Carbon Monoxide Poisoning

Transcript

34043/01/14 Diagnosing Poisoning: Carbon Monoxide (CO) Headache, nausea/vomiting, drowsiness, dizziness, dyspnoea, chest pain COULD THIS BE A CASE OF CO POISONING? 1 You are confident: This is NOT a case of CO poisoning You are suspicious: Could this be a case of CO poisoning? Action to take: The Pharmaceutical Society of Ireland A N R I A LT Ó I R C Ó G A I S Í O C H TA T H E P H A R M A C Y R E G U L AT O R Ask the patient: Patient presenting with: • Do you feel better away from your house or place of work? • Is anybody else in your family or house experiencing the same symptoms as you? • Have you recently had a heating or cooking appliance installed? • Have all gas, coke/coal, wood, peat or oil fired appliances, eg. cookers, fires, boilers at your home been serviced within the last year? • Have you recently started to re-use heating appliances/ boilers after the summer break/during an unexpected cold spell? • Do you ever use your oven or gas stove for heating purposes as well as for cooking? • Has there been any change in ventilation in your home recently, eg. fitting double glazing? • Have you noticed any sooty stains around appliances or an increase in condensation? • Does your work involve possible exposure to smoke, fumes, motor vehicle exhausts or wood pellets? • Is your home detached, semi-detached, terraced, a bedsit or hostel? 2 GP - General Practice ED - Emergency Department 1. Test for CO GP - breath test for exhaled CO if device is available. (Note: Only indicates recent exposure; interpretation difficult in smokers. For interpretation of results see TOXBASE). ED - h  eparinized venous blood sample for COHb estimation. For interpretation of results see TOXBASE and contact the National Poisons Information Centre (NPIC). 3. P  rotect your patient and others - Contact your HSE local Department of Public Health. They will co-ordinate services for your patient and provide further CO guidance. Telephone gas, oil or solid fuel helpline (see notes). 4. D  O NOT allow patient home without a warning NOT to use the suspect appliances. 5. F  ollow up GP - note that symptoms may persist or develop later. ED - advise patient to see GP for follow-up. Note this advice in discharge letter. 3 Bibliography Crowley D, Scallan E, Herbert J, Staines A, Herity B, Tracey J. Carbon monoxide poisoning in the Republic of Ireland. Ir Med J. 2003 Mar;96(3):83-6. Meredith T, Vale A. Carbon Monoxide Poisoning. British Medical Journal, 1988; 296(6615):77-79. Ernst A, Zibrak J. Carbon Monoxide Poisoning. New England Journal of Medicine, 1998; 339:1603-1608. Stewart RD, Hake CL. Paint-remover hazard. Journal of the American Medical Association, 1976;235:398-401. Hughes NJ, Tracey JA. A case of Methylene chloride (Nitromors) poisoning, effects on carboxyhaemoglobin levels. Human & Experimental Toxicology, 1993; 12:159-160. Varnon J, Marik P, Fromm R, Gueler A. Carbon Monoxide Poisoning: A review for Clinicians. Journal of Emergency Medicine, 1999;17(1):87-93. Thom SR, Keim LW. Carbon monoxide poisoning: A review: Epidemiology, pathophysiology, clinical findings and treatment options including hyperbaric oxygen therapy. Clinical Toxicology, 1989; 27(3):141-156. Smith SJ, Brandon S. Morbidity from acute carbon monoxide poisoning at three-year follow-up. British Medical Journal, 1973:318-321. Hausberg M, Somers VK. Neural circulatory responses to carbon monoxide in healthy humans. Hypertension 1997;29:1114-8. 2. Management - Commence oxygen therapy GP - follow advice on TOXBASE; refer to ED if required. ED - follow advice on TOXBASE. Contact NPIC for severe poisoning. Miller RL, Toal BF, Foscue K, Hansen H, Bayer M. Unintentional Carbon Monoxide Poisoning in residential settings. Connecticut, November 1993-March 1994. MMWR Weekly, 1995;44(41); 765-7. Wilson RC, Saunders PJ, Smith G. An epidemiological study of acute carbon monoxide poisoning in the West Midlands. Occup Environ Med. 1998; 55(11):723-8. Centers For Disease Control and Prevention National Center for Environmental Health. Checklist for the prevention of carbon monoxide poisoning. 1998. Balzan MV, Agius G, Debono AG. Carbon monoxide poisoning: easy to treat but difficult to recognise. Postgraduate Medical Journal 1996;72: 470-473. International Programme on Chemical Safety (IPCS) Environmental Health Criteria 213: Carbon Monoxide (second edition). WHO Task Group, WHO: Geneva & New York, 1999. 464pp. Vreman HJ, Mahoney JJ,Stevenson DK. Carbon monoxide and carboxyhaemoglobin. Advances in Paediatrics, 1995;42:303-334. Calman K. Carbon Monoxide, the Forgotten Killer, Department of Health, UK. 1998. Department of Environment, Community and Local Government. Regulatory Impact Assessment (RIA). Part J (Heating Producing Appliances) of the Building Regulations. 2012. Produced by the Health Protection Unit, Population Health, Health Services Executive and Bord Gáis Networks If patient does not improve: • Contact NPIC for advice. • Contact HSE local Department of Public Health for advice. • Reconsider diagnosis. For further information or to download this fact sheet visit www.carbonmonoxide.ie or call 1850 79 79 79 A guide for GPs and other medical professionals This fact sheet covers: • Sources of carbon monoxide • How to diagnose carbon monoxide poisoning • Clinical signs • Management of carbon monoxide poisoning * In total, approximately 40 people die each year in Ireland from CO poisoning. Approximately half of the deaths from unintentional CO poisonings result from the inhalation of smoke from fires. Other significant causes are vehicle exhausts and deaths in industrial/commercial settings. Sources of carbon monoxide Carbon monoxide is produced by the incomplete •  combustion of carbon-containing fuel including gas (natural, piped or bottled), coal, coke, oil, turf, biofuel and wood. Gas fuel leaks per se are not a source of carbon monoxide •  unless there is a combustion process of some sort involved. 