Overview of Carbon Monoxide
Carbon monoxide is a colorless, odorless, and nonirritating gas. It works by
displacing oxygen from hemoglobin, which leads to:
Early tissue hypoxia (lack of oxygen).
Delayed neurologic damage.
Common Sources of Exposure:
Incomplete combustion of fuels (gasoline, kerosene, natural gas, charcoal).
Metabolism of inhaled methylene chloride (found in paint strippers).
Clinical Features
Diagnosis should be considered when there is a history of exposure to gas/propane
motors, heaters, smoke inhalation, or multiple victims presenting with altered mental
status.
Symptoms: Highly variable and primarily affect the cardiovascular and
neurologic systems. They often mimic "flu-like" illnesses, including headache,
dizziness, nausea, vomiting, and coma.
Physical Findings: While "cherry red lips" are often cited as a classic sign,
the text notes this is rarely seen in living patients.
Long-term Effects: Significant poisoning can lead to permanent neurological
and cognitive deficits.
Common Signs and Symptoms
The text lists various acute presentations, including:
Neurologic: Headache, confusion, ataxia, seizures, and focal deficits.
Cardiovascular: Chest pain, ischemic ECG changes, and dysrhythmias.
Other: Visual disturbances, bullous skin lesions, and retinal hemorrhage.
Diagnosis and Differential
Gold Standard: Blood cooximetry is the most reliable diagnostic test.
Carboxyhemoglobin (COHb) Levels: While elevated levels confirm
exposure, they do not necessarily correlate with the severity of symptoms or
the patient's prognosis.
o Baseline levels: Can be up to 5% in nonsmokers and 10% in smokers.
Carboxyhaemoglobin levels 1
3–5%: normal
6–10%: normal for smokers
>25%: high risk of neurological derangement and cardiac ischaemia; late
neurological complications likely
>60%: highly likely to die
Carboxyhaemoglobin levels do not always equate to severity of poisoning.
Pulse Oximetry Warning: Standard pulse oximetry is unreliable because
oxygen saturation readings will appear artificially high or normal even in the
presence of high COHb levels.
Diagnostic Limitations & Lab Findings
A critical takeaway is that standard pulse oximetry is unreliable in these cases;
because it cannot distinguish between oxyhemoglobin and carboxyhemoglobin
(COHb), it will show falsely normal or high oxygen saturation.
Symptomatic patients may present with several secondary clinical abnormalities:
Metabolic: Elevated anion gap metabolic acidosis and elevated lactate.
Cardiac: Elevated troponin and creatine phosphokinase (CPK), or ECG
changes consistent with ischemia.
Neurologic Imaging: Brain imaging may reveal bilateral globus pallidus
lesions.
Emergency Care & Treatment
The primary step is to remove the patient from the source of exposure and stabilize
their airway, breathing, and circulation.
1. Supplemental Oxygen
All patients suspected of poisoning should immediately receive the highest
concentration of supplemental oxygen available (e.g., 100% oxygen via a
non-rebreather facemask).
Treatment should continue until the patient is completely asymptomatic.
2. Hyperbaric Oxygen Therapy (HBO)
Certain severe cases require referral for HBO. This involves breathing pure oxygen in
a pressurized chamber to accelerate the removal of CO from the blood.
Indications for HBO Referral
Neurologic: Syncope, coma, seizures, confusion/altered mental status, or focal
neurologic deficits.
Cardiac: Evidence of acute myocardial ischemia.
Levels & Pregnancy: Carboxyhemoglobin >25% in any patient, or >15% in
pregnant patients (due to increased risks for the fetus).
Disposition
Before discharge, it is essential to ensure that the patient's home or work environment
has been cleared of the carbon monoxide source to prevent re-exposure.
Symptom Severity Disposition Comments
Minimal/No Symptoms Home Assess safety issues.
Headache, Vomiting, Home after Administer 100% oxygen;
Elevated CO symptom resolution observe for 4 hours; assess
safety.
Ataxia, Seizure, Syncope, Hospitalize Administer 100% oxygen;
Chest Pain, Dyspnea consult hyperbaric specialist.