Notes – Carbon Monoxide/Smoke Inhalation

Carbon Monoxide/Smoke Inhalation

Patient Safety Considerations

  1. Consider affixing a carbon monoxide detector to an equipment bag that is routinely taken into scene (if it signals alarm, don appropriate respiratory protection and exit scene) to assist with detection of occult CO toxicity
  2. Remove patient and response personnel from potentially hazardous environment as soon as possible
  3. Provide instruction to the patient, the patient’s family, and other appropriate bystanders to not enter the environment (e.g. building, car) where the carbon monoxide exposure occurred until the source of the poisoning has been eliminated
  4. Do not look for cherry red skin coloration as an indication of carbon monoxide poisoning, as this is an unusual finding
  5. CO oximeter devices may yield inaccurate low/normal results for patients with CO poisoning. All patients with probable or suspected CO poisoning should be transported to the nearest appropriate hospital based on their presenting signs and symptoms

Notes/Educational Pearls

Key Considerations

  1. Pulse oximetry is inaccurate due to the carbon monoxide binding with hemoglobin
  2. As maternal carboxyhemoglobin levels do not accurately reflect fetal carboxyhemoglobin levels, pregnant patients are more likely to be treated with hyperbaric oxygen
  3. Consider cyanide toxicity if carbon monoxide poisoning is from a fire
  4. A patient light wavelength analysis device to detect carboxyhemoglobin is useful to indicate if there is a carbon monoxide exposure in a non-arrested patient – do not anticipate an immediate change in readings with oxygen administration.
    1. g. Massimo Rad-57 Co-Oximeter

Pertinent Assessment Findings

  1. Early and repeat assessment of patient’s mental status and motor function are extremely useful in determining response to therapy and the need for hyperbaric therapy
  2. Identification of possible etiology of poisoning
  3. Time of symptom onset and time of initiation of exposure-specific treatment
  4. Response to therapy

Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01)

  • 9914167 – Exposure-Carbon Monoxide
  • 9914173 – Exposure-Smoke Inhalation

Key Documentation Elements

  • If using an environmental carbon monoxide detector, record the level detected
  • Evidence of soot or burns around the face, nares or pharynx
  • Early and repeat assessment of patient’s mental status and motor function are extremely useful in determining response to therapy and the need for hyperbaric therapy
  • Accurate exposure history
    • Time of ingestion/exposure
    • Route of exposure
    • Quantity of medication or toxin taken (safely collect all possible mediations or agents)
    • Alcohol or other intoxicant taken
  • Signs and symptoms of other patients encountered at same location, if present

Performance Measures

  • Early airway management in the rapidly deteriorating patient.
  • Accurate exposure history
    • Time of ingestion/exposure
    • Route of exposure
    • Quantity of medication or toxin taken (safely collect all possible mediations or agents)
    • Alcohol or other intoxicant taken
  • Appropriate protocol selection and management
  • Multiple frequent documented reassessments

References

  1. Buckley NA, Juurlink DN, Isbister G, Bennett MH, Lavonas EJ. Hyperbaric oxygen for carbon monoxide poisoning. Cochrane Database Syst Rev. 2011 Apr 13;(4): CD002041.
  2. Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department with Acute Carbon Monoxide Poisoning. ACEP Clinical Policies Subcommittee (Writing Committees) on Carbon Monoxide Poisoning, American College of Emergency Physicians; Ann Emerg Med. 2017;69:98-107.
  3. Hampson N. Practice Recommendations: the diagnosis, management and prevention of carbon monoxide poisoning. Am J Respir Crit Care Med. 2012;186(11):1095-101.
  4. Hoffman RS, Howland MA, Lewin NA, Nelson LS, Goldfrank LR. Goldfrank’s Toxicologic Emergencies, 10th Edition. China: McGraw-Hill Education; 2015.
  5. Hampson NB. Pulse oximetry in severe carbon monoxide poisoning. Chest. 1998;114(4):1036-41.
  6. Jones A. Recent advances in the management of poisoning. Ther Drug Monit. 2002;24(1):150-5.
  7. Touger M, Birnbaum A, Wang J, Chou K, Pearson D, Bijur P. Performance of the RAD-57 pulse co-oximeter compared with standard laboratory carboxyhemoglobin measurement. Ann Emerg Med. 2010;56(4):382-8.