4 A N R I A LT Ó I R C Ó G A I S Í O C H TA T H E P H A R M A C Y R E G U L AT O R Diagnostic algorithm reproduced with the kind permission of the UK Health Protection Agency. PAGE 6 | CARBON MONOXIDE POISONING • Mechanisms of action of carbon monoxide • Diagnostic algorithm • Bibliography Carbon Monoxide (also known as CO) is a colourless, odourless, poisonous gas and is a common yet preventable cause of death from poisoning worldwide. On average 6 people die each year in Ireland from unintentional CO poisoning in incidents related to heating or other fossil fuel installations*. Many more are treated in hospital suffering from CO poisoning. Because of the non-specific nature of its symptoms, poisoning by carbon monoxide is most probably under-diagnosed and there could well be a large number of people being exposed and suffering the ill effects of exposure. Older people, children, pregnant women and their babies and those with breathing problems or cardiovascular disease are at increased risk. Poisoning can result in lasting neurological damage. • Carbon monoxide can also be produced by the natural oxidation of wood pellets in storage even without combustion. The Pharmaceutical Society of Ireland G26678 BG CO GP FactSheet_A4_v11.indd 2 CARBON MONOXIDE POISONING Potential sources include the following: gas stoves, fires •  and boilers, barbeques and patio heaters, gas powered water heaters, paraffin heaters, solid fuel stoves, boilers and room heaters. CUMANN CÓGAISEOIRÍ NA hÉIREANN PAGE 5 | CARBON MONOXIDE POISONING CUMANN CÓGAISEOIRÍ NA hÉIREANN Inadequate maintenance leading to poor combustion and •  partially blocked or damaged flues and chimneys are the main causes of indoor carbon monoxide accumulation. Carbon monoxide can also seep into properties via shared •  flues and chimneys. Integral garages can be a source of carbon monoxide if car •  or other engines are run without adequate ventilation. Barbeques can produce large amounts of carbon monoxide •  and can be very dangerous if used indoors or under cover. Carbon monoxide poisoning is not restricted to poorer •  homes, student accommodation or those from lower income groups. Carbon monoxide can occur in modern homes fitted with modern appliances. Holiday residences, caravans, boats and mobile homes •  are also at risk as they often use portable appliances which burn fuel. Exhaust gases from vehicle engines and generators of electricity can also contain high levels of CO. All forms of carbon fuel combustion can lead to •  production of carbon monoxide gas. CARBON MONOXIDE POISONING | PAGE 1 16/01/2014 19:59 How to diagnose carbon monoxide poisoning See also the Diagnostic Algorithm on Page 5 The diagnosis of carbon monoxide poisoning can be difficult as it may simulate many other conditions: unless poisoning is suspected the diagnosis may be missed. The onset of symptoms is often insidious and may not be recognised by either the patient or the doctor. The most common symptoms and an indication of their approximate frequency in carbon monoxide poisoning are shown below: • Headache - 90% • Nausea and vomiting - 50% • Vertigo - 50% • Alteration in consciousness - 30% • Subjective weakness - 20% Whilst exposure to high concentrations of carbon monoxide leads to collapse, chronic exposure to lower concentrations may lead to the symptoms and signs of influenza, food poisoning (apparently classic cases of food poisoning of a whole family may be produced by carbon monoxide poisoning), migraine, tension headaches and depression. Prolonged exposure to concentrations that produce only minor symptoms may, in some cases, be associated with lasting neurological effects including difficulty in concentrating and emotional lability. Complaints about such problems should alert the doctor to the possibility of carbon monoxide poisoning. Headache is the most common symptom – think CO! Clues to the diagnosis The source of CO may be in the home, in the car due to a leaking exhaust system, or in the workplace. Gas, oil, coal, coke and wood heating appliances are the most common sources in the home. Carbon monoxide can also leak into a semi-detached or terraced house/apartment from neighbouring premises. The following are suggestive of domestic carbon The following signs may be recognised in the home: monoxide poisoning: • Black sooty marks on the radiants of gas fires. • More than one person in the house affected. • Black sooty marks on the wall around stoves, boilers and fires. • Symptoms disappear when away from the house eg. on holiday or at work, but recur on • S moke and/or excessive condensation accumulating returning home. in rooms due to faulty flues (though you cannot smell carbon monoxide you can smell other • Symptoms related to cooking: oven, stove or grill in use. combustion products).  ellow or orange instead of blue flames from gas • S ymptoms worse in winter: heating in use or fires lit. • Y appliances or boiler pilot lights. Carbon monoxide sources are multiple – there may be more than one source of exposure. Clinical signs The cherry red skin colour produced when carboxyhaemoglobin (COHb) concentrations exceed about 20% is rarely seen in life. Neurological signs must be looked for: a neurological examination, including tests of fine movement and balance (finger-nose movement, Rhomberg’s test, normal gait and heel-toe walking), a mini-mental state examination and testing of short term memory and the ability to subtract 7, serially, from 100, are key to determining a chronic poisoning event. Carbon monoxide is produced continuously in the body as a by-product of haem breakdown. This leads to a normal baseline COHb concentration of about 0.5%. In pregnancy and especially in haemolytic anaemias this can rise towards 5%. Cigarette smoking leads to COHb concentrations of up to about 13% in heavy smokers. PAGE 2 | CARBON MONOXIDE POISONING G26678 BG CO GP FactSheet_A4_v11.indd 3 Management of carbon monoxide poisoning in a primary care setting Monitors are available such as those used in smoking cessation clinics that measure carbon monoxide concentration in expired air and convert this value into COHb concentration in blood. These devices should be used where available, but must be used soon after likely exposure: there is no point in taking a measurement if the patient has spent hours away from the source of carbon monoxide. CO levels in the blood decline with a half life of about 6 hours, so measurements taken the next day at the surgery may be misleading. Alternatively, if a monitor is not available, and carbon monoxide poisoning is suspected, the patient may be referred to the local Emergency Department for further assessment. COHb can be measured in blood by any clinical chemistry laboratory. Venous blood should be taken into anti-coagulant and sent to the local clinical chemical laboratory for analysis. COHb should be measured directly: measuring PO2 and calculating the % saturation of haemoglobin with oxygen will be misleading as the PO2 in CO poisoning may well be normal. Several suitable instruments are available, for example: the radiometer co-oximeter. Pulse oximetry in cases of suspected carbon monoxide poisoning is not recommended because false high oxygen saturations are likely to be recorded due to the similar light absorbance of carboxyhaemoglobin and oxyhaemoglobin. Rapid measurement of expired air CO is useful in diagnosis. Blood COHb is also useful. Expired air CO and blood COHb are poor guides to prognosis and the need for hyperbaric treatment. For interpretation of results and detailed advice on CO poisoning see TOXBASE and/or call the National Poisons Information Centre (NPIC). Remember that a normal concentration of COHb does not disprove CO poisoning unless the sample has been taken soon after exposure