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Matias FR, Groves I, Durrans J, Herigstad M. Carbon monoxide affects early cardiac development in an avian model. Birth Defects Res 2024; 116:e2330. [PMID: 38488476 DOI: 10.1002/bdr2.2330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 02/21/2024] [Accepted: 02/28/2024] [Indexed: 03/19/2024]
Abstract
INTRODUCTION Carbon monoxide (CO) is a toxic gas that can be lethal in large doses and may also cause physiological damage in lower doses. Epidemiological studies suggest that CO in lower doses over time may impact on embryo development, in particular cardiac development, however other studies have not observed this association. METHODS Here, we exposed chick embryos in ovo to CO at three different concentrations (3, 9, 18 ppm) plus air control (4 protocols in total) for the first 9 days of development, at which point we assessed egg and embryo weight, ankle length, developmental stage, heart weight, ventricular wall thickness, ventricular-septal thickness and atrial wall thickness. RESULTS We found that heart weight was reduced for the low and moderate exposures compared to air, that atrial wall and ventricular wall thickness was increased for the moderate and high exposures compared to air and that ventricular septal thickness was increased for low, moderate and high exposures compared to air. Ventricular wall thickness was also significantly positively correlated with absolute CO exposures across all protocols. CONCLUSIONS This intervention study thus suggests that CO even at very low levels may have a significant impact on cardiac development.
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Affiliation(s)
- Filipa Rombo Matias
- Lisbon School of Health Technology, Polytechnic Institute of Lisbon, Lisbon, Portugal
| | - Ian Groves
- School of Mathematics and Statistics, The University of Sheffield, Sheffield, UK
- School of Biosciences, The University of Sheffield, Sheffield, UK
| | - Joshua Durrans
- Biomolecular Sciences Research Centre, Sheffield Hallam University, Sheffield, UK
| | - Mari Herigstad
- Biomolecular Sciences Research Centre, Sheffield Hallam University, Sheffield, UK
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Yoo KH, Kang H, Oh J, Lim TH, Cho Y, Lee J, Lee SH, Jung S, Kim WY, Sohn CH, Ko BS. Predicting acute brain lesions on magnetic resonance imaging in acute carbon monoxide poisoning: a multicenter prospective observational study. Sci Rep 2023; 13:22090. [PMID: 38086978 PMCID: PMC10716396 DOI: 10.1038/s41598-023-49216-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 12/05/2023] [Indexed: 12/18/2023] Open
Abstract
An acute brain lesion (ABL) identified by brain magnetic resonance imaging (MRI) after acute carbon monoxide (CO) poisoning is a strong prognostic factor for the development of delayed neuropsychiatric syndrome (DNS). This study aimed to identify predictors of ABLs on MRI in patients with acute CO poisoning. This was a multicenter prospective registry-based observational study conducted at two tertiary hospitals. A total of 1,034 patients were included. Multivariable logistic regression analysis showed that loss of consciousness (LOC) (adjusted odds ratio [aOR] 2.68, 95% Confidence Interval [CI]: 1.49-5.06), Glasgow Coma Scale (GCS) score < 9 (aOR 2.41, 95% CI: 1.49-3.91), troponin-I (TnI) (aOR 1.22, 95% CI: 1.08-1.41), CO exposure duration (aOR 1.09, 95% CI: 1.05-1.13), and white blood cell (WBC) (aOR 1.05, 95% CI: 1.01-1.09) were independent predictors of ABLs on MRI. LOC, GCS score, TnI, CO exposure duration, and WBC count can be useful predictors of ABLs on MRI in patients with acute CO poisoning, helping clinicians decide the need for an MRI scan or transfer the patient to an appropriate institution for MRI or hyperbaric oxygen therapy.
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Affiliation(s)
- Kyung Hun Yoo
- Department of Emergency Medicine, College of Medicine, Hanyang University, 222 Wangsimni-ro, Seongdong-gu, Seoul, 04763, South Korea
| | - Hyunggoo Kang
- Department of Emergency Medicine, College of Medicine, Hanyang University, 222 Wangsimni-ro, Seongdong-gu, Seoul, 04763, South Korea
| | - Jaehoon Oh
- Department of Emergency Medicine, College of Medicine, Hanyang University, 222 Wangsimni-ro, Seongdong-gu, Seoul, 04763, South Korea
| | - Tae Ho Lim
- Department of Emergency Medicine, College of Medicine, Hanyang University, 222 Wangsimni-ro, Seongdong-gu, Seoul, 04763, South Korea
| | - Yongil Cho
- Department of Emergency Medicine, College of Medicine, Hanyang University, 222 Wangsimni-ro, Seongdong-gu, Seoul, 04763, South Korea
| | - Juncheol Lee
- Department of Emergency Medicine, College of Medicine, Hanyang University, 222 Wangsimni-ro, Seongdong-gu, Seoul, 04763, South Korea
| | - Sang Hwan Lee
- Department of Emergency Medicine, College of Medicine, Hanyang University, 222 Wangsimni-ro, Seongdong-gu, Seoul, 04763, South Korea
| | - Seungkyo Jung
- Department of Emergency Medicine, College of Medicine, Hanyang University, 222 Wangsimni-ro, Seongdong-gu, Seoul, 04763, South Korea
| | - Won Young Kim
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea
| | - Chang Hwan Sohn
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea.
| | - Byuk Sung Ko
- Department of Emergency Medicine, College of Medicine, Hanyang University, 222 Wangsimni-ro, Seongdong-gu, Seoul, 04763, South Korea.
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Meng YH, Hsieh MS, Chi YC, How CK, Chen PC, Chang CM. Effect of Carbon Monoxide Poisoning on Epilepsy Development: A Nationwide Population-Based Cohort Study. Ann Emerg Med 2023:S0196-0644(22)01315-4. [PMID: 36797130 DOI: 10.1016/j.annemergmed.2022.11.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 11/10/2022] [Accepted: 11/22/2022] [Indexed: 02/17/2023]
Abstract
STUDY OBJECTIVE Carbon monoxide (CO) poisoning causes central nervous system toxicity resulting in delayed neurologic sequelae. This study aims to evaluate the risk of epilepsy in patients with a history of CO intoxication. METHODS We conducted a retrospective population-based cohort study using the Taiwan National Health Insurance Research Database and enrolled patients with and without CO poisoning matched for age, sex, and index year in a 1:5 ratio, between 2000 and 2010. Multivariable survival models were used to assess the risk of epilepsy. The primary outcome was newly developed epilepsy after the index date. All patients were followed until a new diagnosis of epilepsy, death, or December 31, 2013. Stratification analyses by age and sex were also conducted. RESULTS This study included 8,264 patients with CO poisoning and 41,320 without. Patients with a history of CO poisoning were strongly associated with subsequent epilepsy (adjusted hazard ratio [HR] 8.40; 95% confidence interval [CI], 6.48 to 10.88). In the age-stratified analysis, intoxicated patients aged 20 to 39 years had the highest HR (adjusted HR 11.06; 95% CI, 7.17 to 17.08). In the sex-stratified analysis, adjusted HRs for male and female patients were 8.00 (95% CI, 5.86 to 10.92) and 9.53 (95% CI, 5.95 to 15.26), respectively. CONCLUSION Patients with CO poisoning were associated with an increased risk of developing epilepsy compared with those without CO poisoning. This association was more prominent in the young population.
