Toxicology of Carbon

Monoxide
Carbon monoxide (CO), an odorless, tasteless, and colorless gas, is the second most common
environmental pollutant after carbon dioxide and contributes to approximately 2700 deaths annually,
according to the Centers for DiseaseControlandPrevention
Pathophysiology

increases in
Hemoglobin direct cellular
protein binding nitric oxide
Binding toxicity
(NO).
Clinical Presentation
Acute Carbon Monoxide Poisoning Chronic Carbon Monoxide Poisoning

Headache, nausea, and dizziness The clinical effects are related to a combin
ation of the level of exposure as well asthe
duration, with presentations that can be de
layed up to several months or 2 to 3 years
Vomiting, malaise, ataxia, seizures, loss of c chronic fatigue, memory deficits, difficulty
onsciousness, and/or shortness of breath working, sleep disturbances, vertigo, neuro
pathy, paresthesias, recurrent infections, ab
dominal pain, and diarrhea
Increased blood pressure, heart rate, and re cardiomegaly and polycythemia, presumab
spiratory rate ly secondary to effects of chronic hypoxia
Clinical findings can progress to include c
onfusion, loss of consciousness, hypotensio
n, poor capillary refill, cardiopulmonary arr
est, coma, or death
Degree of Severity

Mild Moderate Severe

cigarette smoke. exposur In mild COP, the level is l The patient is unconscio
e is defined by a COHb ess than 30%, whereas in us and has a COHb level
level greater than 2% to moderate COP, it is great greater than 40%.
3% in nonsmokers or gre er than 30% to 40%. The
ater than 9% to 10% in s Patient may or may not
mokers. The Patient may have symptoms
or may not have sympto
ms
Methods of COHb Evaluation

• Levels of COHb can be measured via pulse CO oximetry, which uses multiple wavelengths of light
to measure the percentage of COHb present (SpCO).
• Its use is helpful in quickly differentiating COP from cyanide poisoning
• Carboxyhemoglobin levels are typically measured with blood gas analysis, either venous or arteria
l
• Venous blood gases will typically reveal an elevated PO2 level of 30 to 50 mm Hg (normally aroun
d 25 mm Hg) in significant CO exposure
Complication
Neurological Cardiac Pulmonary Metabolic Renal Fetal and Pe
diatric Consi
derations
Ischemia or decreased m Pulmonary e Respiratory a Renal failure Carbon mon
necrosis in t yocardial fun dema lkalosis is po and rhabdo oxide poison
he brain ction ssible in mild myolysis occ ing affects in
cases, where ur because o fants more s
as metabolic f the direct t everely than
acidosis is co oxic effect of adults becau
mmon in sev CO on skelet se CO binds
ere cases al muscle more closely
to fetal hem
oglobin than
adult hemog
lobin
 Case 1
A 68-year-old white woman, Ms F., presented to the ED in November with complaints of
throbbing headaches intermittently for the past 3 days. She reported taking ibuprofen every 8 hours for
2 days without relief. She also reported shortness of breath, dizziness, weakness, and intermittent
chest pain. On the day prior to coming to the ED, she went shopping and ‘‘felt better.’’ Ms F. also
admitted that her son and daughter-in-law who live in the second-floor apartment above her have also
not been feeling well for the past few days and have complained of headaches. They all denied recent
travel or exposure to persons with infections. MsF.’s medical history was significant for asthma that
was controlled with regular use of inhaled bronchodilators.
She denies hospitalization for asthma. She had no known drug allergies. Physical
examination in the ED revealed her to be slightly overweight and in mild respiratory distress, with a
respiratory rate of 28 breaths per minute.Herblood pressure is 140/86 mm Hg, pulse is 92 beats per
minute, temperature is 98.4-F, and oxygen saturation is 95% on room air. Breath sounds were clear
bilaterally. The ED physician obtained laboratory work, which revealed the patient’s carboxyhemoglobin
(COHb) level is 20%. Less than 10% is normal. Her other laboratory work was unremarkable including
normal cardiac enzymes. Her electrocardiogram showed normal sinus rhythm with noST-Twave
changes. Because of the patient’s complaints of headaches for the past 3 days after turning on the
heating system and intermittent shortness of breath that resolves when she leaves the house, a
diagnosis of COP was made. It was requested to have her other family members come to the hospital
to get tested as well. Ms F. denies having any family pets.
 Case 2
A male patient, Mr S., presented to the ED having been driven there by his wife after she found him
‘‘barely breathing in the garage with his car running.’’ She stated she was at work and came home to
find him in his car ‘‘very groggy.’’ She reported, ‘‘he has been depressed for several weeks after losing
his job and consequently having financial hardships.’’ Mr S. was in a state of respiratory arrest and
was intubated shortly after being admitted to the EDand placed on 100% oxygen. His pupils were
dilated and very sluggish. As he was being intubated, he had a grand mal seizure. His medical history
is significant for diabetes mellitus and according to his wife ‘‘has been fairly well controlled until this
past year. ’’Heal so had coronary artery bypass surgery 2 years ago and is on blood pressure and
cholesterol medications. He is allergic to sulfa medications. Physical examination in the ED revealed a
pale man of 74 in who is unkempt and slightly overweight. He was very lethargic and disoriented. His
blood pressure was 166/102 mm Hg, pulse is 102 beats per minute, temperature is 96.4-F, and
oxygen saturation is 92% on room air. His wife stated he is not a smoker. Breath sounds were
diminished, and his respiratory rate was 6 breaths per minute before being intubated. The ED
physician obtained a venous blood sample, which revealed the patient’s COHb level to be 49%, blood
sugar of 185 mg/dL, and total cholesterol level of 260 mg/dL; cardiac enzymes and troponin T were
within reference range. His electrocardiogram showed sinus tachycardia with no ST-Twave changes.
An arterial blood gas was ordered, and plan swere underway to transport Mr S. to a facility where
hyperbaric oxygenation (HBO2) could be provided.
Thankyou