Waterpipe vs non-Waterpipe carbon monoxide poisoning: Comparison of patient characteristics, clinical presentation and outcomes.

OBJECTIVE: The aim of this study is to describe the difference between carboxyhemoglobin (CO-Hb) acute poisoning caused by waterpipe vs non-waterpipe exposures as they relate to demographics, clinical presentations and outcome of patients. DESIGN: Retrospective cohort study conducted in the Emergency Department (ED) at the Lebanon. PATIENTS: All adult patients presenting with a CO-Hb level ≥ 10 between January 2019 and August 2023 with exposure types stratified as waterpipe or non-waterpipe. MEASUREMENTS AND MAIN RESULTS: 111 ED visits were identified. Among these, 73.9% were attributed to waterpipe exposure, while 26.1% were non-waterpipe sources. These included cigarette smoking (17.2%), burning coal (24.1%), fire incidents (3.6%), gas leaks (6.9%), heating device use (10.3%), and undocumented sources (37.9%). Patients with waterpipe-related carbon monoxide exposure were younger (41 vs 50 years, p = 0.015) women (63.4 vs 41.4%, p = 0.039) with less comorbidities compared to non-waterpipe exposures (22.2 vs 41.4%, p = 0.047). Waterpipe smokers were more likely to present during the summer (42.7 vs 13.8%, p = 0.002) and have shorter ED length of stays (3.9 vs 4.5 h, p = 0.03). A higher percentage of waterpipe smokers presented with syncope (52.4 vs 17.2%, p = 0.001) whereas cough/dyspnea were more common in non-waterpipe exposures (31 vs 9.8%, p = 0.006). The initial CO-Hb level was found to be significantly higher in waterpipe exposure as compared to non-waterpipe (19.7 vs 13.7, p = 0.004). Non-waterpipe exposures were more likely to be admitted to the hospital (24.1 vs 4.9%, p = 0.015). Waterpipe smokers had significantly higher odds of experiencing syncope, with a 5.74-fold increase in risk compared to those exposed to non-waterpipe sources (p = 0.004) irrespective of their CO-Hb level. Furthermore, males had significantly lower odds of syncope as compared to females, following carbon monoxide exposure (aOR 0.31, 95% CI 0.13-0.74). CONCLUSION: CO-Hb poisoning related to waterpipe smoking has distinctive features. Syncope is a commonly associated presentation that should solicit a focused social history in communities where waterpipe smoking is common. Furthermore, CO-Hb poisoning should remain on the differential in patients presenting with headache, syncope, dizziness, vomiting or shortness of breath, even outside of the non-waterpipe exposure peaks of winter season.

Fire deaths in Cape Town, South Africa: A retrospective review of medico-legal and toxicological findings (2006 - 2018).

BACKGROUND: In South Africa, fire-related deaths are common, particularly within dense informal housing settlements. Published data on deaths from fire incidents in Cape Town is sparse. Additionally, little emphasis has been placed on the role of toxicological investigations in these deaths, despite the known risk of alcohol and drug impairment to burn injury. METHODS: A retrospective, descriptive analysis of post-mortem case reports from Salt River Mortuary was conducted to investigate all deaths in which fires were involved in the west metropole of Cape Town, between 2006 to 2018. Demographic, circumstantial, and toxicological data were analyzed using R software. RESULTS: In total 1370 fire deaths occurred over 13 years, with a mean of 106 (SD ± 18) cases per annum (≈3% of the annual caseload and a mortality rate of 5.5 per 100,000). Males (70.4%), adults (mean=30.7 years), and toddlers (1-4 years old) were notably at risk. Deaths typically occurred in the early morning (00h00 - 06h00) (45.7%), during winter (32.1%), and in lower socioeconomic areas with highly dense informal settlements (65.6%), with 29% of deaths occurring in multi-fatality incidents. Ethanol was detected (≥0.01 g/100 mL) in 55.1% of cases submitted for analysis (71.5%), with a mean of 0.18 g/100 mL, and with 93.8% of positive cases > 0.05 g/100 mL. Carboxyhaemoglobin (COHb) analysis was requested in 76.4% of cases, with 57% of cases having a %COHb of ≥ 20%. Toxicology results (for drugs other than ethanol) from the national laboratory were outstanding in 34.4% of the cases at the conclusion of the study. BAC and %COHb were significantly higher in deaths from burns and smoke inhalation (usually accidents) than deaths from combined trauma and burns (typically homicides). Fire deaths with high COHb levels were more likely to display cherry-red discoloration (OR=3.1) and soot in the airways (OR=2.7) at autopsy. CONCLUSION: This article provides an updated description of fire deaths in the west metropole of Cape Town. The importance of BAC and COHb testing in these cases was noted, and the authors call for an investigation of the role of drug impairment (specifically frequently misused drugs methamphetamine and methaqualone) as a risk factor in these deaths. Areas of high-density informal settlements, where open flames are used to heat, light, and cook, were noted as high risk.