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Affiliation(s)
- Yu-Hsiang Meng
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Emergency Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Ming-Shun Hsieh
- Department of Emergency Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Department of Emergency Medicine, Taipei Veterans General Hospital Taoyuan Branch, Taoyuan, Taiwan
| | - Yu-Chi Chi
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Nursing, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chorng-Kuang How
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Emergency Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Institute of Emergency and Critical Care Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Pau-Chung Chen
- Institute of Environmental and Occupational Health Sciences, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Chia-Ming Chang
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Emergency Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Institute of Environmental and Occupational Health Sciences, College of Public Health, National Taiwan University, Taipei, Taiwan.
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Rhee B, Kim HH, Choi S, Min YG. Incidence patterns of nervous system diseases after carbon monoxide poisoning: a retrospective longitudinal study in South Korea from 2012 to 2018. Clin Exp Emerg Med 2021; 8:111-119. [PMID: 34237816 PMCID: PMC8273670 DOI: 10.15441/ceem.20.099] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 09/16/2020] [Indexed: 01/25/2023] Open
Abstract
Objective To analyze the incidence patterns of nervous system diseases in survivors of carbon monoxide (CO) poisoning using nationwide claims data from South Korea. Methods A national cohort was abstracted from a database that includes patients diagnosed with CO poisoning between January 2012 and December 2018. For all nervous system diseases, we investigated the frequency, pattern of incidence, effect of intensive care unit admission, and the standardized incidence ratios (SIRs) to estimate the risk of nervous system disease after CO poisoning. Results Of 26,778 patients, 18,720 (69.9%) were diagnosed with nervous system diseases after CO poisoning. The most common disease was disorders of sleep initiation and maintenance (n=701, 3.74%), followed by tension-type headache (n=477, 2.55%) and anoxic brain injury (n=406, 2.17%). Over half of the nervous system diseases occurred within the first year after CO poisoning. The cumulative hazard ratio for nervous system diseases in patients admitted to the intensive care unit was 2.25 (95% confidence interval [CI], 2.07–2.44). Among the frequent nervous system diseases after CO poisoning, patients had a higher risk of disorders of initiating and maintaining sleep (SIR, 1.61; 95% CI, 1.52–1.71), tension-type headache (SIR, 2.41; 95% CI, 2.23–2.61), anoxic brain injury (SIR, 58.76; 95% CI, 53.95–63.88), and post-zoster neuralgia (SIR, 1.94; 95% CI, 1.70–2.20). Conclusion Patients who experience CO poisoning are at higher risk for several nervous system diseases. Therefore, monitoring for specific nervous system diseases is important after CO poisoning within the first year.
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Affiliation(s)
- Bangshill Rhee
- Department of Emergency Medicine, Ajou University School of Medicine, Suwon, Korea
| | - Hyuk-Hoon Kim
- Department of Emergency Medicine, Ajou University School of Medicine, Suwon, Korea
| | - Sangchun Choi
- Department of Emergency Medicine, Ajou University School of Medicine, Suwon, Korea
| | - Young Gi Min
- Department of Emergency Medicine, Ajou University School of Medicine, Suwon, Korea
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Lee H, Kang H, Ko BS, Oh J, Lim TH, Cho Y. Initial creatine kinase level as predictor for delayed neuropsychiatric sequelae associated with acute carbon monoxide poisoning. Am J Emerg Med 2021; 43:195-199. [DOI: 10.1016/j.ajem.2020.02.054] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 02/21/2020] [Accepted: 02/25/2020] [Indexed: 10/24/2022] Open
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Effect of ethanol in carbon monoxide poisoning and delayed neurologic sequelae: A prospective observational study. PLoS One 2021; 16:e0245265. [PMID: 33428685 PMCID: PMC7799805 DOI: 10.1371/journal.pone.0245265] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 12/26/2020] [Indexed: 11/24/2022] Open
Abstract
Objectives Carbon monoxide (CO) is one of the most common poisoning substances, which causes mortality and morbidity worldwide. Delayed neurologic sequelae (DNS) have been reported to occur from several days to months after exposure to CO. Thus, there is a need for prevention, recognition, and treatment of DNS. Patients with CO poisoning as a component of intentional suicide often also consume ethanol, but there is debate regarding its role in DNS. We explored whether ethanol has a neuroprotective effect in CO poisoning. Methods This prospective observational study included patients who visited the emergency department from August 2016 to August 2019 due to CO poisoning. After treatment of acute CO poisoning, patients were interviewed by telephone to ascertain whether DNS had occurred within 2 weeks, 1 month, and 3 months from the time of CO exposure. Results During the study period, 171 patients were enrolled. 28 patients (16.37%) developed DNS. The initial Glasgow Coma Scale (GCS) scores were 15 (10.5–15) for the non-DNS group and 10 (7–15) for the DNS group (p = 0.002). The ethanol levels were 11.01 ± 17.58 mg/dL and 1.49 ± 2.63 mg/dL for each group (p < 0.001). In multivariate logistic regression analysis, the GCS score had an odds ratio of 0.770 (p < 0.001) and the ethanol level had 0.882 (p < 0.030) for onset of DNS. Conclusions Higher ethanol level and higher initial GCS score were associated with lower incidence of DNS. Ethanol could have a neuroprotective effect on the occurrence of DNS in CO poisoning patients.
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Raam R, Tabatabai RR. Headache in the Emergency Department: Avoiding Misdiagnosis of Dangerous Secondary Causes, An Update. Emerg Med Clin North Am 2020; 39:67-85. [PMID: 33218663 DOI: 10.1016/j.emc.2020.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
In the initial assessment of the headache patient, the emergency physician must consider several dangerous secondary causes of headache. A thorough history and physical examination, along with consideration of a comprehensive differential diagnosis may alert the emergency physician to the diagnosis of a secondary headache particularly when the history is accompanied by any of the following clinical features: sudden/severe onset, focal neurologic deficits, altered mental status, advanced age, active or recent pregnancy, coagulopathy, malignancy, fever, visual deficits, and/or loss of consciousness.
