Assessment and management of carbon monoxide toxicity in emergency patients

1. Dr Tricia Scott PhD Cert Ed RGN RMN Senior Lecturer, Emergency Care Research Lead, Centre for Research in Primary and Community Care, University of Hertfordshire p.scott3@herts.ac.uk Assessment and management ofcarbon monoxide toxicityin emergency patients

2. Collaborators Theresa Foster Research Manager, East of England Ambulance Service NHS Trust Erica Ley Hazardous Area Response Team East of England Ambulance Service NHS Trust Dr David Wellsted Head of Centre for Lifespan and Chronic Illness University of Hertfordshire

3. Aetiology • Carbon monoxide is a life threatening gas which develops in situations where there is incomplete combustion of carbon fuels. • Colourless and odourless therefore earns the reputation of being ‘The Silent Killer’. • Signs and symptoms of mild to moderate CO poisoning can be confused with flu-like symptoms, particularly during the winter months. • Often leads to fatalities and frequently results in long-term debilitating physical and neuropsychological conditions (Chee et al 2008).

4. CO toxicity arises following absorption of the products of incomplete combustion of carbon fuels into the blood through the alveoli. • CO competes with oxygen for binding to haemoglobin having 240 times its affinity and subsequent oxygen displacement leads to the production of COHb leading to hypoxaemia (Greaves, Porter and Ryan, 2009). • Left shift of the oxyhaemoglobin dissociation curve. • Most people are considered to have a base level of <2.5% however, smokers generally have higher levels and a COHb level of <5%, commonly found in smokers, causes no symptoms (WHO, 2000).

5. Oxygen Dissociation Curve(Anaesthesia UK, 2005)

6. Clinical suspicion • Clinicians should be suspicious if a patient presents with vague signs and symptoms consistent with CO poisoning (Baum, 2008; Roth et al, 2011). • COHbhas a half-life of 250 minutes in a patient breathing room air, which reduces to 40 minutes when 100% oxygen is administered (Greaves, Porter and Ryan, 2009). • Delay in treatment may compound neuropsychological sequelae.

7. http://www.gassaferegister.co.uk/news/gas_safe_news/hangover_or_carbon_monoxide_po.aspxhttp://www.gassaferegister.co.uk/news/gas_safe_news/hangover_or_carbon_monoxide_po.aspx

8. Commonest misdiagnoses • Chronic fatigue / ‘Tired all the time’ • Migraine or other cause of acute • Headache • Labyrinthitis / ear infection • ‘Stroke’ / TIA • ‘Collapse ? cause’ • A ‘viral illness’ / URTI • Many people are advised to go home, wrap-up warmly and turn up the heating, with fatal consequence.

9. Altered physiology (Weaver et al, 2009) • CO increases cystolicheme levels, leading to oxidative stress (Cronje et al 2004) • Binds to platelet hemeprotein and cytochrome c oxidase (Thom 2008) • Interrupts cellular respiration (Alonso 2003) • Leads to neuronal necrosis (Thom et al 2006) • Apoptosis (Piandatosi et al 1997) • Neurologic and cardiac injury results from the development of multiple inflammatory pathways.

10. The problem • Under-reporting of CO cases in the UK. • Inadequate assessment for CO by emergency services and GPs. • Many emergency practitioners are unfamiliar with the signs and symptoms of CO toxicity. • Lack of point-of-care testing devices available either in the ambulance or in the ED.

11. Good practice • Some ambulance trusts equip vehicles with e.g. exhaled air device or CO-oximetry device either as a dedicated machine or as an electronic adjunct lead attached to the lifepack apparatus. • Availability of CO devices among all trusts is yet to be universally established and this investment also extends to EDs. • Limited device use despite CO monitoring devices being available in vehicles and departments.

12. Mode of entry • Mode of entry into the body, physiological consequences and treatment options are well documented (Bledsoe et al 2010; Touger 2010; Coulange 2008; Barker 2006; Hampson, Scott and Zmaeff 2005;). • Until recently little was known about the extent to which the UK population is affected.