Carbon monoxide poisoning cases in the emergency department are increasing in the last decade in Jerusalem.

BACKGROUND AND AIMS: The aim of our study was to describe the epidemiology of Carbon monoxide poisoning in the Emergency Department. METHODS: A retrospective descriptive analysis of patients with Carbon monoxide poisoning who were presented to the Emergency Department of Hadassah hospital in Jerusalem from 2007 to 2016. All patients that were included are confirmed cases [carboxyhemoglobin level > 5%]. Sources of exposure, seasonal variation, and demographic characteristics were analyzed. RESULTS: There were 244 patients (60% males) with 37 family clusters that accounted for 135 (55.3%) patients. One hundred seventy-three (70.9%) patients presented during the winter months. The main sources of exposure were: non-gas residential heating system, mainly charcoal grills and kerosene stoves (n = 100, 41%). Other sources were fires (n = 70, 28.7%), faulty gas heater (n = 34, 13.9%) and smoking (n = 15, 6.1%). The estimated annual incidence increased from an average of 20.8 cases a year between 2007-2011 to an average of 34 cases in 2011-2016. High-risk poisoning (levels > 25%) occurred in 28 patients (11.5%). Factors associated with severe poisoning were female gender and exposure in clusters compared with individual patients. CONCLUSION: Our current study has showed an increase of Carbon Monoxide poisoning in contrary to our study performed in the previous decade. Fortunately, we did find a lower rate of cases with severe poisoning. Beside the implementation of safer standards for residential heating systems, customized public education is advised in order to lower rates of poisoning in the future. A predicted heavy snow fall should be considered a trigger for a public health warning regarding the risk of CO poisoning.

Effect and molecular mechanism of Sulforaphane alleviates brain damage caused by acute carbon monoxide poisoning:Network pharmacology analysis, molecular docking, and experimental evidence.

Sulforaphane (SFN) has attracted much attention due to its ability on antioxidant, anti-inflammatory, and anti-apoptotic properties, while its functional targets and underlying mechanism of action on brain injury caused by acute carbon monoxide poisoning (ACOP) have not been fully elucidated. Herein, we used a systematic network pharmacology approach to explore the mechanism of SFN in the treatment of brain damage after ACOP. In this study, the results of network pharmacology demonstrated that there were a total of 81 effective target genes of SFN and 36 drug-disease targets, which were strongly in connection with autophagy-animal signaling pathway, drug metabolism, and transcription disorders in cancer. Upon the further biological function and KEGG signaling pathway enrichment analysis, a large number of them were involved in neuronal death, reactive oxygen metabolic processes and immune functions. Moreover, based on the results of bioinformatics prediction associated with multiple potential targets and pathways, the AMP-activated protein kinase (AMPK) signaling pathway was selected to elucidate the molecular mechanism of SFN in the treatment of brain injury caused by ACOP. The following molecular docking analysis also confirmed that SFN can bind to AMPKα well through chemical bonds. In addition, an animal model of ACOP was established by exposure to carbon monoxide in a hyperbaric oxygen chamber to verify the predicted results of network pharmacology. We found that the mitochondrial ultrastructure of neurons in rats with ACOP was seriously damaged, and apoptotic cells increased significantly. The histopathological changes were obviously alleviated, apoptosis of cortical neurons was inhibited, and the number of Nissl bodies was increased in the SFN group as compared with the ACOP group (p < .05). Besides, the administration of SFN could increase the expressions of phosphorylated P-AMPK and MFN2 proteins and decrease the levels of DRP1, Caspase3, and Casapase9 proteins in the brain tissue of ACOP rats. These findings suggest that network pharmacology is a useful tool for traditional Chinese medicine (TCM) research, SFN can effectively inhibit apoptosis, protect cortical neurons from the toxicity of carbon monoxide through activating the AMPK pathway and may become a potential therapeutic strategy for brain injury after ACOP.

Aspectos por considerar en autopsias por intoxicación aguda con monóxido de carbono, el asesino silente. A propósito de dos casos / Aspects to consider in autopsies for acute carbon monoxide poisoning, the silent killer. About two cases

El monóxido de carbono (CO) es un gas que se produce durante la combustión incompleta de diferentes materiales orgánicos. Una vez que se inhala, se absorbe hacia la sangre, ejerciendo su efecto a nivel sistémico. Se une fuertemente a la hemoglobina, y forma la carboxihemoglobina lo que provoca una disminución del transporte de oxígeno a los tejidos y dependiendo de su concentración puede ser mortal. Los hallazgos comúnmente encontrados en la autopsia son color rojo cereza en la piel y órganos, así como edema pulmonar, entre otros. El diagnóstico de intoxicación por CO se basa en la medición post mortem de carboxihemoglobina en sangre, por lo que se deben tomar muestras para cuantificar estos niveles. Con respecto al manejo en estos casos, se presenta dos casos correspondientes a la autopsia médica legal en las que se estableció como causa de muerte la intoxicación por monóxido de carbono.