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Affiliation(s)
- Ryan Raam
- Keck School of Medicine of USC, LAC+USC Emergency Medicine Residency, 1200 North State Street #1011, Los Angeles, CA 90033, USA.
| | - Ramin R Tabatabai
- Keck School of Medicine of USC, LAC+USC Emergency Medicine Residency, 1200 North State Street #1011, Los Angeles, CA 90033, USA
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Kokulu K, Mutlu H, Sert ET. Serum netrin-1 levels at presentation and delayed neurological sequelae in unintentional carbon monoxide poisoning. Clin Toxicol (Phila) 2020; 58:1313-1319. [DOI: 10.1080/15563650.2020.1743302] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Kamil Kokulu
- Department of Emergency Medicine, Ümraniye Training and Research Hospital, University of Health Sciences, İstanbul, Turkey
| | - Hüseyin Mutlu
- Department of Emergency Medicine, Aksaray University Training and Research Hospital, Aksaray, Turkey
| | - Ekrem Taha Sert
- Department of Emergency Medicine, Aksaray University Training and Research Hospital, Aksaray, Turkey
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Jeon SB, Sohn CH, Seo DW, Oh BJ, Lim KS, Kang DW, Kim WY. Acute Brain Lesions on Magnetic Resonance Imaging and Delayed Neurological Sequelae in Carbon Monoxide Poisoning. JAMA Neurol 2019; 75:436-443. [PMID: 29379952 DOI: 10.1001/jamaneurol.2017.4618] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Importance Preventing delayed neurological sequelae is a major goal of treating acute carbon monoxide poisoning, but to our knowledge there are no reliable tools for assessing the probability of these sequelae. Objectives To determine whether acute brain lesions on diffusion-weighted imaging are related to subsequent development of delayed neurological sequelae after acute carbon monoxide poisoning. Design, Setting, and Participants This registry-based observational study was conducted at a university hospital in Seoul, Korea, between April 1, 2011, and December 31, 2015. Of 700 patients (aged ≥18 years) with acute carbon monoxide poisoning, 433 patients (61.9%) who underwent diffusion-weighted imaging at an emergency department were considered for the study. Patients who developed cardiac arrest before diffusion-weighted imaging (n = 3), had persistent neurological symptoms at discharge (n = 8), committed suicide soon after discharge (n = 1), and were lost to follow-up (n = 34) were excluded. Exposure The presence of unambiguous, high-signal-intensity, acute brain lesions on diffusion-weighted imaging (b = 1000 s/mm2). Main Outcomes and Measures Development of delayed neurological sequelae defined as any neurological symptoms or signs that newly developed within 6 weeks of discharge. Results Of the 387 included patients (143 women [37.0%]; median age, 42.0 years [interquartile range, 32.0-56.0 years]), acute brain lesions on diffusion-weighted imaging were observed in 104 patients (26.9%). Among these, 77 patients (19.9%) had globus pallidus lesions, 13 (3.4%) had diffuse lesions, and 57 (14.7%) had focal lesions (37 patients [9.6%] had >1 pattern concurrently). Lesions were supratentorial and infratentorial in 101 and 23 patients, respectively. Delayed neurological sequelae occurred in 101 patients (26.1%). Multivariable logistic regression analysis indicated that the presence of acute brain lesions was independently associated with development of delayed neurological sequelae (adjusted odds ratio, 13.93; 95% CI, 7.16-27.11; P < .001). The sensitivity and specificity of acute brain lesions to assess the probability of delayed neurological sequelae were 75.2% (95% CI, 66.8%-83.7%) and 90.2% (95% CI, 86.8%-93.7%), respectively. In addition, the positive and negative predictive values were 73.1% (95% CI, 64.6%-81.6%) and 91.2% (95% CI, 87.9%-94.5%), respectively. Conclusions and Relevance The presence of acute brain lesions was significantly associated with the development of delayed neurological sequelae. Diffusion-weighted imaging during the acute phase of carbon monoxide poisoning may therefore help identify patients at risk of developing these debilitating sequelae.
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Affiliation(s)
- Sang-Beom Jeon
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chang Hwan Sohn
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong-Woo Seo
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Bum Jin Oh
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kyoung Soo Lim
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong-Wha Kang
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Won Young Kim
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Kim H, Choi S, Park E, Yoon E, Min Y, Lampotang S. Serum markers and development of delayed neuropsychological sequelae after acute carbon monoxide poisoning: anion gap, lactate, osmolarity, S100B protein, and interleukin-6. Clin Exp Emerg Med 2018; 5:185-191. [PMID: 30269454 PMCID: PMC6166038 DOI: 10.15441/ceem.17.217] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 08/29/2017] [Indexed: 12/15/2022] Open
Abstract
Objective Reliable biomarkers of delayed neuropsychological sequelae (DNS) after acute carbon monoxide (CO) poisoning are lacking. This study investigated the associations between potential serum markers and the development of DNS after acute CO poisoning. Methods Retrospective chart reviews were conducted for patients diagnosed with acute CO poisoning during a 28-month period. The patients were divided into two groups according to the presence or absence of having developed DNS. Multivariate analysis was performed to identify predictors of DNS after CO poisoning. Results Of a total of 102 patients, 10 (9.8%) developed DNS. The levels of serum osmolarity, S100B protein, and serum lactate, as well as serum anion gap, were statistically significant in univariate analysis. Multiple logistic regression analysis showed that anion gap (adjusted odds ratio [AOR], 1.36; 95% confidence interval [CI], 1.11 to 1.88), serum lactate level (AOR, 1.74; 95% CI, 1.26 to 2.75), and serum S100B protein level ([AOR, 7.02×105; 95% CI, 4.56×102 to 9.00×1010] in model 1, [AOR, 3.69×105; 95% CI, 2.49×102 to 2.71×1011] in model 2) were independently associated with DNS development. Conclusion Based on our preliminary results, serum lactate level, serum anion gap, and serum S100B protein level in the emergency department could be informative predictors of DNS development in patients with acute CO poisoning. These markers might have the potential to improve early recognition of DNS in patients with acute CO poisoning.
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Affiliation(s)
- Hyukhoon Kim
- Department of Emergency Medicine, Ajou University School of Medicine, Suwon, Korea
| | - Sangchun Choi
- Department of Emergency Medicine, Ajou University School of Medicine, Suwon, Korea.,Center for Safety, Simulation & Advanced Learning Technologies, University of Florida, Gainesville, FL, USA
| | - Eunjung Park
- Department of Emergency Medicine, Ajou University School of Medicine, Suwon, Korea
| | - Eunhui Yoon
- Center for Safety, Simulation & Advanced Learning Technologies, University of Florida, Gainesville, FL, USA
| | - Younggi Min
- Department of Emergency Medicine, Ajou University School of Medicine, Suwon, Korea
| | - Samsun Lampotang
- Center for Safety, Simulation & Advanced Learning Technologies, University of Florida, Gainesville, FL, USA
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Abstract
BACKGROUND Carbon monoxide (CO) poisoning is the leading cause of accidental poisoning worldwide. This study undertook a meta-analysis to examine differences in neuropsychological functioning in patients with CO poisoning as compared to healthy controls, and examined the longer-term neuropsychological effects of CO poisoning. METHODS Studies performed between the years 1995 and 2016 were identified through a search of the electronic databases Medline and PsycInfo. Data from the papers identified were pooled to determine standard mean differences using a random-effects model. RESULTS Ten studies were included in the analysis, with healthy controls performing significantly better than CO poisoned participants on the domains of divided attention, immediate memory, and processing speed. No statistically significant differences were found for sustained attention, recent memory, working memory, visuospatial/constructional ability, and expressive language. Performance by participants with CO poisoning for the domains of sustained attention, recent memory, visuospatial/constructional abilities, and working memory significantly improved over time after initial exposure, demonstrating recovery of these functions over time. No statistically significant differences were evident for divided attention or expressive language. CONCLUSIONS This evidence indicates that healthy controls perform better than do individuals with CO poisoning on a range of neuropsychological domains; however, it also indicates that performance in some domains does improve over time. (JINS, 2018, 24, 405-415).