ended. Mechanisms of action of carbon monoxide Recent studies have shown that carbon monoxide may function as a local transmitter substance in the body playing a role in controlling permeability of the micro-vasculature and may increase adhesion of inflammatory cells and platelets to the capillary endothelium. Carbon monoxide poisoning leads to leakage of fluid across cerebral capillaries and thus to cerebral oedema. In those who have been exposed to enough carbon monoxide to produce unconsciousness, delayed neurological damage due to leuko-encephalopathy may occur. Damage tends to be focused PAGE 3 | CARBON MONOXIDE POISONING Preventing further exposure is the most important thing you can do. If you strongly suspect CO poisoning do not wait for the result of the analysis Investigations Carbon monoxide binds to haemoglobin with about 240 times the affinity of oxygen and also causes a left shift in the oxyhaemoglobin dissociation curve. These effects combine to reduce oxygen delivery to the tissues. In addition, carbon monoxide is transported dissolved in plasma and binds to intracellular myoglobin and mitochondrial cytochrome enzymes. Binding to cytochrome A3 is thought to play an important part in the toxicity of this gas. Management on those parts of the brain lying at the boundaries of the fields supplied by two cerebral arterial systems, eg. the basal ganglia. Neurological damage seems to be the result of free radical generation and lipid peroxidation. It is possible that the binding of carbon monoxide to cytochrome A3 reduces the capacity of cells to deal with free radicals. Carbon monoxide bound to haemoglobin has a half-life of about 320 minutes under normal circumstances. This can be reduced by exposing the patient to 100% oxygen: This reduces the half-life to 80 minutes; or to 100% oxygen at 2 atmospheres pressure (hyperbaric oxygen) which reduces the half-life to 23 minutes. The half-life of carbon monoxide bound to mitochondrial cytochromes may well be much longer than that of carboxyhaemoglobin and hyperbaric oxygen has been suggested as being important in attacking this binding site. Carbon monoxide binds to fetal haemoglobin and shifts the already left-shifted oxyhaemoglobin dissociation curve further to the left. The half-life of carbon monoxide in the fetus is longer than that in the mother. • Remove the patient and others from the source of carbon monoxide. • Give 100% oxygen - A tightly fitting mask with an inflated face-seal is necessary for the administration of 100% oxygen. • Consider referring for hyperbaric oxygen treatment (see below). • If a natural gas appliance is suspected, advise to arrange a FREE safety check by calling 1850 79 79 79, or if you consider the situation an emergency and others may be at immediate risk, call Bord Gáis Networks on 1850 20 50 50. • For other fuel types, contacting the relevant safety service for the fuel type is essential: OFTEC (01 877 5450) for oil. For other fuel types, contact the fuel supplier or a qualified service agent for the appliance. • Arrange checking of appliances, flues and chimneys and measurement of CO concentration in the house before allowing anyone back. • Contact social services, if necessary. • Contact your HSE local Department of Public Health to co-ordinate environmental health, safety, social and other services to protect your patient and others. Contact details can be found on the HSE website. • Follow-up is important as further consequences of chronic exposure to CO may be delayed, or mild symptoms may persist, multiply or intensify. • Recommend the purchase of an audible carbon monoxide alarm for installation in the home. • Follow the advice on TOXBASE (www.toxbase.org) or refer to the National Poisons Information Centre (NPIC) on 01 837 9964 / 01 809 2566 for more detailed advice on the management of CO poisoning. • Further information and advice on carbon monoxide causes, prevention and protection measures can be found at www.carbonmonoxide.ie Indications for hyperbaric oxygen therapy (HBOT) There is debate about the added value provided by hyperbaric oxygen. A COHb concentration of >20% should be an indication to consider hyperbaric oxygen and the decision should be taken on the basis of the indicators listed below: • Loss of consciousness at any stage. • Neurological signs other than headache. • Myocardial ischaemia/arrhythmia diagnosed by ECG. • The patient is pregnant. HBOT is also thought to be of use for extensive exposure to CO and if neurological damage is suspected, its use should be on a case by case basis. CARBON MONOXIDE POISONING | PAGE 4 16/01/2014 19:59 How to diagnose carbon monoxide poisoning See also the Diagnostic Algorithm on Page 5 The diagnosis of carbon monoxide poisoning can be difficult as it may simulate many other conditions: unless poisoning is suspected the diagnosis may be missed. The onset of symptoms is often insidious and may not be recognised by either the patient or the doctor. The most common symptoms and an indication of their approximate frequency in carbon monoxide poisoning are shown below: • Headache - 90% • Nausea and vomiting - 50% • Vertigo - 50% • Alteration in consciousness - 30% • Subjective weakness - 20% Whilst exposure to high concentrations of carbon monoxide leads to collapse, chronic exposure to lower concentrations may lead to the symptoms and signs of influenza, food poisoning (apparently classic cases of food poisoning of a whole family may be produced by carbon monoxide poisoning), migraine, tension headaches and depression. Prolonged exposure to concentrations that produce only minor symptoms may, in some cases, be associated with lasting neurological effects including difficulty in concentrating and emotional lability. Complaints about such problems should alert the doctor to the possibility of carbon monoxide poisoning. Headache is the most common symptom – think CO! Clues to the diagnosis The source of CO may be in the home, in the car due to a leaking exhaust system, or in the workplace. Gas, oil, coal, coke and wood heating appliances are the most common sources in the home. Carbon monoxide can also leak into a semi-detached or terraced house/apartment from neighbouring premises. The following are suggestive of domestic carbon The following signs may be recognised in the home: monoxide poisoning: • Black sooty marks on the radiants of gas fires. • More than one person in the house affected. • Black sooty marks on the wall around stoves, boilers and fires. • Symptoms disappear when away from the house eg. on holiday or at work, but recur on • S moke and/or excessive condensation accumulating returning home. in rooms due to faulty flues (though you cannot smell carbon monoxide you can smell other • Symptoms related to cooking: oven, stove or grill in use. combustion products).  