Fatal unintended carbon monoxide poisoning in West Virginia from nonvehicular sources

Carbon monoxide-related deaths in Ankara between 2001 and 2011

OBJECTIVE

The aim of the present study was to describe the epidemiology of unintentional carbon monoxide (CO) poisonings (between 2001 and 2011) in Ankara, Turkey.

METHODS

Data were collected from the records of Ankara Branch of Council of Forensic Medicine and the licensed official institutes and hospitals for medico-legal autopsies. A total of 10,720 medico-legal autopsy reports were obtained and reviewed by the authors.

RESULTS

Among 622 fatal poisoning cases during the period, 380 deaths were due to unintentional CO poisoning. The mean CO saturation of the groups was 55.4 ± 13.4 (% saturation). The minimum and maximum levels of CO in blood was 3.6 and 86.5 (% saturation), respectively. Of all the fatal poisonings determined by Ankara Branch of Council of Forensic Medicine, CO poisoning was the most common mortality cause (61.1%). Among the cases, 301 (79.2%) were found to be death in their houses, 43 (11.3%) in hospitals, 15 (3.9%) in their workplaces and 11 (2.9%) in some public places such as park and garden. Most of the cases were from the capital city of Turkey, Ankara (n = 203, 53.4%). When we compared the cities according to their population, it was realized that the highest death rate due to CO poisoning was in Kirikkale (12.3/100,000), followed by Karabuk (8.3/100,000), Cankiri (7.8/100,000) and Kirsehir (5.0/100,000).

DISCUSSION AND CONCLUSION

These findings add new data to the pool of knowledge in terms of the need of safety, proper heating system instructions and more education on CO poisoning in Turkey.

Carbon monoxide-related injury estimation using ICD-coded data: methodologic implications for public health surveillance

Estimates of unintentional deaths from carbon monoxide (CO) poisoning can be obtained from national mortality data. We explored ways of accurately estimating CO-related deaths from International Classification of Diseases, 9th Revision (ICD-9) coded U.S. mortality data. We evaluated and identified CO-related ICD-9 codes and created five classes of codes for case ascertainment that represented a continuum of the degree of certainty that the ICD-coded death was truly CO-related. We conducted single (underlying) cause-of-death and multiple-cause-of-death analysis using 20 years of data (1979-1998), and calculated sensitivity and positive predictive value using different criteria for case ascertainment. Single-cause analysis provided accurate estimates only when we used CO-exclusive E-codes, however this method failed to identify approximately one third of the CO-related deaths over the study period. Single-cause analysis overestimated the number of CO-related deaths when we used E-codes that were not exclusive to CO exposure. Identification of true CO-related deaths required multiple cause-of-death analysis and use of the CO nature-of-injury code, N986, to confirm suspected cases. Sensitivity of N986 was 99.5%, and positive predictive value of the individual E-codes in single cause-of-death analysis ranged from 1.5% to 92%. Estimating CO-related deaths from ICD-coded data requires a thorough understanding of the ICD codes, coding rules, and of the limitations imposed by case selection criteria and single cause-of-death analysis.

Occupational Carbon Monoxide Poisoning Among West Virginia Workers’ Compensation Claims: Diagnosis, Treatment Duration, and Utilization

Incidence rates and characterizations of occupational carbon monoxide (CO) poisoning in terms of sources of exposures, diagnosis, treatment, and health care utilization are critical for public health planning. We identified 182 CO poisoning cases occurring over a 6-year period (IR = 4.3/100000 worker-years) in the West Virginia workers' compensation data. Frequent sources of poisoning were gas-powered engines (28%) and furnaces (20%). Minimum treatment duration ranged from 1 day to 8 years with significant differences in mental health comorbidities between cases treated within 1 year compared with cases treated for more than 1 year (OR = 20.75; 95% CI = 3.5-128.4). The average cost (medical and wage loss replacement) for CO claims was dollars 2130 and median lost time was 45 days. CO poisoning could lead to prolonged disability and treatment in patients with mental health comorbidities, suggesting a possible role for early intervention.

Unintentional carbon monoxide deaths in California from residential and other nonvehicular sources

To investigate risk factors of unintentional carbon monoxide deaths in California from nonvehicular sources, we identified 270 deaths resulting from nonvehicular sources of carbon monoxide poisoning from death certificates and coroners' investigation reports. Data recorded between 1979 and 1988 in the state of California on risk factors and carbon monoxide sources were abstracted from investigation reports. We also used census and state statistics to calculate rates and relative risks. The highest rates, which occurred in winter, were found among males, African Americans, and the elderly. Relative risks (in parentheses) were higher among individuals who (a) lived in multiunit dwellings (2.1), (b) dwelled in mobile/trailer homes (4.7), and (c) resided in temporary shelters (30.0) than among individuals who lived in single-family houses (1.0). Unvented combustion heating appliances and charcoal fuel were associated significantly with the risks of fatal unintentional carbon monoxide poisoning.