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da Silva IRF, Frontera JA. Neurologic complications of acute environmental injuries. HANDBOOK OF CLINICAL NEUROLOGY 2017; 141:685-704. [PMID: 28190442 DOI: 10.1016/b978-0-444-63599-0.00037-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Environmental injuries can result in serious neurologic morbidity. This chapter reviews neurologic complications of thermal burns, smoke inhalation, lightning strikes, electric injury, near drowning, decompression illness, as well as heat stroke and accidental hypothermia. Knowing the pathophysiology and clinical presentation of such injuries is essential to proper management of primary and secondary medical complications. This chapter highlights the most frequently encountered neurologic injuries secondary to common environmental hazards, divided into the topics: injuries related to fire, electricity, water, and the extremes of temperature.
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Affiliation(s)
- I R F da Silva
- Neurocritical Care Unit, Americas Medical City, Rio de Janeiro, Brazil
| | - J A Frontera
- Neurological Institute, Cleveland Clinic, Cleveland, OH, USA.
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Headache in the Emergency Department: Avoiding Misdiagnosis of Dangerous Secondary Causes. Emerg Med Clin North Am 2016; 34:695-716. [PMID: 27741984 DOI: 10.1016/j.emc.2016.06.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
There are a number of dangerous secondary causes of headaches that are life, limb, brain, or vision threatening that emergency physicians must consider in patients presenting with acute headache. Careful history and physical examination targeted at these important secondary causes of headache will help to avoid misdiagnosis in these patients. Patients with acute thunderclap headache have a differential diagnosis beyond subarachnoid hemorrhage. Considering the "context" of headache "PLUS" some other symptom or sign is one strategy to help focus the differential diagnosis.
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Hopkins RO, Woon FLM. Neuroimaging, Cognitive, and Neurobehavioral Outcomes Following Carbon Monoxide Poisoning. ACTA ACUST UNITED AC 2016; 5:141-55. [PMID: 16891556 DOI: 10.1177/1534582306289730] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Carbon monoxide is a colorless, odorless gas produced as a byproduct of combustion. Carbon monoxide is the leading cause of poisoning injury and death worldwide. Morbidity following CO poisoning includes neurologic sequelae, neuropathologic abnormalities on brain imaging, neurobehavioral changes, and cognitive impairments. It is estimated that as high as 50% of individuals with carbon monoxide poisoning will develop neurologic, neurobehavioral, or cognitive sequelae. Carbon monoxide related cognitive impairments included impaired memory, attention, executive function, motor, visual spatial, and slow mental processing speed. Given the high rate of brain related morbidity and the fact that the majority of carbon monoxide is avoidable, awareness and prevention of carbon monoxide poisoning is warranted.
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Abstract
OBJECTIVES Carbon monoxide (CO) poisoning is a worldwide health problem. We have limited information regarding psychological adversities of CO poisoning in children and adolescents. The aim of this study was (1) to investigate the effects of severe CO poisoning on cognitive functions, mood, and behaviors in children and adolescents and (2) to identify factors related to occurrence of neuropsychological symptoms. METHODS This study included pediatric patients, who were evaluated after CO poisoning at the Department of Child and Adolescent Psychiatry between January 2012 and April 2013. The patients were evaluated at 2 time points. The first evaluation was done when they were discharged from emergency department, and the second evaluation was done 1 month after CO poisoning. Turkish versions of internationally recognized tests were used to evaluate anxiety, depressive symptoms, attention, visual-spatial skills, memory, and behaviors of patients. RESULTS Twenty-seven patients were analyzed. The mean age of the patients was 11.8 ± 2.7 years (range, 6-18 years). The mean carboxyhemoglobin level was 31.5% ± 7.8% (range, 19%-51%) dir. Delayed neurological sequel was observed in only 1 patient, who had headache and tinnitus. We found that carboxyhemoglobin level was not correlated with later neuropsychiatric test scores. However, we found a correlation between history of loss of consciousness and anxiety symptom level, hyperbaric oxygen (HBO) therapy session and behavioral problems, and time to HBO therapy and attention problems. CONCLUSIONS We suggest that CO exposure duration, history of loss of consciousness, time to HBO therapy, and the number of HBO therapy session affect neuropsychological symptom levels and occurrence of attention and behavioral problems.
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Wong CS, Lin YC, Hong LY, Chen TT, Ma HP, Hsu YH, Tsai SH, Lin YF, Wu MY. Increased Long-Term Risk of Dementia in Patients With Carbon Monoxide Poisoning: A Population-Based Study. Medicine (Baltimore) 2016; 95:e2549. [PMID: 26817904 PMCID: PMC4998278 DOI: 10.1097/md.0000000000002549] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Carbon monoxide (CO) poisoning may cause toxicity of the central nervous system and heart. However, the association between CO poisoning and long-term dementia risk remains unestablished. We investigated the incidence of dementia in patients with CO poisoning in Taiwan and evaluated whether they had a higher risk of dementia than did the general population.A nationwide population-based cohort study was conducted among patients with CO poisoning identified using Taiwan's National Health Insurance Research Database (NHIRD) during 2004 to 2013. CO poisoning was defined according to the International Classification of Diseases, Ninth Revision, Clinical Modification codes. The study cohort comprised patients with CO poisoning between 2005 and 2010 (N = 14,590). Each patient was age-, sex-, and index date-matched with 4 randomly selected controls from the comparison cohort (N = 58,360). All patients were followed from the study date until dementia development, death, or the end of 2013. Cox proportional hazards regressions were performed for comparing the hazard ratios for dementia between the 2 cohorts.Incident cases of dementia were identified from the NHIRD.After adjustment for potential confounders, the study cohort was independently associated with a higher dementia risk (adjusted hazard ratio, 2.75; 95% confidence interval, 2.26-3.35).This population-based cohort study indicated that patients with CO poisoning have a higher risk of dementia than do people without CO poisoning.