ellow or orange instead of blue flames from gas • S ymptoms worse in winter: heating in use or fires lit. • Y appliances or boiler pilot lights. Carbon monoxide sources are multiple – there may be more than one source of exposure. Clinical signs The cherry red skin colour produced when carboxyhaemoglobin (COHb) concentrations exceed about 20% is rarely seen in life. Neurological signs must be looked for: a neurological examination, including tests of fine movement and balance (finger-nose movement, Rhomberg’s test, normal gait and heel-toe walking), a mini-mental state examination and testing of short term memory and the ability to subtract 7, serially, from 100, are key to determining a chronic poisoning event. Carbon monoxide is produced continuously in the body as a by-product of haem breakdown. This leads to a normal baseline COHb concentration of about 0.5%. In pregnancy and especially in haemolytic anaemias this can rise towards 5%. Cigarette smoking leads to COHb concentrations of up to about 13% in heavy smokers. PAGE 2 | CARBON MONOXIDE POISONING G26678 BG CO GP FactSheet_A4_v11.indd 3 Management of carbon monoxide poisoning in a primary care setting Monitors are available such as those used in smoking cessation clinics that measure carbon monoxide concentration in expired air and convert this value into COHb concentration in blood. These devices should be used where available, but must be used soon after likely exposure: there is no point in taking a measurement if the patient has spent hours away from the source of carbon monoxide. CO levels in the blood decline with a half life of about 6 hours, so measurements taken the next day at the surgery may be misleading. Alternatively, if a monitor is not available, and carbon monoxide poisoning is suspected, the patient may be referred to the local Emergency Department for further assessment. COHb can be measured in blood by any clinical chemistry laboratory. Venous blood should be taken into anti-coagulant and sent to the local clinical chemical laboratory for analysis. COHb should be measured directly: measuring PO2 and calculating the % saturation of haemoglobin with oxygen will be misleading as the PO2 in CO poisoning may well be normal. Several suitable instruments are available, for example: the radiometer co-oximeter. Pulse oximetry in cases of suspected carbon monoxide poisoning is not recommended because false high oxygen saturations are likely to be recorded due to the similar light absorbance of carboxyhaemoglobin and oxyhaemoglobin. Rapid measurement of expired air CO is useful in diagnosis. Blood COHb is also useful. Expired air CO and blood COHb are poor guides to prognosis and the need for hyperbaric treatment. For interpretation of results and detailed advice on CO poisoning see TOXBASE and/or call the National Poisons Information Centre (NPIC). Remember that a normal concentration of COHb does not disprove CO poisoning unless the sample has been taken soon after exposure ended. Mechanisms of action of carbon monoxide Recent studies have shown that carbon monoxide may function as a local transmitter substance in the body playing a role in controlling permeability of the micro-vasculature and may increase adhesion of inflammatory cells and platelets to the capillary endothelium. Carbon monoxide poisoning leads to leakage of fluid across cerebral capillaries and thus to cerebral oedema. In those who have been exposed to enough carbon monoxide to produce unconsciousness, delayed neurological damage due to leuko-encephalopathy may occur. Damage tends to be focused PAGE 3 | CARBON MONOXIDE POISONING Preventing further exposure is the most important thing you can do. If you strongly suspect CO poisoning do not wait for the result of the analysis Investigations Carbon monoxide binds to haemoglobin with about 240 times the affinity of oxygen and also causes a left shift in the oxyhaemoglobin dissociation curve. These effects combine to reduce oxygen delivery to the tissues. In addition, carbon monoxide is transported dissolved in plasma and binds to intracellular myoglobin and mitochondrial cytochrome enzymes. Binding to cytochrome A3 is thought to play an important part in the toxicity of this gas. Management on those parts of the brain lying at the boundaries of the fields supplied by two cerebral arterial systems, eg. the basal ganglia. Neurological damage seems to be the result of free radical generation and lipid peroxidation. It is possible that the binding of carbon monoxide to cytochrome A3 reduces the capacity of cells to deal with free radicals. Carbon monoxide bound to haemoglobin has a half-life of about 320 minutes under normal circumstances. This can be reduced by exposing the patient to 100% oxygen: This reduces the half-life to 80 minutes; or to 100% oxygen at 2 atmospheres pressure (hyperbaric oxygen) which reduces the half-life to 23 minutes. The half-life of carbon monoxide bound to mitochondrial cytochromes may well be much longer than that of carboxyhaemoglobin and hyperbaric oxygen has been suggested as being important in attacking this binding site. Carbon monoxide binds to fetal haemoglobin and shifts the already left-shifted oxyhaemoglobin dissociation curve further to the left. The half-life of carbon monoxide in the fetus is longer than that in the mother. • Remove the patient and others from the source of carbon monoxide. • Give 100% oxygen - A tightly fitting mask with an inflated face-seal is necessary for the administration of 100% oxygen. • Consider referring for hyperbaric oxygen treatment (see below). • If a natural gas appliance is suspected, advise to arrange a FREE safety check by calling 1850 79 79 79, or if you consider the situation an emergency and others may be at immediate risk, call Bord Gáis Networks on 1850 20 50 50. • For other fuel types, contacting the relevant safety service for the fuel type is essential: OFTEC (01 877 5450) for oil. For other fuel types, contact the fuel supplier or a qualified service agent for the appliance. • Arrange checking of appliances, flues and chimneys and measurement of CO concentration in the house before allowing anyone back. • Contact social services, if necessary. • Contact your HSE local Department of Public Health to co-ordinate environmental health, safety, social and other services to protect your patient and others. Contact details can be found on the HSE website. • Follow-up is important as further consequences of chronic exposure to CO may be delayed, or mild symptoms may persist, multiply or intensify. • Recommend the purchase of an audible carbon monoxide alarm for installation in the home. • Follow the advice on TOXBASE (www.toxbase.org) or refer to the National Poisons Information Centre (NPIC) on 01 837 9964 / 01 809 2566 for more detailed advice on the management of CO poisoning. • Further information and advice on carbon monoxide causes, prevention and protection measures can be