Carbon monoxide (CO) is a gas that is produced during the incomplete combustion of different organic materials. Once inhaled, it is absorbed into the blood, exerting its effect at the systemic level. It strongly binds to hemoglobin, and forms carboxyhemoglobin, which causes a decrease in oxygen transport to the tissues and, depending on its concentration, can be fatal. The findings commonly found in the autopsy are cherry red color in the skin and organs, as well as pulmonary edema, among others. The diagnosis of CO poisoning is based on the postmortem measurement of carboxyhemoglobin in the blood, so samples must be taken to quantify these levels. Regarding the handling of these cases, two cases corresponding to the legal medical autopsy are presented in which carbon monoxide poisoning was established as the cause of death.

Neuro-protective effects of n-butylphthalide on carbon monoxide poisoning rats by modulating IL-2, AKT and BCL-2.

Acute carbon monoxide poisoning (CO-poisoning) causes neurotoxicity by inducing necrosis, apoptosis, lipid peroxidation, and oxidative stress. DL-3-n-butylphthalide (NBP) is a synthetic compound originally extracted from the seeds of Chinese celery and based on pure l-3-n-butylphthalide. In ischemia/reperfusion, it exerts neuroprotective effects through its anti-apoptotic, anti-necrotic and antioxidant properties, and activation of pro-survival pathways. Our study performed bioinformatic analysis to identify the differential expression genes. CO-poisoning patients' blood was collected to confirm the findings. Male rats were exposed to CO 3000 ppm for 40 min, and NBP (100 mg/kg/day) was continuously injected intraperitoneally immediately after poisoning and for the next 15 days. After NBP treatment, the rats were evaluated by Morris water maze test. At the end of experiments, blood and brain tissues of the rats were collected to evaluate the expression levels of IL-2, AKT and BCL-2. We found that IL-2 was elevated in CO-poisoning patients and animal models. Brain tissue damage in CO-poisoning rats was significantly alleviated after NBP treatment. Furthermore, NBP increased the expression of IL-2, AKT and BCL-2 in rat CO-poisoning model. NBP showed neuroprotective action by increasing IL-2, AKT, and BCL-2 expressions.

Health risks associated with the production and usage of charcoal: a systematic review.

Charcoal production and utilisation are linked to various health issues and occupational hazards. However, to our knowledge, no systematic review has primarily focused on the health implications of charcoal production and its use while distinguishing charcoal from other solid fuels such as wood and coal. OBJECTIVES: This systematic review presents a synthesis of the evidence on the health risks associated with producing and using charcoal across the world. DESIGN: Systematic review using a systematic narrative synthesis approach. DATA SOURCES: MEDLINE (through Ovid interface), CINAHL, Embase, Web of Science, PsycINFO, Cochrane Library and SCOPUS, from inception to 26 February 2021. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Peer-reviewed journal articles reporting empirical findings on the associations between charcoal usage/production and health parameters. DATA EXTRACTION AND SYNTHESIS: Two independent reviewers extracted data and assessed the quality of primary studies. RESULTS: Our findings showed that charcoal production and usage are linked with specific adverse health outcomes, including respiratory diseases (n=21), cardiorespiratory and neurological diseases (n=1), cancer (n=3), DNA damage (n=3), carbon monoxide (CO) poisoning (n=2), physical injury (n=2), sick house syndrome (n=1), unintentional weight loss and body mass index (BMI) reduction (n=2), increase in blood pressure (n=1) and CO death (n=1). Among the included articles that reported respiratory diseases (n=21), there was one case of asthma and tuberculosis and two cases of chronic obstructive pulmonary disease. CONCLUSIONS: This review links charcoal production/usage and some associated human health risks. These include respiratory diseases and other non-respiratory illnesses such as sick-building syndrome, cardiovascular diseases, DNA damage, CO poisoning and death, unintentional weight loss and BMI reduction, and physical injuries.

The Critical Assessment of Oxidative Stress Parameters as Potential Biomarkers of Carbon Monoxide Poisoning.