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Affiliation(s)
- Chung-Shun Wong
- From the Emergency Department, Shuang Ho Hospital (CSW, H-PM, S-HT); Graduate Institute of Clinical Medicine, College of Medicine (CSW, Y-FL); Emergency department, school of Medicine, Taipei Medical University, Taipei (CSW, H-PM); Department of Family Medicine, Shuang Ho Hospital (Y-CL); Department of Family Medicine, School of Medicine, College of Medicine (Y-CL); Division of Nephrology, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University (LYH, Y-HH, Y-FL, M-YW); Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University (T-TC, M-YW); Department of Internal Medicine, School of Medicine, College of Medicine (Y-HH, Y-FL, M-YW); and College of Public Health and Nutrition, Taipei Medical University, Taipei, Taiwan (S-HT)
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Lai CY, Huang YW, Tseng CH, Lin CL, Sung FC, Kao CH. Patients With Carbon Monoxide Poisoning and Subsequent Dementia: A Population-Based Cohort Study. Medicine (Baltimore) 2016; 95:e2418. [PMID: 26735545 PMCID: PMC4706265 DOI: 10.1097/md.0000000000002418] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The present study evaluated the dementia risk after carbon monoxide poisoning (CO poisoning). Using the National Health Insurance Research Database of Taiwan, a total of 9041 adults newly diagnosed with CO poisoning from 2000 to 2011 were identified as the CO poisoning cohort. Four-fold (N = 36,160) of non-CO poisoning insured people were randomly selected as controls, frequency-matched by age, sex, and hospitalization year. Incidence and hazard ratio (HR) of dementia were measured by the end 2011. The dementia incidence was 1.6-fold higher in the CO exposed cohort than in the non-exposed cohort (15.2 vs 9.76 per 10,000 person-years; n = 62 vs 174) with an adjusted HR of 1.50 (95% CI = 1.11-2.04). The sex- and age-specific hazards were higher in male patients (adjusted HR = 1.74, 95% CI = 1.20-2.54), and those aged <= 49 years (adjusted HR = 2.62, 95% CI = 1.38-4.99). CO exposed patients with 7-day or longer hospital stay had an adjusted HR of 2.18 (95% CI = 1.42, 3.36). The CO poisoning patients on hyperbaric oxygen (HBO2) therapy had an adjusted HR of 1.80 (95% CI = 0.96-3.37). This study suggests that CO poisoning may have association with the risk of developing dementia, which is significant for severe cases. The effectiveness of HBO2 therapy remains unclear in preventing dementia. Patients with CO poisoning are more prevalent with depression.
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Affiliation(s)
- Ching-Yuan Lai
- From the Department of Emergency Medicine, China Medical University Hospital, Taichung (C-YL); Department of Critical Care Medicine, E-DA Hospital, Department of Community Medicine, E-DA Hospital and I-Shou University Kaohsiung (Y-WH), Department of Neurology, China Medical University Hospital (C-HT), Management Office for Health Data China Medical University Hospital (C-LL), College of Medicine (C-LL), Graduate Institute of Clinical Medical Science and School of Medicine, College of Medicine (C-HK), Department of Health Services Administration (F-CS); and Department of Nuclear Medicine and PET Center, China Medical University Hospital, Taichung, Taiwan (C-HK)
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Sykes OT, Walker E. The neurotoxicology of carbon monoxide - Historical perspective and review. Cortex 2015; 74:440-8. [PMID: 26341269 DOI: 10.1016/j.cortex.2015.07.033] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2015] [Revised: 07/16/2015] [Accepted: 07/23/2015] [Indexed: 10/23/2022]
Abstract
Carbon monoxide (CO) has been recognized as a poison for centuries, and remains one of the most common causes of both accidental and deliberate poisoning worldwide. Despite this, there are widespread misconceptions with regards to the mechanisms, diagnosis and outcomes of CO induced poisoning such as the idea that CO poisoning is rare; that carboxyhaemoglobin levels above 20% and loss of consciousness are required before nervous system damage ensues; and that the binding of CO to haemoglobin is the only mechanism of toxicity. Prevention and diagnosis of CO poisoning is hampered by the lack of awareness of CO as a cause of illness, among both the general public and healthcare professionals. To complicate matters further there is no standardized definition of CO poisoning. Carboxyhaemoglobin levels are often used as a marker of CO poisoning, yet plasma levels rapidly reduce upon removal of the source and are therefore an unreliable biomarker of exposure and tissue damage. Adverse neuropsychiatric outcomes after CO poisoning are difficult to define, especially as they fluctuate, mimic other non-specific complaints, and are not present in all survivors. This paper challenges a number of misconceptions about CO poisoning which can result in misdiagnosis, and consequently in mismanagement. We illustrate how recent developments in the understanding of CO toxicology explain the particular susceptibility of the central nervous system to the effects of CO exposure.
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Affiliation(s)
- Oliver T Sykes
- Department of Anaesthesia, Royal National Throat, Nose and Ear Hospital, University College London Hospitals NHS Foundation Trust, London, UK.
| | - Edward Walker
- Department of Emergency Medicine, Mid-Yorkshire Hospitals NHS Trust, Wakefield, UK
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Abstract
Carbon monoxide (CO) is a colorless, odorless, nonirritant gas that accounts for numerous cases of CO poisoning every year from a variety of sources of incomplete combustion of hydrocarbons. These include poorly functioning heating systems, indoor propane-powered forklifts, indoor burning of charcoal burning briquettes, riding in the back of pick-up trucks, ice skating rinks using propane-powered resurfacing machines, and gasoline-powered generators that are not in correct locations. Once CO is inhaled it binds with hemoglobin to form carboxyhemoglobin (COHb) with an affinity 200 times greater than oxygen that leads to decreased oxygen-carrying capacity and decreased release of oxygen to tissues leading to tissue hypoxia. Ischemia occurs with CO poisoning when there is loss of consciousness that is accompanied by hypotension and ischemia in the arterial border zones of the brain. Besides binding to many heme-containing proteins, CO disrupts oxidative metabolism leading to the formation of free radicals. Once hypotension and unconsciousness occur with CO poisoning, lipid peroxidation and apoptosis follow. Because COHb has a short half-life, examination of other biomarkers of CO neurotoxicity that reflect inflammation or neuronal damage has not demonstrated consistent results. The initial symptoms with CO exposure when COHb is 15-30% are nonspecific, namely, headache, dizziness, nausea, fatigue, and impaired manual dexterity. However individuals with ischemic heart disease may experience chest pain and decreased exercise duration at COHb levels between 1% and 9%. COHb levels between 30% and 70% lead to loss of consciousness and eventually death. Following resolution of acute symptoms there may be a lucid interval of 2-40 days before the development of delayed neurologic sequelae (DNS), with diffuse demyelination in the brain accompanied by lethargy, behavior changes, forgetfulness, memory loss, and parkinsonian features. Seventy-five percent of patients with DNS recover within 1 year. Neuropsychologic abnormalities with chronic CO exposure are found even when magnetic resonance imaging (MRI) and magnetic resonance spectroscopy are normal. White-matter damage in the centrum semiovale and periventricular area and abnormalities in the globus pallidus are most commonly seen on MRI following CO exposure. Though not as common, toxic or ischemic peripheral neuropathies are associated with CO exposure in humans and animals. The cornerstone for treatment for CO poisoning is 100% oxygen using a tight-fitting mask for greater than 6 hours. The indications for treatment with hyperbaric oxygen to decrease the half-life of COHb remain controversial.