Carbon monoxide fatalities in medicolegal autopsies

All post-mortem medicolegal reports issued by Jordan University Hospital (JUH) during the period 1978-96 were reviewed. Carbon monoxide (CO) as a silent killer was responsible for 31.5% (n = 110) of poisoning fatalities. These were due to unintentional exposure to CO sources in confined spaces (bedrooms (24.6%), worker lodgings (23.6%) and bathrooms (16.4%), and without the victims being aware of CO hazards. Sixty-five per cent of CO fatalities occurred during December to February and 30% of the cases involved the age group 20-29 years, followed by the age group 30-39 years (20%). Non-Jordanians constituted 50% of CO fatalities and Egyptian workers accounted for 78%. Being unaccustomed to cold climates, and on low incomes, they had been using simple and unsafe heating devices. Many of these deaths could have been prevented. Safety educational campaigns to increase awareness of the general population of CO sources, their hazards and how to avoid them should be held continuously during the cold months of the year. All health and safety sectors are advised to be involved.

An epidemiological study of acute carbon monoxide poisoning in the West Midlands

OBJECTIVES

To describe the epidemiology of carbon monoxide (CO) poisoning in a defined population, identifying those at greatest risk from acute poisoning resulting in admission to hospital or death.

METHODS

A retrospective study with routinely collected information, set in the former West Midlands Regional Health Authority; population of 5.2 million. The data comprised 939 deaths and 701 hospital admissions due to CO poisoning between January 1988 to December 1994. The main outcome measures were age and sex standardised incidence rates (SIRs) for non-intentional, suicidal, and undetermined poisonings for health authorities and the linear relation with socioeconomic deprivation.

RESULTS

Overall rate of non-intentional poisonings over the 7 year period was 7.6/100,000, an annual rate of 1.1/100,000. The 7 year rates were highest in people > or = 85; men 24.0/100,000 and women 19.7/100,000. For suicides the 7 year rate was 19.6/100,000, an annual rate of 2.8/100,000. The 7 year rates were highest for men of 35-39, 64.1/100,000, and for women aged 45-49, 15.3/100,000. None of the causes of poisoning were related to deprivation. Non-intentional poisonings showed a strong seasonal variation with the highest rates being recorded in the months October to March. Increased rates of poisoning were found in the rural districts of the West Midlands. There seems to have been a decline in suicides coinciding with the introduction of three way catalytic converters on cars.

CONCLUSIONS

Elderly people and the very young are at the greatest risk from non-intentional CO poisoning and rates are highest in the winter months. Although deaths from non-intentional CO poisoning are declining nationally, in the West Midlands they have remained stable and hospital admissions are increasing. It is not solely an urban phenomenon with rates for non-intentional CO poisoning and suicides higher in the rural districts. Health authorities need to consider all populations in any prevention programme. Further work is needed to establish the extent of the burden of chronic CO poisoning and the impact of catalytic converters on suicides.

Causes of unintentional deaths from carbon monoxide poisonings in California

The purpose of this study was to determine the annual number and incidence of unintentional deaths from carbon monoxide (CO) poisonings in California and to identify specific factors that caused or contributed to the deaths. Unintentional CO deaths in California over a ten-year period (1979 to 1988) were identified from the database of the California Master Mortality File and coroners' investigation reports. Factors associated with unintentional CO deaths were determined based on the information from the investigation reports. The annual number of unintentional CO deaths varied from 27 to 58 over the ten years examined, with an average annual death incidence of 1.7 x 10(-6). Death rates were high among males and African-Americans. Alcohol appeared to be a factor in 31% of the cases. The types of combustion sources associated with unintentional CO deaths were: heating or cooking appliances; motor vehicles; charcoal grills and hibachis; small engines; and camping equipment. Factors associated with unintentional CO deaths interact in a complex way. To reduce the rate of unintentional CO deaths effectively, joint efforts involving several prevention methods are suggested.