found at www.carbonmonoxide.ie Indications for hyperbaric oxygen therapy (HBOT) There is debate about the added value provided by hyperbaric oxygen. A COHb concentration of >20% should be an indication to consider hyperbaric oxygen and the decision should be taken on the basis of the indicators listed below: • Loss of consciousness at any stage. • Neurological signs other than headache. • Myocardial ischaemia/arrhythmia diagnosed by ECG. • The patient is pregnant. HBOT is also thought to be of use for extensive exposure to CO and if neurological damage is suspected, its use should be on a case by case basis. CARBON MONOXIDE POISONING | PAGE 4 16/01/2014 19:59 How to diagnose carbon monoxide poisoning See also the Diagnostic Algorithm on Page 5 The diagnosis of carbon monoxide poisoning can be difficult as it may simulate many other conditions: unless poisoning is suspected the diagnosis may be missed. The onset of symptoms is often insidious and may not be recognised by either the patient or the doctor. The most common symptoms and an indication of their approximate frequency in carbon monoxide poisoning are shown below: • Headache - 90% • Nausea and vomiting - 50% • Vertigo - 50% • Alteration in consciousness - 30% • Subjective weakness - 20% Whilst exposure to high concentrations of carbon monoxide leads to collapse, chronic exposure to lower concentrations may lead to the symptoms and signs of influenza, food poisoning (apparently classic cases of food poisoning of a whole family may be produced by carbon monoxide poisoning), migraine, tension headaches and depression. Prolonged exposure to concentrations that produce only minor symptoms may, in some cases, be associated with lasting neurological effects including difficulty in concentrating and emotional lability. Complaints about such problems should alert the doctor to the possibility of carbon monoxide poisoning. Headache is the most common symptom – think CO! Clues to the diagnosis The source of CO may be in the home, in the car due to a leaking exhaust system, or in the workplace. Gas, oil, coal, coke and wood heating appliances are the most common sources in the home. Carbon monoxide can also leak into a semi-detached or terraced house/apartment from neighbouring premises. The following are suggestive of domestic carbon The following signs may be recognised in the home: monoxide poisoning: • Black sooty marks on the radiants of gas fires. • More than one person in the house affected. • Black sooty marks on the wall around stoves, boilers and fires. • Symptoms disappear when away from the house eg. on holiday or at work, but recur on • S moke and/or excessive condensation accumulating returning home. in rooms due to faulty flues (though you cannot smell carbon monoxide you can smell other • Symptoms related to cooking: oven, stove or grill in use. combustion products).  ellow or orange instead of blue flames from gas • S ymptoms worse in winter: heating in use or fires lit. • Y appliances or boiler pilot lights. Carbon monoxide sources are multiple – there may be more than one source of exposure. Clinical signs The cherry red skin colour produced when carboxyhaemoglobin (COHb) concentrations exceed about 20% is rarely seen in life. Neurological signs must be looked for: a neurological examination, including tests of fine movement and balance (finger-nose movement, Rhomberg’s test, normal gait and heel-toe walking), a mini-mental state examination and testing of short term memory and the ability to subtract 7, serially, from 100, are key to determining a chronic poisoning event. Carbon monoxide is produced continuously in the body as a by-product of haem breakdown. This leads to a normal baseline COHb concentration of about 0.5%. In pregnancy and especially in haemolytic anaemias this can rise towards 5%. Cigarette smoking leads to COHb concentrations of up to about 13% in heavy smokers. PAGE 2 | CARBON MONOXIDE POISONING G26678 BG CO GP FactSheet_A4_v11.indd 3 Management of carbon monoxide poisoning in a primary care setting Monitors are available such as those used in smoking cessation clinics that measure carbon monoxide concentration in expired air and convert this value into COHb concentration in blood. These devices should be used where available, but must be used soon after likely exposure: there is no point in taking a measurement if the patient has spent hours away from the source of carbon monoxide. CO levels in the blood decline with a half life of about 6 hours, so measurements taken the next day at the surgery may be misleading. Alternatively, if a monitor is not available, and carbon monoxide poisoning is suspected, the patient may be referred to the local Emergency Department for further assessment. COHb can be measured in blood by any clinical chemistry laboratory. Venous blood should be taken into anti-coagulant and sent to the local clinical chemical laboratory for analysis. COHb should be measured directly: measuring PO2 and calculating the % saturation of haemoglobin with oxygen will be misleading as the PO2 in CO poisoning may well be normal. Several suitable instruments are available, for example: the radiometer co-oximeter. Pulse oximetry in cases of suspected carbon monoxide poisoning is not recommended because false high oxygen saturations are likely to be recorded due to the similar light absorbance of carboxyhaemoglobin and oxyhaemoglobin. Rapid measurement of expired air CO is useful in diagnosis. Blood COHb is also useful. Expired air CO and blood COHb are poor guides to prognosis and the need for hyperbaric treatment. For interpretation of results and detailed advice on CO poisoning see TOXBASE and/or call the National Poisons Information Centre (NPIC). Remember that a normal concentration of COHb does not disprove CO poisoning unless the sample has been taken soon after exposure ended. Mechanisms of action of carbon monoxide Recent studies have shown that carbon monoxide may function as a local transmitter substance in the body playing a role in controlling permeability of the micro-vasculature and may increase adhesion of inflammatory cells and platelets to the capillary endothelium. Carbon monoxide poisoning leads to leakage of fluid across cerebral capillaries and thus to cerebral oedema. In those who have been exposed to enough carbon monoxide to produce unconsciousness, delayed neurological damage due to leuko-encephalopathy may occur. Damage tends to be focused PAGE 3 | CARBON MONOXIDE POISONING Preventing further exposure is the most important thing you can do. If you strongly suspect CO poisoning do not wait for the result of the analysis Investigations Carbon monoxide binds to haemoglobin with about 240 times the affinity of oxygen and also causes a left shift in the oxyhaemoglobin dissociation curve. These effects combine to reduce oxygen delivery to the tissues. In addition, carbon