In conventional clinical toxicology practice, the blood level of carboxyhemoglobin is a biomarker of carbon monoxide (CO) poisoning but does not correspond to the complete clinical picture and the severity of the poisoning. Taking into account articles suggesting the relationship between oxidative stress parameters and CO poisoning, it seems reasonable to consider this topic more broadly, including experimental biochemical data (oxidative stress parameters) and patients poisoned with CO. This article aimed to critically assess oxidative-stress-related parameters as potential biomarkers to evaluate the severity of CO poisoning and their possible role in the decision to treat. The critically set parameters were antioxidative, including catalase, 2,2-diphenyl-1-picryl-hydrazyl, glutathione, thiol and carbonyl groups. Our preliminary studies involved patients (n = 82) admitted to the Toxicology Clinical Department of the University Hospital of Jagiellonian University Medical College (Kraków, Poland) during 2015-2020. The poisoning was diagnosed based on medical history, clinical symptoms, and carboxyhemoglobin blood level. Blood samples for carboxyhemoglobin and antioxidative parameters were collected immediately after admission to the emergency department. To evaluate the severity of the poisoning, the Pach scale was applied. The final analysis included a significant decrease in catalase activity and a reduction in glutathione level in all poisoned patients based on the severity of the Pach scale: I°-III° compared to the control group. It follows from the experimental data that the poisoned patients had a significant increase in level due to thiol groups and the 2,2-diphenyl-1-picryl-hydrazyl radical, with no significant differences according to the severity of poisoning. The catalase-to-glutathione and thiol-to-glutathione ratios showed the most important differences between the poisoned patients and the control group, with a significant increase in the poisoned group. The ratios did not differentiate the severity of the poisoning. The carbonyl level was highest in the control group compared to the poisoned group but was not statistically significant. Our critical assessment shows that using oxidative-stress-related parameters to evaluate the severity of CO poisoning, the outcome, and treatment options is challenging.

El rol del laboratorio en los hallazgos de intoxicación y exposición a monóxido de carbono / The role of the laboratory in findings of carbon monoxide poisoning and exposure

El monóxido de carbono es un gas altamente tóxico que se origina principalmente por la combustión incompleta de combustibles fósiles. La intoxicación presenta síntomas inespecíficos que solapan otras patologías y por lo tanto es indispensable la confirmación mediante la medición de la carboxihemoglobina en sangre. El laboratorio incorporó la determinación en el informe del estado ácido base a partir de octubre del 2018, debido a que previamente el médico debía solicitarla frente a la sospecha de una intoxicación. El objetivo del trabajo fue evaluar si esta medida implementada por el laboratorio contribuyó a mejorar el diagnóstico de intoxicación por CO, analizar las características de los pacientes con COHb mayor o igual a 5% y definir un valor de reporte inmediato para la COHb. El 46% de los casos con COHb mayor o igual a 5% no se relacionaban con una intoxicación y/o exposición a CO. De los casos de intoxicación se encontró que el 77% fueron diagnosticados a partir de la sospecha médica y un 23% por hallazgo del laboratorio. Se concluyó que es de mucha utilidad el rol del laboratorio en detectar aquellos casos que no fueron evidentes clínicamente. Existen ciertas patologías como las oncológicas o la enfermedad de Wilson donde se vieron valores elevados de COHb sin presentar intoxicación y se definió finalmente, como valor de reporte inmediato 7% para la COHb. (AU)

Carbon monoxide is a highly toxic gas that originates mainly from incomplete combustion of fossil fuels. Intoxication causes nonspecific symptoms that overlap with other conditions and, therefore, confirmation by measuring blood carboxyhemoglobin is essential. The laboratory incorporated the measurement in the acid-base status report as of October 2018, as it was previously required to be requested by the physician in case of suspected intoxication. The aim of this study was to evaluate whether this measure implemented by the laboratory contributed to the improvement of the diagnosis of CO intoxication, to analyze the characteristics of patients with COHb greater than or equal to 5% and to define an immediate reporting value for COHb. Overall, 46% of the cases with COHb greater than or equal to 5% were not related to CO poisoning and/or exposure. Of the cases of intoxication, 77% were diagnosed based on medical suspicion and 23% on laboratory findings. It was concluded that the laboratory has a useful role in detecting cases that were not clinically evident. There are certain diseases including different types of cancer or Wilson's disease where elevated COHb values were seen without intoxication and finally, 7% for COHb was defined as the immediate reporting value (AU)

Use of CO-oximetry to confirm carboxyhemoglobinemia in cats involved in secondary arson homicide.

The body of a deceased human and 4 deceased cats were found in a house while a fire was being extinguished. As a result of these findings, arson, homicide, and animal death investigations were opened. As part of the animal death investigation, all of the cats were submitted for veterinary forensic autopsies. All cats had soot on the fur and had soot deposits within the oral cavity, esophagus, and respiratory tract. Two cats had soot within the stomach. Cardiac blood was analyzed for carboxyhemoglobin using a CO-oximeter, and all cats had levels >65%. The cause of death was determined to be due to toxic smoke inhalation from the structure fire. Case findings support the potential use of CO-oximeter for determination of carboxyhemoglobin levels in cats and continued research in this area of forensic practice.

