of CO poisoning.
1. COHb levels do not correlate well with severity of illness, outcomes or response to therapy so it is important to assess clinical symptoms and history of exposure when determining type and intensity of treatment.
2. Other testing, such as a finger stick blood sugar, alcohol and toxicology screen, head CT scan or lumbar punc‐ ture may be needed to exclude other causes of altered mental status when the diagnosis of carbon monoxide poi‐ soning is inconclusive. 3. Note: carbon monoxide can be produced endogenously as a byprod‐ uct of heme metabolism. Patients with sickle cell disease can have an elevated COHb level as a result of hemolytic ane‐ mia or hemolysis.
Guidance for Management of Confirmed or Suspected CO Poisoning
1. Administer 100% oxygen until the patient is symptom‐free, usually about 4‐5 hours. Serial neurologic exams should be performed to assess progress, and to detect the signs of developing cerebral edema. 2. Consider hyperbaric oxygen thera‐ py (HBO) therapy when the patient has a COHb level of more than 25‐ 30%, there is evidence of cardiac involve‐ ment, severe acidosis, transient or pro‐ longed unconsciousness, neurological impairment, abnormal neuropsychi‐ atric testing, or the patient is greater than 36 years in age. HBO is also admin‐ istered at lower COHb(<25%) levels if suggested by clinical condition and/his‐ tory of exposure.
3. Hyperbaric oxygen is the treat‐ ment of choice for pregnant women, even if they are less severely poisoned. Hyperbaric oxygen is safe to administer and international consensus favors it as part of a more aggressive role in treat‐ ing pregnant women.
Other Considerations
1. Cardiac injury during poisoning increases risk of mortality over 10 years following poisoning, so in patients with severe CO poisoning, it may be impor‐ tant to perform an EKG and measure‐ ment of troponin and cardiac enzymes. 2. Chest radiography is recommend‐ ed for seriously poisoned patients, especially those with loss of conscious‐ ness or cardiopulmonary signs and symptoms. Brain computed tomogra‐ phy or MRI is also recommended in these cases; these tests may show signs of cerebral infarction secondary to hypoxia or ischemia.
3. All discharged patients should be warned of possible delayed neurologi‐ cal complications and given instruc‐ tions on what to do if these occur. Follow‐up should include a repeat med‐ ical and neurological exam in 2 weeks.
EMS
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