monoxide is transported dissolved in plasma and binds to intracellular myoglobin and mitochondrial cytochrome enzymes. Binding to cytochrome A3 is thought to play an important part in the toxicity of this gas. Management on those parts of the brain lying at the boundaries of the fields supplied by two cerebral arterial systems, eg. the basal ganglia. Neurological damage seems to be the result of free radical generation and lipid peroxidation. It is possible that the binding of carbon monoxide to cytochrome A3 reduces the capacity of cells to deal with free radicals. Carbon monoxide bound to haemoglobin has a half-life of about 320 minutes under normal circumstances. This can be reduced by exposing the patient to 100% oxygen: This reduces the half-life to 80 minutes; or to 100% oxygen at 2 atmospheres pressure (hyperbaric oxygen) which reduces the half-life to 23 minutes. The half-life of carbon monoxide bound to mitochondrial cytochromes may well be much longer than that of carboxyhaemoglobin and hyperbaric oxygen has been suggested as being important in attacking this binding site. Carbon monoxide binds to fetal haemoglobin and shifts the already left-shifted oxyhaemoglobin dissociation curve further to the left. The half-life of carbon monoxide in the fetus is longer than that in the mother. • Remove the patient and others from the source of carbon monoxide. • Give 100% oxygen - A tightly fitting mask with an inflated face-seal is necessary for the administration of 100% oxygen. • Consider referring for hyperbaric oxygen treatment (see below). • If a natural gas appliance is suspected, advise to arrange a FREE safety check by calling 1850 79 79 79, or if you consider the situation an emergency and others may be at immediate risk, call Bord Gáis Networks on 1850 20 50 50. • For other fuel types, contacting the relevant safety service for the fuel type is essential: OFTEC (01 877 5450) for oil. For other fuel types, contact the fuel supplier or a qualified service agent for the appliance. • Arrange checking of appliances, flues and chimneys and measurement of CO concentration in the house before allowing anyone back. • Contact social services, if necessary. • Contact your HSE local Department of Public Health to co-ordinate environmental health, safety, social and other services to protect your patient and others. Contact details can be found on the HSE website. • Follow-up is important as further consequences of chronic exposure to CO may be delayed, or mild symptoms may persist, multiply or intensify. • Recommend the purchase of an audible carbon monoxide alarm for installation in the home. • Follow the advice on TOXBASE (www.toxbase.org) or refer to the National Poisons Information Centre (NPIC) on 01 837 9964 / 01 809 2566 for more detailed advice on the management of CO poisoning. • Further information and advice on carbon monoxide causes, prevention and protection measures can be found at www.carbonmonoxide.ie Indications for hyperbaric oxygen therapy (HBOT) There is debate about the added value provided by hyperbaric oxygen. A COHb concentration of >20% should be an indication to consider hyperbaric oxygen and the decision should be taken on the basis of the indicators listed below: • Loss of consciousness at any stage. • Neurological signs other than headache. • Myocardial ischaemia/arrhythmia diagnosed by ECG. • The patient is pregnant. HBOT is also thought to be of use for extensive exposure to CO and if neurological damage is suspected, its use should be on a case by case basis. CARBON MONOXIDE POISONING | PAGE 4 16/01/2014 19:59 34043/01/14 Diagnosing Poisoning: Carbon Monoxide (CO) Headache, nausea/vomiting, drowsiness, dizziness, dyspnoea, chest pain COULD THIS BE A CASE OF CO POISONING? 1 You are confident: This is NOT a case of CO poisoning You are suspicious: Could this be a case of CO poisoning? Action to take: The Pharmaceutical Society of Ireland A N R I A LT Ó I R C Ó G A I S Í O C H TA T H E P H A R M A C Y R E G U L AT O R Ask the patient: Patient presenting with: • Do you feel better away from your house or place of work? • Is anybody else in your family or house experiencing the same symptoms as you? • Have you recently had a heating or cooking appliance installed? • Have all gas, coke/coal, wood, peat or oil fired appliances, eg. cookers, fires, boilers at your home been serviced within the last year? • Have you recently started to re-use heating appliances/ boilers after the summer break/during an unexpected cold spell? • Do you ever use your oven or gas stove for heating purposes as well as for cooking? • Has there been any change in ventilation in your home recently, eg. fitting double glazing? • Have you noticed any sooty stains around appliances or an increase in condensation? • Does your work involve possible exposure to smoke, fumes, motor vehicle exhausts or wood pellets? • Is your home detached, semi-detached, terraced, a bedsit or hostel? 2 GP - General Practice ED - Emergency Department 1. Test for CO GP - breath test for exhaled CO if device is available. (Note: Only indicates recent exposure; interpretation difficult in smokers. For interpretation of results see TOXBASE). ED - h  eparinized venous blood sample for COHb estimation. For interpretation of results see TOXBASE and contact the National Poisons Information Centre (NPIC). 3. P  rotect your patient and others - Contact your HSE local Department of Public Health. They will co-ordinate services for your patient and provide further CO guidance. Telephone gas, oil or solid fuel helpline (see notes). 4. D  O NOT allow patient home without a warning NOT to use the suspect appliances. 5. F  ollow up GP - note that symptoms may persist or develop later. ED - advise patient to see GP for follow-up. Note this advice in discharge letter. 3 Bibliography Crowley D, Scallan E, Herbert J, Staines A, Herity B, Tracey J. Carbon monoxide poisoning in the Republic of Ireland. Ir Med J. 2003 Mar;96(3):83-6. Meredith T, Vale A. Carbon Monoxide Poisoning. British Medical Journal, 1988; 296(6615):77-79. Ernst A, Zibrak J. Carbon Monoxide Poisoning. New England Journal of Medicine, 1998; 339:1603-1608. Stewart RD, Hake CL. Paint-remover hazard. Journal of the American Medical Association, 1976;235:398-401. Hughes NJ, Tracey JA. A case of Methylene chloride (Nitromors) poisoning, effects on carboxyhaemoglobin levels. Human & Experimental Toxicology, 1993; 12:159-160. Varnon J, Marik P, Fromm R, Gueler A. Carbon Monoxide Poisoning: A review for Clinicians. Journal of Emergency Medicine, 1999;17(1):87-93. Thom SR, Keim LW. Carbon monoxide poisoning: A review: Epidemiology, pathophysiology, clinical findings and treatment options including hyperbaric oxygen therapy. Clinical Toxicology, 1989; 27(3):141-156. Smith SJ, Brandon S. Morbidity from acute carbon monoxide poisoning at three-year follow-up. British Medical Journal, 1973:318-321. Hausberg M, Somers VK. Neural circulatory responses to carbon monoxide in healthy humans. Hypertension 1997;29:1114-8. 