Acute carbon monoxide poisoning as a cause of rhabdomyolysis in a case of flame burn.

Carbon monoxide (CO) poisoning typically occurs from inhalation of CO at excessive levels. Rhabdomyolsis is not an uncommon complication following acute CO poisoning, yet there are very few reported cases in the literature. It is characterised by rapid breakdown of skeletal muscles and release of its contents into the circulation, leading to acute kidney injury (AKI). Early diagnosis and treatment are crucial to avoid anticipated morbidity and mortality. We are presenting a case of a woman in her 40s with 28% flame burn in a closed space. The patient developed CO poisoning, which led to rhabdomyolysis as evidenced by clinical manifestations and laboratory findings (creatine kinase had reached an unmeasurable level). The patient developed AKI and was successfully managed in our ICU. Here, we are highlighting the importance of considering CO poisoning as one of the potential causes of rhabdomyolysis in burn victim.

Extracorporeal membrane oxygenators with light-diffusing fibers for treatment of carbon monoxide poisoning: Experiments, mathematical modeling, and performance assessment with unit cells.

BACKGROUND AND OBJECTIVES: Approximately 50,000 emergency department visits per year due to carbon monoxide (CO) poisoning occur in the United States alone. Tissue hypoxia can occur at very low CO concentration exposures because CO binds with a 250-fold higher affinity than oxygen to hemoglobin. The most effective therapy is 100% hyperbaric oxygen (HBO) respiration. However, there are only a limited number of cases with ready accessibility to the specialized HBO chambers. In previous studies, we developed an extracorporeal veno-venous membrane oxygenator that facilitates exposure of blood to an external visible light source to photo-dissociate carboxyhemoglobin (COHb) and significantly increase CO removal from CO-poisoned blood (photo-extracorporeal veno-venous membrane oxygenator [p-ECMO]). One objective of this study was to describe in vitro experiments with different laser wavelength sources to compare CO elimination rates in a small unit-cell ECMO device integrated with a light-diffusing optical fiber. A second objective was to develop a mathematical model that predicts CO elimination rates in the unit-cell p-ECMO  device design upon which larger devices can be based. STUDY DESIGN/MATERIAL AND METHODS: Two small unit-cell p-ECMO devices consisted of a plastic capillary with a length and inside diameter of 10 cm and 1.15 mm, respectively. Either five (4-1 device) or seven (6-1 device) gas exchange tubes were placed in the plastic capillary and a light-diffusing fiber was inserted into one of the gas exchange tubes. Light from lasers emitting either 635 nm or 465 nm wavelengths was coupled into the light-diffusing fiber as oxygen flowed through the gas exchange membranes. To assess the ability of the device to remove CO from blood in vitro, the percent COHb reduction in a single pass through the device was assessed with and without light. The Navier Stokes equations, Carreau-Yesuda model, Boltzman equation for light distribution, and hemoglobin kinetic rate equations, including photo-dissociation, were combined in a mathematical model to predict COHb elimination in the experiments. RESULTS: For the unit-cell devices, the COHb removal rate increases with increased 635 nm laser power, increased blood time in the device, and greater gas exchange membrane surface-to-blood volume ratio. The 6-1 device COHb half-life versus that of the 4-1 device with 4 W at 635 nm light was 1.5 min versus 4.25 min, respectively. At 1 W laser power, 635 nm and 465 nm exhibited similar CO removal rates. The COHb half-life times of the 6-1 device were 1.25, 2.67, and 8.5 min at 635 nm (4 W), 465 nm (1 W), and 100% oxygen only, respectively. The mathematical model predicted the experimental results. An analysis of the in vivo COHb half-life of oxygen respiration therapy versus an adjunct therapy with a p-ECMO device and oxygen respiration shows a reduction from 90 min to as low as 10 min, depending on the device design. CONCLUSION: In this study, we experimentally studied and developed a mathematical model of a small unit-cell ECMO device integrated with a light-diffusing fiber illuminated with laser light. The unit-cell device forms the basis for a larger device and, in an adjunct therapy with oxygen respiration, has the potential to remove COHb at much higher rates than oxygen therapy alone. The mathematical model can be used to optimize the design in practical implementations to quickly and efficiently remove CO from CO-poisoned blood.

Optical, flow, and thermal analysis of a phototherapy extracorporeal membrane oxygenator for treating carbon monoxide poisoning.

