min) Oxygen availability Exhaust efficiency Exhaust efficiency Mechanisms of intoxication Effect of breathing CO gas Subjectively none Objectively Diffusion solution in plasma Competitive binding to Hemoglobin 3
4 Hyperacute intoxication = blood (haemoglobin) intoxication Minor levels are not always symptomatic Hypoxemia possibly lethal when > 60% blocked Hemoglobin blockade - RAPID An exposure of some minutes may be sufficient to obtain high levels of CO-Hb Longer intoxication = tissue intoxication Cellular intoxication - SLOW CO binds to energy producing enzymes in cell Myoglobin (heart, muscle) Cytochrome c,c3 (respiratory chain mitochondria) Estimated 15-45% of all CO in the body is thus fixed in tissues Depends on level and duration of intoxication Can not be measured directly Brain, heart = most vulnerable How fast are tissues intoxicated? Longo et al sheep experiments (foetal) Delay of 1-2 hours Release of CO: delay of more than 6 hours Symptoms of CO intoxication 4
5 Recognizing CO intoxication Symptoms Headache, nausea, weakness, vertigo Cardiac complaints (angina pectoris) Decreased consciousness (stuporous, coma) Sudden loss of consciousness (bathroom) Circumstances - Environment! Combustion device present Duration of exposure! Meteorological Multiple persons - Pet animals! Recognizing CO intoxication Emergency Medical Services CO detector in air SaCO measurement Carboxyhemoglobin measurement in (venous) blood Beware: LOW Carboxyhemoglobin is NOT EQUAL to minor intoxication!! Tissue vs Blood intoxication Persons at risk: elderly, cardiac, young children Duration of intoxication Chronic intoxication : UNDERDIAGNOSED Treatment of CO intoxication Antidote = oxygen 100% O 2 needed Rapid elimination of CO from COHb resume O2 transport CPR BLS/ALS with high flow oxygen 100% in non-rebreathing mask (types of mask!!) Duration: needs to desintoxicate the brain! 6-12 Hrs = in function of duration and CO level! Do all CO-intoxications need Hyperbaric Oxygen therapy? Only Tissue Intoxications REALLY benefit from HBO Tissue oxygenation independent of oxygen-carrying capacity of Haemoglobin Brain/cardiac re-oxygenation almost instantly Indication for HBO (virtually) INDEPENDENT from carboxyhemoglobin level! Evaluation and Treatment Algorithm (ACHOBEL Recommended reading Poison centre website ( Overview of CO-intoxication HALLOWEEN folder downloadable ACHOBEL website ( CO Intoxication Evaluation and Treatment Algorhitm Information about Hyperbaric Oxygen Therapy Contact information HBO Centres Belgium/Luxemburg/ Europe Many local initiatives prevention educative websites knowledge = safety 5
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