2. Management - Commence oxygen therapy GP - follow advice on TOXBASE; refer to ED if required. ED - follow advice on TOXBASE. Contact NPIC for severe poisoning. Miller RL, Toal BF, Foscue K, Hansen H, Bayer M. Unintentional Carbon Monoxide Poisoning in residential settings. Connecticut, November 1993-March 1994. MMWR Weekly, 1995;44(41); 765-7. Wilson RC, Saunders PJ, Smith G. An epidemiological study of acute carbon monoxide poisoning in the West Midlands. Occup Environ Med. 1998; 55(11):723-8. Centers For Disease Control and Prevention National Center for Environmental Health. Checklist for the prevention of carbon monoxide poisoning. 1998. Balzan MV, Agius G, Debono AG. Carbon monoxide poisoning: easy to treat but difficult to recognise. Postgraduate Medical Journal 1996;72: 470-473. International Programme on Chemical Safety (IPCS) Environmental Health Criteria 213: Carbon Monoxide (second edition). WHO Task Group, WHO: Geneva & New York, 1999. 464pp. Vreman HJ, Mahoney JJ,Stevenson DK. Carbon monoxide and carboxyhaemoglobin. Advances in Paediatrics, 1995;42:303-334. Calman K. Carbon Monoxide, the Forgotten Killer, Department of Health, UK. 1998. Department of Environment, Community and Local Government. Regulatory Impact Assessment (RIA). Part J (Heating Producing Appliances) of the Building Regulations. 2012. Produced by the Health Protection Unit, Population Health, Health Services Executive and Bord Gáis Networks If patient does not improve: • Contact NPIC for advice. • Contact HSE local Department of Public Health for advice. • Reconsider diagnosis. For further information or to download this fact sheet visit www.carbonmonoxide.ie or call 1850 79 79 79 A guide for GPs and other medical professionals This fact sheet covers: • Sources of carbon monoxide • How to diagnose carbon monoxide poisoning • Clinical signs • Management of carbon monoxide poisoning * In total, approximately 40 people die each year in Ireland from CO poisoning. Approximately half of the deaths from unintentional CO poisonings result from the inhalation of smoke from fires. Other significant causes are vehicle exhausts and deaths in industrial/commercial settings. Sources of carbon monoxide Carbon monoxide is produced by the incomplete •  combustion of carbon-containing fuel including gas (natural, piped or bottled), coal, coke, oil, turf, biofuel and wood. Gas fuel leaks per se are not a source of carbon monoxide •  unless there is a combustion process of some sort involved. 4 A N R I A LT Ó I R C Ó G A I S Í O C H TA T H E P H A R M A C Y R E G U L AT O R Diagnostic algorithm reproduced with the kind permission of the UK Health Protection Agency. PAGE 6 | CARBON MONOXIDE POISONING • Mechanisms of action of carbon monoxide • Diagnostic algorithm • Bibliography Carbon Monoxide (also known as CO) is a colourless, odourless, poisonous gas and is a common yet preventable cause of death from poisoning worldwide. On average 6 people die each year in Ireland from unintentional CO poisoning in incidents related to heating or other fossil fuel installations*. Many more are treated in hospital suffering from CO poisoning. Because of the non-specific nature of its symptoms, poisoning by carbon monoxide is most probably under-diagnosed and there could well be a large number of people being exposed and suffering the ill effects of exposure. Older people, children, pregnant women and their babies and those with breathing problems or cardiovascular disease are at increased risk. Poisoning can result in lasting neurological damage. • Carbon monoxide can also be produced by the natural oxidation of wood pellets in storage even without combustion. The Pharmaceutical Society of Ireland G26678 BG CO GP FactSheet_A4_v11.indd 2 CARBON MONOXIDE POISONING Potential sources include the following: gas stoves, fires •  and boilers, barbeques and patio heaters, gas powered water heaters, paraffin heaters, solid fuel stoves, boilers and room heaters. CUMANN CÓGAISEOIRÍ NA hÉIREANN PAGE 5 | CARBON MONOXIDE POISONING CUMANN CÓGAISEOIRÍ NA hÉIREANN Inadequate maintenance leading to poor combustion and •  partially blocked or damaged flues and chimneys are the main causes of indoor carbon monoxide accumulation. Carbon monoxide can also seep into properties via shared •  flues and chimneys. Integral garages can be a source of carbon monoxide if car •  or other engines are run without adequate ventilation. Barbeques can produce large amounts of carbon monoxide •  and can be very dangerous if used indoors or under cover. Carbon monoxide poisoning is not restricted to poorer •  homes, student accommodation or those from lower income groups. Carbon monoxide can occur in modern homes fitted with modern appliances. Holiday residences, caravans, boats and mobile homes •  are also at risk as they often use portable appliances which burn fuel. Exhaust gases from vehicle engines and generators of electricity can also contain high levels of CO. All forms of carbon fuel combustion can lead to •  production of carbon monoxide gas. CARBON MONOXIDE POISONING | PAGE 1 16/01/2014 19:59 34043/01/14 Diagnosing Poisoning: Carbon Monoxide (CO) Headache, nausea/vomiting, drowsiness, dizziness, dyspnoea, chest pain COULD THIS BE A CASE OF CO POISONING? 1 You are confident: This is NOT a case of CO poisoning You are suspicious: Could this be a case of CO poisoning? Action to take: The Pharmaceutical Society of Ireland A N R I A LT Ó I R C Ó G A I S Í O C H TA T H E P H A R M A C Y R E G U L AT O R Ask the patient: Patient presenting with: • Do you feel better away from your house or place of work? • Is anybody else in your family or house experiencing the same symptoms as you? • Have you recently had a heating or cooking appliance installed? • Have all gas, coke/coal, wood, peat or oil fired appliances, eg. cookers, fires, boilers at your home been serviced within the last year? • Have you recently started to re-use heating appliances/ boilers after the summer break/during an unexpected cold spell? • Do you ever use your oven or gas stove for heating purposes as well as for cooking? • Has there been any change in ventilation in your home recently, eg. fitting double glazing? • Have you noticed any sooty stains around appliances or an increase in condensation? • Does your work involve possible exposure to smoke, fumes, motor vehicle exhausts or wood pellets? • Is your home detached, semi-detached, terraced, a bedsit or hostel? 2 GP - General Practice ED - Emergency Department 1. Test for CO GP - breath test for exhaled CO if device is available. (Note: Only indicates recent exposure; interpretation difficult in smokers. For interpretation of results see TOXBASE). ED - h  eparinized venous blood sample for COHb estimation. For interpretation of results see TOXBASE and contact the National Poisons Information Centre (NPIC). 