BACKGROUND: Extracorporeal membrane oxygenators (ECMO) are currently utilized to mechanically ventilate blood when lung or lung and heart function are impaired, like in cases of acute respiratory distress syndrome (ARDS). ARDS can be caused by severe cases of carbon monoxide (CO) inhalation, which is the leading cause of poison-related deaths in the United States. ECMOs can be further optimized for severe CO inhalation using visible light to photo-dissociate CO from hemoglobin (Hb). In previous studies, we combined phototherapy with an ECMO to design a photo-ECMO device, which significantly increased CO elimination and improved survival in CO-poisoned animal models using light at 460, 523, and 620 nm wavelengths. Light at 620 nm was the most effective in removing CO. OBJECTIVE: The aim of this study is to analyze the light propagation at 460, 523, and 620 nm wavelengths and the 3D blood flow and heating distribution within the photo-ECMO device that increased CO elimination in CO-poisoned animal models. METHODS: Light propagation, blood flow dynamics, and heat diffusion were modeled using the Monte Carlo method and the laminar Navier-Stokes and heat diffusion equations, respectively. RESULTS: Light at 620 nm propagated through the device blood compartment (4 mm), while light at 460 and 523 nm only penetrated 48% to 50% (~2 mm). The blood flow velocity in the blood compartment varied with regions of high (5 mm/s) and low (1 mm/s) velocity, including stagnant flow. The blood temperatures at the device outlet for 460, 523, and 620 nm wavelengths were approximately 26.7°C, 27.4°C, and 20°C, respectively. However, the maximum temperatures within the blood treatment compartment rose to approximately 71°C, 77°C, and 21°C, respectively. CONCLUSIONS: As the extent of light propagation correlates with efficiency in photodissociation, the light at 620 nm is the optimal wavelength for removing CO from Hb while maintaining blood temperatures below thermal damage. Measuring the inlet and outlet blood temperatures is not enough to avoid unintentional thermal damage by light irradiation. Computational models can help eliminate risks of excessive heating and improve device development by analyzing design modifications that improve blood flow, like suppressing stagnant flow, further increasing the rate of CO elimination.

Intoxicación por monóxido de carbono: estudio observacional de pacientes que acudieron a Urgencias durante 2020 / Carbon monoxide poisoning: an observational study of patients admitted to Emergency Department during 2020

El objetivo fue describir las intoxicaciones monóxido de carbono. Se diseñó un corte transversal que incluyó una muestra consecutiva de mediciones de carboxihemoglobina (COHb), realizadas Enero y Diciembre 2020 en la Central de Emergencias del Hospital Italiano de Buenos Aires. Se utilizaron bases secundarias y revisión manual de historias clínicas para recolección de varia-bles de interés. Durante el período de estudio hubo 20 pacientes confirmados, con media de 50 años (DE 20), 55% sexo masculino, 20% tabaquistas, y una única embarazada. El 70% correspondieron al trimestre Junio-Julio-Agosto. La fuente de intoxicación más frecuente se debió a accidentes domésticos (calefón, estufa, brasero, hornalla, salamandra) que representaron el 50% de los casos, 30% por incendios, y el 20% restante explicado por tabaco o factor desconocido. Los estudios de laboratorio más solicitados fueron: 95% recuento de glóbulos blancos, 85% glucemia, 70% CPK, y 55% troponina. Los hallazgos relevantes fueron COHb con mediana de 7.15%, CPK con mediana de 89 U/mL, y troponina con mediana de 8.5 pg/mL. La totalidad se realizó electrocardiograma: 15% presentaron arritmia como hallazgo patológico, y ninguno isquemia. En cuanto la presentación clínica: 30% presentó cefalea, 15% síncope, 15% coma, 10% mareos y 10% convulsiones. Sólo 25% tuvieron tomografía y 15% resonancia de cerebro, sin hallazgos críticos. Sin embargo, 15% fueron derivados para trata-miento con cámara hiperbárica. La mayoría ocurrieron en invierno y explicados por accidentes domésticos. Será necesario un fortalecimiento del rol preventivo que apunte al control de la instalación y el buen funcionamiento de artefactos, como mantener los ambientes bien ventilados (AU)