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Affiliation(s)
- Margit L Bleecker
- Center for Occupational and Environmental Neurology, Baltimore, MD, USA.
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Betterman K, Patel S. Neurologic complications of carbon monoxide intoxication. HANDBOOK OF CLINICAL NEUROLOGY 2014; 120:971-9. [DOI: 10.1016/b978-0-7020-4087-0.00064-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Dries DJ, Endorf FW. Inhalation injury: epidemiology, pathology, treatment strategies. Scand J Trauma Resusc Emerg Med 2013; 21:31. [PMID: 23597126 PMCID: PMC3653783 DOI: 10.1186/1757-7241-21-31] [Citation(s) in RCA: 141] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2012] [Accepted: 04/11/2013] [Indexed: 01/19/2023] Open
Abstract
Lung injury resulting from inhalation of smoke or chemical products of combustion continues to be associated with significant morbidity and mortality. Combined with cutaneous burns, inhalation injury increases fluid resuscitation requirements, incidence of pulmonary complications and overall mortality of thermal injury. While many products and techniques have been developed to manage cutaneous thermal trauma, relatively few diagnosis-specific therapeutic options have been identified for patients with inhalation injury. Several factors explain slower progress for improvement in management of patients with inhalation injury. Inhalation injury is a more complex clinical problem. Burned cutaneous tissue may be excised and replaced with skin grafts. Injured pulmonary tissue must be protected from secondary injury due to resuscitation, mechanical ventilation and infection while host repair mechanisms receive appropriate support. Many of the consequences of smoke inhalation result from an inflammatory response involving mediators whose number and role remain incompletely understood despite improved tools for processing of clinical material. Improvements in mortality from inhalation injury are mostly due to widespread improvements in critical care rather than focused interventions for smoke inhalation. Morbidity associated with inhalation injury is produced by heat exposure and inhaled toxins. Management of toxin exposure in smoke inhalation remains controversial, particularly as related to carbon monoxide and cyanide. Hyperbaric oxygen treatment has been evaluated in multiple trials to manage neurologic sequelae of carbon monoxide exposure. Unfortunately, data to date do not support application of hyperbaric oxygen in this population outside the context of clinical trials. Cyanide is another toxin produced by combustion of natural or synthetic materials. A number of antidote strategies have been evaluated to address tissue hypoxia associated with cyanide exposure. Data from European centers supports application of specific antidotes for cyanide toxicity. Consistent international support for this therapy is lacking. Even diagnostic criteria are not consistently applied though bronchoscopy is one diagnostic and therapeutic tool. Medical strategies under investigation for specific treatment of smoke inhalation include beta-agonists, pulmonary blood flow modifiers, anticoagulants and antiinflammatory strategies. Until the value of these and other approaches is confirmed, however, the clinical approach to inhalation injury is supportive.
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Affiliation(s)
- David J Dries
- Department of Surgery, Regions Hospital, St. Paul, MN 55101, USA.
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Abstract
Carbon monoxide (CO) poisoning is the leading cause of death as a result of unintentional poisoning in the United States. CO toxicity is the result of a combination of tissue hypoxia-ischemia secondary to carboxyhemoglobin formation and direct CO-mediated damage at a cellular level. Presenting symptoms are mostly nonspecific and depend on the duration of exposure and levels of CO. Diagnosis is made by prompt measurement of carboxyhemoglobin levels. Treatment consists of the patient's removal from the source of exposure and the immediate administration of 100% supplemental oxygen in addition to aggressive supportive measures. The use of hyperbaric oxygen is controversial.
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Park E, Ahn J, Min YG, Jung YS, Kim K, Lee J, Choi SC. The usefulness of the serum s100b protein for predicting delayed neurological sequelae in acute carbon monoxide poisoning. Clin Toxicol (Phila) 2012; 50:183-8. [PMID: 22372785 DOI: 10.3109/15563650.2012.658918] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
CONTEXT Some patients with acute carbon monoxide poisoning will experience delayed neurological sequelae. Several factors associated with delayed neurological sequelae have been reported, but these factors are unsatisfactory for the assessment of unconscious patients. OBJECTIVE The aim of this study was to assess the usefulness of the serum S100B protein as a biochemical marker for predicting delayed neurological sequelae. MATERIALS AND METHODS In this retrospective study, we evaluated the data for patients who visited an emergency medical center once during a period of 7 months. The enrollment criteria were the diagnosis of acute carbon monoxide poisoning and the measurement of the serum S100B level. A standardized extraction using medical records was performed. RESULT A total of 71 patients were enrolled, and 10 patients (14.1%) presented delayed neurological sequelae. The delayed neurological sequelae group had a longer duration of carbon monoxide exposure, a longer duration of loss of consciousness, and a worse mental status (p-value < 0.001). In addition, the S100B protein levels were higher in the delayed neurological sequelae group (0.891 vs. 0.063, p-value < 0.001). Multiple logistic regression analysis showed that only the serum S100B protein level was independently associated with the development of delayed neurological sequelae (OR, 120.594; 95% CI, 4.194-3467.220), and a serum S100B protein level of more than 0.165 μg/L predicted the development of delayed neurological sequelae (sensitivity 90%, specificity 87%). DISCUSSION AND CONCLUSION In the present study, the level of serum S100B protein was found to be useful for evaluating acute CO poisoning patients and was found to be an independent predictor of the development of DNS after acute CO poisoning.
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Affiliation(s)
- Eunjung Park
- Department of Emergency Medicine, Ajou University School of Medicine, Suwon, Republic of Korea
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Katirci Y, Kandiş H, Aslan Ş, Kirpinar İ. Neuropsychiatric disorders and risk factors in carbon monoxide intoxication. Toxicol Ind Health 2010; 27:397-406. [DOI: 10.1177/0748233710387632] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Neuropsychiatric sequelae may be observed in the late phases of carbon monoxide (CO) intoxication. Establishing a link between CO-related neuropsychiatric disorders and associated risk factors may decrease morbidity and mortality by means of appropriate treatment and counseling. The aim of the present study was to determine the relationship between neuropsychiatric outcomes of CO intoxication and demographic and clinical variables. Thirty patients who presented with CO intoxication and had no known neuropsychiatric disease, and 30 healthy controls were included. Physical examinations and laboratory tests were performed. Following the 1st therapy, they underwent mental and psychiatric tests 5 times (the time of discharge, during the 1st week, and during the 1st, 3rd, and 6th months). They underwent cerebral magnetic resonance imaging (MRI) at the end of the 1st month. They were evaluated by cognitive function tests at the 6th month. Lesions relevant to CO intoxication were detected in 46.7% of the patients via cranial computed tomography and in 13.3% via MRI. Evaluation of psychiatric tests revealed a clear decrease in cognitive functions, such as immediate memory, learning, reaching the criterion, spontaneous recall, attention, visual memory, and logical memory. It was found that the patients had anxiety within the 1st month, and the frequency of anxiety reached to the value of the control group by the end of the 6th month. In conclusion, we suggested that CO intoxication might lead to neuropsychiatric disorders. Our results emphasized that in addition to standard treatment, neuropsychiatric evaluation should also be performed in patients with CO intoxication.
