eMedicine Specialties > Pediatrics: Cardiac Disease and Critical Care Medicine > Toxicology

Toxicity, Carbon Monoxide: Treatment & Medication

Author: Samara Soghoian, MD, Medical Toxicology Fellow, Bellevue Hospital Center, New York University School of Medicine
Coauthor(s): Christopher I Doty, MD, FAAEM, Assistant Professor of Emergency Medicine, Residency Program Director, Department of Emergency Medicine, Kings County Hospital Center, State University of New York Downstate Medical Center; Michael Lucchesi, MD, Chair, Associate Professor, Department of Emergency Medicine, State University of New York at Brooklyn; Guy N Shochat, MD, Associate Clinical Professor of Emergency Medicine, University of California at San Francisco
Contributor Information and Disclosures

Updated: Nov 6, 2008

Treatment

Medical Care

Treatment of carbon monoxide (CO) poisoning is as follows:

  • Prehospital Care
    • Patients should immediately be removed from the source of exposure and given supplemental high-flow oxygen by means of nonrebreather face mask.
    • Patients should be kept calm and still to avoid exertion. Increased oxygen demand exacerbates symptoms.
    • Comatose patients and patients with severely altered mental status should be intubated for airway protection.
    • Cardiac monitoring should be started as soon as possible because of the high incidence of dysrhythmias and cardiac arrest.
    • If possible, emergency medical system (EMS) personnel should try to estimate the total time of exposure and the time elapsed since the patient was removed from the source.
  • Emergency department care
    • As always, attention to the A, B, C, D of resuscitation is the mainstay of emergency care for the patient with carbon monoxide intoxication.
    • Obtunded, comatose, or severely hypoxic patients should be intubated for airway protection.
    • All patients with suspected or confirmed carbon monoxide exposure should be given on 100% oxygen until they are asymptomatic and when carboxyhemoglobin (HbCO) levels are below at least 10%.
    • Cardiac monitoring should be started immediately, and a 12-lead ECG should be performed as soon as possible.
    • Pulse oximetry readings may be falsely elevated in the setting of HbCO because light absorption is nearly identical for HbCO and oxyhemoglobin. Arterial blood gas analysis with co-oximetry should be done to directly measure the HbCO level, to determine the degree of hypoxia, and to monitor the patient's acid-base status.
    • The half-life of HbCO is about 320 minutes (5.3 h) while the person is breathing room air. This decreases to 30-90 minutes with 100% oxygen, which decreases to 15-23 minutes at 2.5-2.8 atm with 100% oxygen. These numbers can be used to estimate the duration of treatment for particular patients.
    • If mild symptoms do not resolve or if severe symptoms are present, hyperbaric oxygen therapy should be strongly considered.
    • Hyperbaric therapy should also be strongly considered for pregnant patients because carbon monoxide readily crosses the placenta, and fetal hemoglobin has greater affinity for carbon monoxide than does normal hemoglobin.
    • Caution should be exercised in treating acidosis because low pH shifts the oxyhemoglobin dissociation curve to the right, increasing oxygen uploading to tissues. Acidosis should improve with oxygenation. Cyanide poisoning should be suspected in cases of severe or recalcitrant acidosis. If concomitant cyanide and carbon monoxide toxicity is suspected, treat the patient with sodium thiosulfate alone. The methemoglobinemia produced by amyl nitrite also shifts the oxyhemoglobin curve to the left, worsening hypoxia at the tissue level.

Consultations

  • Consultation for hyperbaric oxygen therapy may be warranted.
    • Good evidence suggests that hyperbaric oxygen therapy does improve long-term neurologic outcome.6,7 If the patient has any mental status changes or a history of neurologic impairment, an immediate consultation for hyperbaric oxygen treatment should be made. This may require transport to another center after the patient's condition is stabilized.
    • Although the use of hyperbaric oxygen therapy in preventing mortality from carbon monoxide poisoning is still debated, it is now the standard of care for moderate-to-severe carbon monoxide poisoning for patients with neurologic impairment, acidosis, severe hypoxia, myocardial dysfunction or systemic inflammatory response syndrome (SIRS); for pregnant patients with symptomatic poisoning; and for pregnant patients with asymptomatic poisoning with HbCO levels of more than 15%.
    • The nearest hyperbaric oxygen center can be located by calling the Divers Alert Network (DAN) at 1-800-446-2671 or 1-919-684-2948 (Monday-Friday, 9 am to 5 pm [Eastern time]), 1-919-684-2948 (nonemergency medical questions), 1-919-684-8111 (emergencies).
  • Patients with moderate-to-severe cases should be admitted to a medical intensive care unit.
  • A cardiologist should be consulted when patients have evidence of cardiac compromise.
  • A neurologist should be consulted at least for patient follow-up because delayed neurologic symptoms are relatively common.