The objective was to describe carbon monoxide poisoning. A cross sectional was designed, which included a consecutive sample of carboxyhemoglobin (COHb) measurements, carried from January to December 2020 at the Emergency Department of tHospital Italiano de Buenos Aires. Secondary databases and manual review of medical records were used to collect variables of interest. During the study period there were 20 confirmed patients, with a mean age of 50 (SD 20), mostly male (55%), 20% smokers, and only one pregnant woman, 70% corresponded to June-July-August. The most frequent source of poisoning was explained to domestic accidents (water heater, stove, brazier, stove, salamander) which represented 50% of cases, 30% due to fires, and the remaining 20% by tobacco or unknown factor. The most laboratory studies were: 95% white blood cell count, 85% glycemia, 70% CPK, and 55% troponin. Meanwhile, relevant findings were carboxyhemoglobin with a median of 7.15%, CPK with a median of 89 U/mL, and troponin with a median of 8.5 pg/mL. All underwent an electrocardiogram: 15% presented arrhythmia as a pathological finding, and none ischemia. Regarding the clinical presentation: 30% presented headache, 15% syncope, 15% coma, 10% dizziness and 10% seizures. Only 25% had brain tomography and 15% MRI, without pathological findings. However, 15% were referred for treatment with a hyperbaric chamber. Most of the cases occurred in winter and explained by domestic accidents. It will be necessary to strengthen the preventive role that aims to control the installation and the proper functioning of devices, such as keeping rooms well ventilated (AU)

Influence of the COVID-19 pandemic on causes for the development of carbon monoxide intoxications.

Introduction: Several causes can lead to carbon monoxide (CO) intoxication. A first-line treatment option for such intoxications is hyperbaric oxygenation (HBO2) therapy. The COVID-19 pandemic has been changing everyday life in Germany since March 2020, mainly caused by statutory provisions. Our aim was to review whether these changes have an influence on the causes and frequency for the development of CO intoxication. Methods: We retrospectively analyzed the data of patients who were treated for CO intoxication in our institution between April 2019 and March 2021. Besides demographic data, we compared the overall number and documented causes for each CO intoxication in the period of April 2020 to March 2021 with the period between April 2019 and March 2020. Results: After applying inclusion and exclusion criteria, 139 patients were included. We found a significant decrease in the overall number of patients who needed treatment since the beginning of the COVID-19 pandemic. However, the share of CO intoxication caused by the indoor use of coal stoves, coal barbecue, or suicide attempts increased. In contrast, the share of cases caused by apartment or house fire, smoking waterpipe, or gas stoves decreased. Conclusion: The COVID-19 pandemic and the associated restrictions lead to a significant reduction in the number of patients in need for HBO2 therapy due to CO-Intoxication. The causes leading to CO intoxication also changed since the beginning of the COVID-19 pandemic. We observed a shift toward causes related to the indoor use of coal-fired stoves and barbecues as well as suicide attempts.

Therapeutic study of hyperbaric oxygen on heme oxygenase-1 (HO-1) in patients with acute carbon monoxide poisoning and myocardial injury.

Carbon monoxide (CO) poisoning causes myocardial injury, which is attenuated by hyperbaric oxygen therapy (HBOT). During CO poisoning, the body increases anti-inflammatory proteins, including heme oxygenase-1 (HO-1), in response to oxidative stress. Considering the myocardial injury resulting from CO poisoning and the lack of sufficient information about the effect of HBOT on HO-1, the present study evaluated the effect of hyperbaric oxygen therapy on heme oxygenase-1 (HO-1) in patients with acute carbon monoxide poisoning and myocardial injury. In this regard, in a before-after Quasi-Experimental study, 20 patients with carbon monoxide poisoning and myocardial injury were studied. All patients underwent 40 daily hyperbaric oxygen therapy sessions for 90 minutes at a pressure of 2.4 ATA. Also, 20 healthy individuals, as a control group, were participated. To evaluate and compare the mRNA level of the HO-1 gene, the Real-time PCR technique was used. Paired t-test was used to compare the two indices of 6min walking distance and pulmonary arterial pressure (PAP) before and after the intervention. The results showed that the difference during 12 weeks was 8.65 ± 4.91 for PAP, and this reduction in pressure was statistically significant (P = 0.0092). The distance traveled increased by 28 ± 10.88 m in 6 minutes at the end of the study (P = 0.0084). Regarding the expression level of HO-1, the results showed that the expression level in the intervention group before the test had a significant increase compared to the control group (p = 0.0004). However, after hyperbaric oxygen therapy, the expression of this gene decreased significantly, and there was no statistically significant difference with the control group (p = 0.062). Overall, the results showed that HBOT significantly decreased HO-1 gene expression in CO poisoning and myocardial injury patients. It indicates the importance of HBOT in the treatment and compensation of cardiac tissue damage caused by CO poisoning.

Prospective Study Investigating Change in Carboxyhemoglobin Blood Level During Operative Hysteroscopy.