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Affiliation(s)
- Yavuz Katirci
- Ankara Teaching and Research Hospital, Emergency Medicine, Ankara, Turkey
| | - Hayati Kandiş
- Department of Emergency Medicine, School of Medicine, Düzce University, Düzce, Turkey,
| | - Şahin Aslan
- Department of Emergency Medicine, School of Medicine, Atatürk University, Erzurum, Turkey
| | - İsmet Kirpinar
- Department of Psychiatry, School of Medicine, Atatürk University, Erzurum, Turkey
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Air pollution and daily emergency department visits for depression. Int J Occup Med Environ Health 2010; 22:355-62. [PMID: 20197262 DOI: 10.2478/v10001-009-0031-6] [Citation(s) in RCA: 123] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVES To investigate the potential correlation between ambient air pollution exposure and emergency department (ED) visits for depression. MATERIALS AND METHODS A hierarchical clusters design was used to study 27 047 ED visits for depression in six cities in Canada. The data used in the analysis contain the dates of visits, daily numbers of diagnosed visits, and daily mean concentrations of air pollutants as well as the meteorological factors. The generalized linear mixed models technique was applied to data analysis. Poisson models were fitted to the clustered counts of ED visits with a single air pollutant, temperature and relative humidity. RESULTS Statistically significant positive correlations were observed between the number of ED visits for depression and the air concentrations of carbon monoxide (CO), nitrogen dioxide (NO2), sulphur dioxide (SO2) and particulate matter (PM10). The percentage increase in daily ED visits was 15.5% (95% CI: 8.0-23.5) for CO per 0.8 ppm and 20.0% (95% CI: 13.3-27.2) for NO2 per 20.1 ppb, for same day exposure in the warm weather period (April-September). For PM10, the largest increase, 7.2% (95% CI: 3.0-11.6) per 19.4 ug/m3, was observed for the cold weather period (October-March). CONCLUSIONS The results support the hypothesis that ED visits for depressive disorder correlate with ambient air pollution, and that a large majority of this pollution results from combustion of fossil fuels (e.g. in motor vehicles).
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Chambers CA, Hopkins RO, Weaver LK, Key C. Cognitive and affective outcomes of more severe compared to less severe carbon monoxide poisoning. Brain Inj 2009; 22:387-95. [DOI: 10.1080/02699050802008075] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Hopkins RO, Weaver LK, Key C, Chambers CA. Response to: ‘The methodology in the paper by Chambers et al. raises serious questions about their conclusions’. Brain Inj 2009. [DOI: 10.1080/02699050802665940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Long-term psychiatric consequences from carbon monoxide exposure: Progression of endogenous cause or toxicant effect?*. Crit Care Med 2009; 37:2116-8. [DOI: 10.1097/ccm.0b013e3181a5eaf4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Affiliation(s)
- Lindell K Weaver
- Department of Hyperbaric Medicine, LDS Hospital, and University of Utah School of Medicine, Salt Lake City 84143, USA.
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30
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Abstract
Inhalation injury consists of a multitude of insults, the first of which is the toxic gases inhaled during the combustion of organic and inorganic substances. Significant morbidity and mortality in patients with burn injury occur due to the varying effects of these gases. This section of the compendium initially addresses two classically described inhaled gases: carbon monoxide and cyanide, followed by a discussion of a gas associated with illicit drug use: metamphetamine. Understanding the varying effects of the toxic gases at the scene of injury may facilitate the development of specific treatment regimens for inhalation injury.
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Biermann T, Stilianakis N, Bleich S, Thürauf N, Kornhuber J, Reulbach U. The hypothesis of an impact of ozone on the occurrence of completed and attempted suicides. Med Hypotheses 2009; 72:338-41. [DOI: 10.1016/j.mehy.2008.09.042] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2008] [Revised: 08/13/2008] [Accepted: 09/12/2008] [Indexed: 11/16/2022]
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Air pollution and emergency department visits for depression in Edmonton, Canada. Int J Occup Med Environ Health 2008; 20:241-5. [PMID: 17932013 DOI: 10.2478/v10001-007-0024-2] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE Depression is a common cause of morbidity. Sufferers are very sensitive to many external factors. Emergency department (ED) visits for this condition can be associated with the concentration of ambient air pollutants. The study objective was to examine and assess the associations between ED visits for depression and ambient air pollution. DESIGN AND METHODS The present study analyzed 15,556 ED visits for depression (ICD-9: 311) at Edmonton hospitals between 1992 and 2002. The data were clustered based on the triplet {year, month, day of the week}. The generalized linear mixed models (GLMM) technique was used to regress the logarithm of the clustered counts for ED visits for depression on the levels of air pollutants (CO, NO2, SO2, O3, PM10 and PM2.5) and the meteorological variables. The number of ED visits for depression was analyzed separately for all patients, and males and females. An analysis by season was also conducted: for the whole year (I-XII), warm season (IV-IX), and cold season (X-III). RESULTS After adjusting for temperature and relative humidity, the following increments in daily depression-related ED visits could be noted: 6.9% (95% CI: 1.3, 12.9) for carbon monoxide (CO) for all patients in warm season; 7.4% (95% CI: 0.5, 14.8) for nitrogen dioxide (NO2) for female patients in warm season; 4.5% (95% CI: 0.1, 9.1) for sulphur dioxide (SO2) for female patients in warm season; 6.9% (95% CI: 0.6, 13.6) for ground level ozone (O3, 1-day lagged) for female patients in warm season; 7.2% (95% CI: 2.7, 12.0) for particulate matter (PM10) for females in cold season; and 7.2% (95% CI: 2.0, 12.8) for particulate matter (PM2.5) for females in cold season. CONCLUSIONS The findings provide support for the hypothesis that ED visits for depression are associated with exposure to ambient air pollution.