More on Toxicity, Carbon Monoxide

Overview: Toxicity, Carbon Monoxide
Differential Diagnoses & Workup: Toxicity, Carbon Monoxide
Treatment & Medication: Toxicity, Carbon Monoxide
Follow-up: Toxicity, Carbon Monoxide
References
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References

  1. American Red Cross. Fact Sheet: Carbon Monoxide Poisoning Prevention. Available at http://www.redcross.org/services/disaster/keepsafe/cofacts.html.

  2. CDC. Centers for Disease Control and Prevention. Unintentional non-fire-related carbon monoxide exposures--United States, 2001-2003. MMWR Morb Mortal Wkly Rep. Jan 21 2005;54(2):36-9. [Medline].

  3. Consumer Product Safety Commission. Carbon Monoxide Detectors Can Save Lives. CPSC Document #5010. Available at http://www.cpsc.gov/cpscpub/pubs/5010.html.

  4. Thomassen O, Brattebo G, Rostrup M. Carbon monoxide poisoning while using a small cooking stove in a tent. Am J Emerg Med. May 2004;22(3):204-6. [Medline].

  5. Suner S, Partridge R, Sucov A, et al. Non-invasive pulse CO-oximetry screening in the emergency department identifies occult carbon monoxide toxicity. J Emerg Med. May 2008;34(4):441-50. [Medline].

  6. Weaver LK, Hopkins RO, Larson-Lohr V. Neuropsychologic and functional recovery from severe carbon monoxide poisoning without hyperbaric oxygen therapy. Ann Emerg Med. Jun 1996;27(6):736-40. [Medline].

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  24. Thom SR, Bhopale VM, Fisher D, et al. Delayed neuropathology after carbon monoxide poisoning is immune-mediated. Proc Natl Acad Sci U S A. Sep 14 2004;101(37):13660-5. [Medline].

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Further Reading

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Keywords

carbon monoxide toxicity, carbon monoxide poisoning, CO exposure, carboxyhemoglobin, HbCO, COHB, hyperbaric oxygen therapy, HBO, asphyxia, myocardial dysfunction, smoking, heart disease, pulmonary disease, nausea, shortness of breath, migraine, tension headache, hyperventilation syndrome, syncope, seizure, altered mental status, vertigo, focal neurologic deficits, retinal hemorrhages, papilledema, lethargy, stupor, coma, gait disturbance, movement disorders, apraxia, agnosia, tics, vestibular dysfunction, hearing and visual loss, rigidity, brisk reflexes, emotional lability, frank psychosis

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Contributor Information and Disclosures

Author

Samara Soghoian, MD, Medical Toxicology Fellow, Bellevue Hospital Center, New York University School of Medicine
Samara Soghoian, MD is a member of the following medical societies: American College of Medical Toxicology and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Christopher I Doty, MD, FAAEM, Assistant Professor of Emergency Medicine, Residency Program Director, Department of Emergency Medicine, Kings County Hospital Center, State University of New York Downstate Medical Center
Christopher I Doty, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Michael Lucchesi, MD, Chair, Associate Professor, Department of Emergency Medicine, State University of New York at Brooklyn
Michael Lucchesi, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Guy N Shochat, MD, Associate Clinical Professor of Emergency Medicine, University of California at San Francisco
Guy N Shochat, MD is a member of the following medical societies: Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Halim Hennes, MD, MS, Pediatric Emergency Medicine Research Director, Professor, Departments of Pediatrics and Emergency Medicine, Medical College of Wisconsin
Halim Hennes, MD is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from broker recommendation; Avanir Pharma Stock Investment from broker recommendation

Managing Editor

Jeffrey R Tucker, MD, Assistant Professor, Department of Pediatrics, Division of Emergency Medicine, University of Connecticut and Connecticut Children's Medical Center
Jeffrey R Tucker, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Pediatrics, and Massachusetts Medical Society
Disclosure: Merck Salary Employment

CME Editor

Paul D Petry, DO, FACOP, FAAP, Consulting Staff, Freeman Pediatric Care, Freeman Health System
Paul D Petry, DO, FACOP, FAAP is a member of the following medical societies: American Academy of Osteopathy, American Academy of Pediatrics, American College of Osteopathic Pediatricians, and American Osteopathic Association
Disclosure: Nothing to disclose.

Chief Editor

Timothy E Corden, MD, Associate Professor of Pediatrics, Co-Director, Policy Core, Injury Research Center, Medical College of Wisconsin; Associate Director, PICU, Children's Hospital of Wisconsin
Timothy E Corden, MD is a member of the following medical societies: American Academy of Pediatrics, Phi Beta Kappa, Society of Critical Care Medicine, and Wisconsin Medical Society
Disclosure: Nothing to disclose.

 
 
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