Carbon monoxide ... the silent killer with an audible solution

Carbon monoxide (CO) is responsible for more poisoning fatalities each year than any other toxic agent. The often insidious nature of the symptom progression and its ability to imitate many common illnesses may result in the failure to diagnose a potentially fatal outcome. CO detectors equipped with an audible alarm can alert potential victims of CO poisoning before toxic sequelae develop. A study was conducted in which all calls to 911 concerning a CO detector in alarm or regarding possible CO poisoning were investigated by a paramedic crew; 101 possible CO exposures were investigated. CO detectors with audible alarms were the genesis of 59.4% of the calls. Detectable CO levels were found in 69.3% of the investigations, and 80% of the homes with detectors had verifiable CO concentrations. The mean CO concentration in homes with detectors was 18.6 ppm, compared with 96.6 ppm when no detector was available; 63.4% of the victims with no alarm were symptomatic, compared with 13.3% of victims with alarms. CO detectors with audible alarms were effective in alerting the potential victims of CO poisoning to its presence. Persons with CO detectors were less likely to become symptomatic from a CO exposure than those who did not have CO detectors.

Carbon monoxide poisoning: easy to treat but difficult to recognise

Carbon monoxide (CO) poisoning is a common medical emergency and a frequent cause of deliberate or accidental death. It can cause acute and chronic central nervous system damage which may be minimised by prompt treatment with 100% oxygen or hyperbaric oxygen therapy. However, recognition of this intoxication can be difficult. Failure to diagnose it may have disastrous effects on the patient, and other members of the household who could subsequently become intoxicated. Guidance on the correct diagnosis of this condition is provided in the light of a number of studies screening emergency room populations. Guidelines for treatment with hyperbaric oxygen therapy are also reviewed.

Unintentional deaths from carbon monoxide poisoning in New Mexico, 1980 to 1988. A comparison of medical examiner and national mortality data

Carbon monoxide was the number 1 cause of poisoning deaths in the United States from 1980 through 1988, with the highest rates reported in the western states. We studied unintentional deaths from carbon monoxide poisoning in New Mexico during this period using the multiple-cause mortality files from the National Center for Health Statistics (NCHS) and data from the New Mexico Office of the Medical Investigator (OMI). We compared the nationally available NCHS data with the more detailed OMI data to determine the sensitivity of NCHS data for the surveillance of this preventable cause of death. The NCHS data were 88% sensitive in identifying deaths from unintentional carbon monoxide poisoning and had a positive predictive value of 81% when compared with OMI data. Half of the unintentional carbon monoxide-related deaths were attributable to a home heating mechanism of some sort, 46% involved motor vehicle exhaust, and at least 42% were associated with alcohol use. We conclude that available NCHS data are a sensitive source of surveillance information about unintentional deaths from carbon monoxide poisoning. Additional details about specific deaths can be obtained from medical examiner files when needed.

Unintentional carbon monoxide poisoning in Colorado, 1986 through 1991

Unintentional carbon monoxide poisonings were identified through death certificates, by hyperbaric chambers, and by laboratories required to report carboxyhemoglobin levels greater than 12%. From 1986 to 1991, 981 cases were reported, including 174 deaths. Deaths most often resulted from fire-related carbon monoxide intoxication (36.2%), followed by motor vehicle exhaust (34.5%), and furnaces (10.3%). Among nonfatal cases, furnaces were the leading source of carbon monoxide exposure (44.3%), followed by motor vehicle exhaust (22.8%). The importance of furnaces and other home heating devices in carbon monoxide intoxication may be underappreciated if only mortality data are examined. Surveillance of carbon monoxide-related morbidity is a useful adjunct to mortality surveillance in guiding prevention efforts.

Warehouse workers' headache: emergency evaluation and management of 30 patients with carbon monoxide poisoning

BACKGROUND

Carbon monoxide (CO) is the leading cause of fatal toxic inhalation in the United States, but the medical literature contains few reports of mass exposures. Warehouse workers' headache (WWH) is an infrequently reported form of CO poisoning due to industrial exposure.

METHODS

We describe 30 persons who developed WWH after inhaling exhaust from a propane-fueled forklift, their emergency medical management at a small community hospital, and their long-term courses.

RESULTS

Workers with more direct exposures to vented exhaust had significantly higher expired CO levels (21.1 +/- 0.7% versus 8.4 +/- 4.8%, P < 0.0001) and higher acute symptom scores (9.0 +/- 2.2 versus 4.7 +/- 3.3, P = 0.01) than persons with less direct exposures. Work location, expired CO levels, and acute symptom scores did not correlate with symptom scores 2 years after exposure. Workers experiencing acute difficulty concentrating or confusion had higher expired CO levels than persons with neither of these symptoms (16.3 +/- 6.7% versus 8.4 +/- 5.2%, P = 0.005) and developed higher chronic symptom scores (3.9 +/- 3.0 versus 1.1 +/- 1.5, P = 0.04), suggesting that this subgroup may require closer follow-up for long-term complications.

CONCLUSION

With earlier recognition of ongoing CO toxicity, this disaster would likely have been averted. Since CO exposures are more common than is often recognized, general internists must be familiar with the manifestations of CO toxicity, its timely evaluation, management, and prevention.