STUDY OBJECTIVES: To evaluate whether the use of radiofrequency energy during resectoscopy leads to increases in patient blood levels of carboxyhemoglobin (COHb) and investigate procedural variables associated with these elevations. DESIGN: A prospective cross-sectional study of 40 subjects undergoing a hysteroscopic procedure using bipolar radiofrequency energy. SETTING, PATIENTS, AND INTERVENTIONS: The study was conducted at an ambulatory surgery center. Procedures for uterine leiomyoma, septa, products of conception, or a combination of these pathologies were included. We measured blood COHb levels before and immediately after the surgery. Abnormal postoperative COHb level was defined as an increase of plasma COHb ≥3.0%. All patients with abnormal postoperative levels were contacted and screened for carbon monoxide toxicity symptoms. Summary statistics included frequency for categorical variables and averages for continuous variables. p values were reported without modification. MEASUREMENTS AND MAIN RESULTS: A total of 17.5% of subjects met the criteria for abnormal postoperative COHb levels. None of these subjects reported symptoms of carbon monoxide toxicity. One subject with an elevated postoperative COHb level had intraoperative hemodynamic changes possibly related to COHb elevation. An abnormal postoperative COHb level was associated with a higher fluid deficit (p = .024) and greater myoma volume (p = .04). CONCLUSION: This study demonstrates that systemic absorption of carbon monoxide is a reproducible phenomenon in hysteroscopic resections using bipolar diathermy. Greater absorption is associated with a higher fluid deficit and greater myoma volume. Although none of the subjects with an abnormal increase screened positive for symptoms in the postoperative setting and only 1 experienced hemodynamic changes intraoperatively, our study looked at a healthy and young patient population. More research is needed on the safety of this COHb exposure in patients with medical comorbidities. Special consideration should be given to the possibility of carbon monoxide absorption and the uncertain long-term effects when planning extensive hysteroscopic resections.

Occupational acute argon gas poisoning: A case report.

RATIONALE: Intentional or unintentional exposure to asphyxiating gases is a significant public health concern worldwide. Argon poisoning is fatal, and its onset is primarily due to neurological damage. PATIENT CONCERNS: A 22-year-old man was admitted to the hospital for argon gas poisoning. While working in a plant containing argon gas, he suddenly lost consciousness, recovered consciousness slightly after on-site treatment, answered questions, and had impaired memory, sensory dullness, normal cognition, and symptoms of dizziness and headache. DIAGNOSIS: Asphyxiating gas poisoning (argon gas poisoning), metabolic encephalopathy, and hepatic insufficiency. INTERVENTIONS: Immediately after admission, the patient was treated with nasal cannula oxygen 3 L/min and hyperbaric oxygen therapy once a day. Mecobalamin tablets 500 µg were given orally 3 times a day. Oral Ginkgo biloba extract tablets 40 mg 3 times a day. OUTCOME: The patient was discharged after treatment with hyperbaric oxygen therapy and nerve-nourishing drugs, with no discomfort, clear consciousness, and good memory, and was followed up by telephone for 2 consecutive months, and the patient is now in good condition with no discomfort. LESSON: This case describes the pathogenesis, neurological damage, and rescue process of argon gas poisoning. Argon poisoning was found to damage bilateral cerebellar hemispheres and bilateral hippocampal regions, affecting the patient's consciousness and memory, and was found to cause abnormal liver function and heart rate disorders.

International Multicenter Registry for Hyperbaric Oxygen Therapy: Results through June 2021.

Introduction: The International Multicenter Registry for Hyperbaric Oxygen Therapy (International Report Registered Identifier DERR1-10.2196/18857) was established in 2011 to capture outcomes and complications data for both Undersea and Hyperbaric Medical Society (UHMS) approved and selected unapproved hyperbaric oxygen (HBO2) therapy indications. Methods: A Research Electronic Data Capture (REDCap) template was designed and distributed to all participating centers for prospective data collection. Centers contributed de-identified demographic, treatment, complications, and outcome data. This report provides summary data on sites and enrollment, as well as pre- and post-treatment data on quality of life (EQ-5D-5L questionnaire), head and neck radiationoutcomes, non-healing wounds (Strauss score), and idiopathic sudden sensorineural hearing loss. Data were analyzed mainly using the Wilcoxon signed-rank test. Results: Twenty-two centers contributed data for 2,880 patients. The most common UHMS-approved indication was delayed radiation injury, followed by enhancement of wound healing, and carbon monoxide poisoning. One hundred and twenty-five patients were treated for non-UHMS approved indications. Quality of life, head and neck radiation symptoms, Strauss wound scores, and hearing were significantly improved after HBO2. Complication rates were low and comparable to previous reports. The registry also offered the ability to analyze factors that affect outcomes, such as smoking and severity of hearing loss. Discussion: The registry accrues prospective data on defined outcomes from multiple centers and allows for analysis of factors affecting outcomes. This registry does not have a control group, which is a limitation. Nevertheless, the registry provides a unique, comprehensive dataset on HBO2 outcomes from multiple centers internationally.