3. P  rotect your patient and others - Contact your HSE local Department of Public Health. They will co-ordinate services for your patient and provide further CO guidance. Telephone gas, oil or solid fuel helpline (see notes). 4. D  O NOT allow patient home without a warning NOT to use the suspect appliances. 5. F  ollow up GP - note that symptoms may persist or develop later. ED - advise patient to see GP for follow-up. Note this advice in discharge letter. 3 Bibliography Crowley D, Scallan E, Herbert J, Staines A, Herity B, Tracey J. Carbon monoxide poisoning in the Republic of Ireland. Ir Med J. 2003 Mar;96(3):83-6. Meredith T, Vale A. Carbon Monoxide Poisoning. British Medical Journal, 1988; 296(6615):77-79. Ernst A, Zibrak J. Carbon Monoxide Poisoning. New England Journal of Medicine, 1998; 339:1603-1608. Stewart RD, Hake CL. Paint-remover hazard. Journal of the American Medical Association, 1976;235:398-401. Hughes NJ, Tracey JA. A case of Methylene chloride (Nitromors) poisoning, effects on carboxyhaemoglobin levels. Human & Experimental Toxicology, 1993; 12:159-160. Varnon J, Marik P, Fromm R, Gueler A. Carbon Monoxide Poisoning: A review for Clinicians. Journal of Emergency Medicine, 1999;17(1):87-93. Thom SR, Keim LW. Carbon monoxide poisoning: A review: Epidemiology, pathophysiology, clinical findings and treatment options including hyperbaric oxygen therapy. Clinical Toxicology, 1989; 27(3):141-156. Smith SJ, Brandon S. Morbidity from acute carbon monoxide poisoning at three-year follow-up. British Medical Journal, 1973:318-321. Hausberg M, Somers VK. Neural circulatory responses to carbon monoxide in healthy humans. Hypertension 1997;29:1114-8. 2. Management - Commence oxygen therapy GP - follow advice on TOXBASE; refer to ED if required. ED - follow advice on TOXBASE. Contact NPIC for severe poisoning. Miller RL, Toal BF, Foscue K, Hansen H, Bayer M. Unintentional Carbon Monoxide Poisoning in residential settings. Connecticut, November 1993-March 1994. MMWR Weekly, 1995;44(41); 765-7. Wilson RC, Saunders PJ, Smith G. An epidemiological study of acute carbon monoxide poisoning in the West Midlands. Occup Environ Med. 1998; 55(11):723-8. Centers For Disease Control and Prevention National Center for Environmental Health. Checklist for the prevention of carbon monoxide poisoning. 1998. Balzan MV, Agius G, Debono AG. Carbon monoxide poisoning: easy to treat but difficult to recognise. Postgraduate Medical Journal 1996;72: 470-473. International Programme on Chemical Safety (IPCS) Environmental Health Criteria 213: Carbon Monoxide (second edition). WHO Task Group, WHO: Geneva & New York, 1999. 464pp. Vreman HJ, Mahoney JJ,Stevenson DK. Carbon monoxide and carboxyhaemoglobin. Advances in Paediatrics, 1995;42:303-334. Calman K. Carbon Monoxide, the Forgotten Killer, Department of Health, UK. 1998. Department of Environment, Community and Local Government. Regulatory Impact Assessment (RIA). Part J (Heating Producing Appliances) of the Building Regulations. 2012. Produced by the Health Protection Unit, Population Health, Health Services Executive and Bord Gáis Networks If patient does not improve: • Contact NPIC for advice. • Contact HSE local Department of Public Health for advice. • Reconsider diagnosis. For further information or to download this fact sheet visit www.carbonmonoxide.ie or call 1850 79 79 79 A guide for GPs and other medical professionals This fact sheet covers: • Sources of carbon monoxide • How to diagnose carbon monoxide poisoning • Clinical signs • Management of carbon monoxide poisoning * In total, approximately 40 people die each year in Ireland from CO poisoning. Approximately half of the deaths from unintentional CO poisonings result from the inhalation of smoke from fires. Other significant causes are vehicle exhausts and deaths in industrial/commercial settings. Sources of carbon monoxide Carbon monoxide is produced by the incomplete •  combustion of carbon-containing fuel including gas (natural, piped or bottled), coal, coke, oil, turf, biofuel and wood. Gas fuel leaks per se are not a source of carbon monoxide •  unless there is a combustion process of some sort involved. 4 A N R I A LT Ó I R C Ó G A I S Í O C H TA T H E P H A R M A C Y R E G U L AT O R Diagnostic algorithm reproduced with the kind permission of the UK Health Protection Agency. PAGE 6 | CARBON MONOXIDE POISONING • Mechanisms of action of carbon monoxide • Diagnostic algorithm • Bibliography Carbon Monoxide (also known as CO) is a colourless, odourless, poisonous gas and is a common yet preventable cause of death from poisoning worldwide. On average 6 people die each year in Ireland from unintentional CO poisoning in incidents related to heating or other fossil fuel installations*. Many more are treated in hospital suffering from CO poisoning. Because of the non-specific nature of its symptoms, poisoning by carbon monoxide is most probably under-diagnosed and there could well be a large number of people being exposed and suffering the ill effects of exposure. Older people, children, pregnant women and their babies and those with breathing problems or cardiovascular disease are at increased risk. Poisoning can result in lasting neurological damage. • Carbon monoxide can also be produced by the natural oxidation of wood pellets in storage even without combustion. The Pharmaceutical Society of Ireland G26678 BG CO GP FactSheet_A4_v11.indd 2 CARBON MONOXIDE POISONING Potential sources include the following: gas stoves, fires •  and boilers, barbeques and patio heaters, gas powered water heaters, paraffin heaters, solid fuel stoves, boilers and room heaters. CUMANN CÓGAISEOIRÍ NA hÉIREANN PAGE 5 | CARBON MONOXIDE POISONING CUMANN CÓGAISEOIRÍ NA hÉIREANN Inadequate maintenance leading to poor combustion and •  partially blocked or damaged flues and chimneys are the main causes of indoor carbon monoxide accumulation. Carbon monoxide can also seep into properties via shared •  flues and chimneys. Integral garages can be a source of carbon monoxide if car •  or other engines are run without adequate ventilation. Barbeques can produce large amounts of carbon monoxide •  and can be very dangerous if used indoors or under cover. Carbon monoxide poisoning is not restricted to poorer •  homes, student accommodation or those from lower income groups. Carbon monoxide can occur in modern homes fitted with modern appliances. Holiday residences, caravans, boats and mobile homes •  are also at risk as they often use portable appliances which burn fuel. Exhaust gases from vehicle engines and generators of electricity can also contain high levels of CO. All forms of carbon fuel combustion can lead to •  production of carbon monoxide gas. CARBON MONOXIDE POISONING | PAGE 1 16/01/2014 19:59