13. Tip of the iceberg • 4,000 people diagnosed in UK emergency departments (ED) as CO poisoning. (All Party Parliamentary Gas Safety Group, 2011) • In a recent study 120 homes in Liverpool and Coventry had high CO levels yet the occupiers were unaware of the threat. (Liverpool John Moores University 2012)

14. Clarke et al (2012) • Determined incidence of CO exposure in patients attending three EDs in England. • Inclusion criteria were a primary presentation of at least one of the following symptoms: • Chest pain characteristic of cardiac disease • Exacerbation of chronic obstructive pulmonary disease (COPD) • Seizures • Flu-like symptoms • Non-traumatic headache.

15. Of 1,758 patients there were 76 positive cases (incidence 4.3 per 100 patients) when either blood or CO-oximeter measurements were analysed. • The highest median COHb level was found in the headachegroup • Provides a useful trigger to alert clinicians to the possibility of CO exposure.

16. The study confirmed that a proportion of patients presenting to EDs have been exposed to CO, who may otherwise have been misdiagnosed. • UK Health Protection Agency Action Card for CO has been amended to incorporate: • awareness of non-gas sources of CO (e.g. shisha pipes) • less reassurance of a normal COHb level as a marker of lack of exposure and • improved liaison between HPA and local authorities.

17. UK government policy was reinforced to heighten awareness of CO toxicity among health practitioners, promote early detection to reduce unnecessary mortality and morbidity and financial burden on the health service associated with this poison. (Department of Health, 2010)

18. The Chief Medical Officer and Chief Nursing Officer called for “...increased vigilance amongst health professionals of the signs and symptoms of exposure in their patients”… (CMO/CNO Letter 2010, p1)

19. Health Protection Agency Yellow Card

20. COMA Cohabitees & companions - is anyone else in the house affected (including pets)? Outdoors - do your symptoms improve when out of the house? Maintenance - are any heating appliances properly maintained? Alarm - do you have a carbon monoxide alarm?

21. Collaboration • Gas Safety charities • COAwareness UK campaign each November - House of Lords • Mobile phone APP • College of Emergency Medicine letter (Walker, May 2012) • All-Party Parliamentary Gas Safety Working Group (Health group) • Policyconnect - House of Commons • Skills2Learn training DVD (multilevel awareness) • Joint Position Paper between CEM, RCN, RCOGP?????

22. Assessment and Management • Pre-hospital assessment for CO in exhaled air or co-oximetry. • Remove the patient from the CO source. • Administer 100% normobaric oxygen therapy (NBOT) (Beware COPD). • Blood gas analysis. • Transfer to a hyperbaric chamber (HBOT) should also be considered (controversial!).

23. References • All-Party Parliamentary Gas Safety Group 2011 Carbon monoxide poisoning. London: DH • Anaesthesia UK (2005) Oxygen Dissociation Curve, available at http://www.frca.co.uk/article.aspx?articleid=10034[accessed 26 July 2012] • Clarke, S. Keshishian, C. Murray, CV. Coultrip, E. Oetterli, S. Earle, D. Ward, P. Bush, S. Ruggles, R. 2012 Non-invasive screening for carbon monoxide exposure in selected patient groups attending rural and urban Emergency Department in England. Report to the Department of Health PRP: 002/0030. • Department of Health. 2010 Carbon monoxide poisoning: needless deaths, unnecessary injury. PL/CMO/2010/02, PL/CNO/2010/02 at: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_121501.pdf[accessed 15 November 2011]

24. References… • Greaves, I. Porter, K. and Garner, J. (Eds.) 2009 Trauma Care Manual 2nd edition. London, Edward Arnold. • Liverpool John Moores University 2012. Carbon monoxide study saves lives: BEST Research Institute. At: http://ljmu.ac.uk/NewsUpdate/index_123350.htm[accessed 10 July 2012] • Weaver, LK. 2009 Carbon monoxide poisoning. The New England Journal of Medicine 360: 1217-1225 • World Health Organisation, 2000. Air quality guidelines for Europe (2nd edition). WHO Regional Publications. European Series No 91. 2000 Available at: http://www.euro.who.int/__data/assets/pdf_file/0005/74732/E71922.pdf [accessed 27 February 201].

25. Thank you