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Toxic Gas, Fume, and Smoke Inhalation. Crit Care Med 2008. [DOI: 10.1016/b978-032304841-5.50051-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Bledsoe BE. The heart dangers of CO. Understanding cardiovascular risks to responders from CO exposure. JEMS : A JOURNAL OF EMERGENCY MEDICAL SERVICES 2007; 32:54-59. [PMID: 18068025 DOI: 10.1016/s0197-2510(07)72446-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
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Weaver LK, Deru K. Carbon monoxide poisoning at motels, hotels, and resorts. Am J Prev Med 2007; 33:23-7. [PMID: 17572307 DOI: 10.1016/j.amepre.2007.02.038] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2006] [Revised: 02/05/2007] [Accepted: 02/28/2007] [Indexed: 11/20/2022]
Abstract
BACKGROUND Each year, more than 200 people in the United States die from carbon monoxide (CO) poisoning. Poisoning has occurred at motels, hotels, and resorts. Congressional mandate requires smoke alarms in all guest rooms; however, smoke alarms do not detect CO. METHODS Data on patients poisoned at hotels, motels, and resorts were evaluated at a hyperbaric medicine service. In 2005, legal databases and online news databanks were searched to discover additional incidents. Only victims evaluated in hospitals or declared dead at the scene were included. Cases of intentional poisoning and poisoning from fires were excluded. RESULTS Between 1989 and 2004, 68 incidents of CO poisoning occurring at hotels, motels, and resorts were identified, resulting in 772 accidentally poisoned: 711 guests, 41 employees or owners, and 20 rescue personnel. Of those poisoned, 27 died, 66 had confirmed sequelae, and 6 had sequelae resulting in a jury verdict. Lodging-operated, faulty room heating caused 45 incidents, pool/spa boilers 16, CO entrained from outdoors 5, and unreported sources caused 2 incidents. Public verdicts have averaged $4.8 million per incident (range, $1 million to $17.5 million). Poisoning occurred at hotels of all classes. Despite these incidents, most properties did not install CO alarms, and requirements for CO alarms at hotels, motels, and resorts are rare. CONCLUSIONS Guests of motels, hotels, and resorts remain at risk for injury or death from CO poisoning. Measures to prevent CO poisoning of guests and employees of the lodging industry should be evaluated.
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Affiliation(s)
- Lindell K Weaver
- Hyperbaric Medicine, Pulmonary/Critical Care Division, Department of Internal Medicine, LDS Hospital, Salt Lake City, Utah, USA.
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36
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Abstract
CO is likely to be the most common cause of poisoning worldwide and often results in persistent neuropathologic and cognitive sequelae. While the displacement of oxygen from hemoglobin by CO has overshadowed the myriad mechanisms by which CO causes injury, mere oxygen displacement has endured as the etiology of CO poisonings and perpetuated a cascade of misdiagnosis, misunderstandings and confusion regarding how and when to treat CO poisoning. Hyperbaric oxygen benefits the brain more than normobaric oxygen by, e.g. improving energy metabolism, preventing lipid peroxidation and decreasing neutrophil adherence. Randomized controlled trials have definitively shown hyperbaric oxygen as the only efficacious therapy for acute CO poisoning if delayed neurological sequelae are to be minimized. Normobaric oxygen should not be used between multiple hyperbaric oxygen treatments as this can contribute to toxicity. Hyperbaric oxygen seems to also have potential in the delayed treatment of CO poisoning using multiple treatments of low dose of oxygen; however, oxygen dosing issues are not yet fully understood for either acute or delayed treatment. It would behoove medical decision-makers to embrace this important tool and make it more accessible as well as helping to disseminate to the medical community what is now known from the available literature.
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Affiliation(s)
- Kenneth P Stoller
- Hyperbaric Medical Center of New Mexico, 404 Brunn School Rd No. D/E, Santa Fe, NM 87505, USA.
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37
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Graber JM, Macdonald SC, Kass DE, Smith AE, Anderson HA. Carbon monoxide: the case for environmental public health surveillance. Public Health Rep 2007; 122:138-44. [PMID: 17357355 PMCID: PMC1820437 DOI: 10.1177/003335490712200202] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Judith M. Graber
- Environmental and Occupational Health Unit, Center for Disease Control and Prevention, Maine Department of Health and Human Services, Augusta, ME
| | | | - Daniel E. Kass
- Environmental Surveillance and Policy, Environmental and Occupational Disease Epidemiology, New York City Department of Health and Mental Hygiene, New York, NY
| | - Andrew E. Smith
- Environmental and Occupational Health Unit, Center for Disease Control and Prevention, Maine Department of Health and Human Services, Augusta, ME
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Montoya T, Gurian PL, Velázquez-Angulo G, Corella-Barud V, Rojo A, Graham JP. Carbon monoxide exposure in households in Ciudad Juárez, México. Int J Hyg Environ Health 2007; 211:40-9. [PMID: 17336583 DOI: 10.1016/j.ijheh.2006.12.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2005] [Revised: 08/18/2006] [Accepted: 12/13/2006] [Indexed: 11/22/2022]
Abstract
This study assessed exposure to carbon monoxide from gas and wood heater emissions in a sample of 64 households in peri-urban residential areas in Ciudad Juárez, Chihuahua, México. Indoor and outdoor carbon monoxide concentrations and temperatures were monitored for a continuous period of 1 week at 1 and 6-min intervals, respectively. The moving average carbon monoxide concentrations were compared to the World Health Organization (WHO) standards for carbon monoxide. Sixty-seven percent of households with gas heaters and 60% of households with wood heaters exceeded a health-based standard at some point during the monitoring. The difference between indoor and outdoor temperatures was modestly correlated with average carbon monoxide exposure (r=0.35, p-value <0.01). Heater type may be a stronger determinant of exposure, as households with a particular heater model (the El Sol FM-210) were significantly more likely to be among the more highly exposed households (odds ratio of 4.8, p-value of 0.02). A variety of health effects were pooled and found at elevated frequency in the households that exceeded the 8-h standard of 9ppm (odds ratio=5.1, p-value=0.031). These results highlight the need for further efforts to identify and mitigate potentially hazardous carbon monoxide exposures, particularly in moderate-income countries with cooler climates.
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Affiliation(s)
- Teresa Montoya
- Center for Environmental Resource Management, University of Texas, El Paso, Texas, USA
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Hopkins RO, Fearing MA, Weaver LK, Foley JF. Basal ganglia lesions following carbon monoxide poisoning. Brain Inj 2006; 20:273-81. [PMID: 16537269 DOI: 10.1080/02699050500488181] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
PRIMARY OBJECTIVES Carbon monoxide (CO) is the most common cause of poisoning and may result in basal ganglia lesions. This study reviewed the literature of carbon monoxide poisoning and basal ganglia lesions and prospectively assessed the prevalence of basal ganglia lesions in a cohort of patients with CO poisoning. RESEARCH DESIGN Literature review and prospective cohort study. METHODS This study conducted a comprehensive review of the literature and assessed 73 CO-poisoned patients for basal ganglia lesions on sequential MR scans. Magnetic resonance scans were obtained on day 1, 2 weeks and 6 months post-CO poisoning. RESULTS The literature review found basal ganglia lesions occur in 4-88% of subjects. Only one patient was found with globus pallidus lesions at 2 weeks and 6 months following CO poisoning, that were not present on the initial day 1 MR scan. CONCLUSIONS Basal ganglia lesions, including lesions of the globus pallidus, may be less common than previously reported.
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Affiliation(s)
- Ramona O Hopkins
- Pyschology Department, Brigham Young University, Provo, Utah 84602-5543, USA.
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