Intracardiac Thrombosis Secondary to the Silent Killer: A Case Report about Monoxide Carbon Poisoning in a Child

Carbon monoxide (CO) poisoning is a frequent cause of emergency room admissions, especially during winter days, the symptoms are varied ranging from a simple headache to a serious cardiac and neurological impairment that can be deadly. Diagnosis is based on the circumstances of occurrence as well as the dosage of carboxyhemoglobin in the blood. Exposure to CO has serious consequences, neurological and cardiac manifestations are not negligible and vary from repolarization disorders to heart attack. Treatment is urgent with normobaric or hyperbaric oxygen therapy. We report a case of a 2-year male child admitted to the emergency room for CO intoxication with an intracardiac thrombus subsequently complicated by an ischemic stroke with a fatal outcome in order to highlight this complication rarely described in literature.

Unintentional Carbon Monoxide Poisoning Outbreak from 2 to 9 October 2019 in Ulaanbaatar, Mongolia

Carbon monoxide poisoning (COP) from 2 to 9 October 2019 was a major public health concern in Ulaanbaatar, Mongolia, after a transition from consumption of raw coal to upgraded briquette fuel. During the period, a total of 186 residents, which is 16 times more than the previous years, were exposed to COP and 6 persons died at home. We conduct a cross-sectional study by using registration data and medical history of all hospitalized patients with a diagnosis of COP from 2 to 9 October 2019 and had an in-depth interview. 144 (77.4%) people from 85 households registered as potential cases and 124 (86.1%) people were diagnosed with COP. All households used upgraded briquettes, and 41 households (48.2%) used them for the first time. In 50% of cases, the stove was broken, the chimney was short, not heated, and the clay joint connecting the wall stove was broken. The majority of interviewees were unaware of COP and improperly used briquettes, and the safety of chimneys and stoves was insufficient which caused unintentional COP. It is necessary to provide information to the local population about the potential risks of COP, install CO alarms in households, and educate the population. In further, a well-established poisoning surveillance system is an important aspect of public health emergency preparedness in Mongolia.

Association of carbon monoxide poisonings and carboxyhemoglobin levels with COVID-19 and clinical severity

BACKGROUND Coronavirus disease 2019(COVID-19),which recently spread throughout the entire world,is still a significant health issue.Additionally,the most common cause of risky poisoning in emergency services is carbon monoxide(CO)poisoning.Both disorders seem to merit more research as they have an impact on all bodily systems via the lungs.AIM To determine how arterial blood gas and carboxyhemoglobin(COHb)levels affect the clinical and prognostic results of individuals requiring emergency treatment who have both COVID-19 and CO poisoning.METHODS Between January 2018 and December 2021,479 CO-poisoning patients participated in this single-center,retrospective study.Patients were primarily divided into two groups for analysis:Pre-pandemic and pandemic periods.Additionally,the pandemic era was divided into categories based on the presence of COVID-19 and,if present,the clinical severity of the infection.The hospital information system was used to extract patient demographic,clinical,arterial blood gas,COVID-19 polymerase chain reaction,and other laboratory data.RESULTS The mean age of the 479 patients was 54.93±11.51 years,and 187(39%)were female.226(47%)patients were in the pandemic group and 143(30%)of them had a history of COVID-19.While the mean potential of hydrogen(pH)in arterial blood gas of all patients was 7.28±0.15,it was 7.35±0.10 in the pre-pandemic group and 7.05±0.16 in the severe group during the pandemic period(P<0.001).COHb was 23.98±4.19%in the outpatients and 45.26%±3.19%in the mortality group(P<0.001).Partial arterial oxygen pressure(PaO2)was 89.63±7.62 mmHg in the pre-pandemic group,and 79.50±7.18 mmHg in the severe group during the pandemic period(P<0.001).Despite the fact that mortality occurred in 35(7%)of all cases,pandemic cases accounted for 30 of these deaths(85.7%)(P<0.001).The association between COHb,troponin,lactate,partial arterial pressure of carbon dioxide,HCO3,calcium,glucose,age,pH,PaO2,potassium,sodium,and base excess levels in the pre-pandemic and pandemic groups was statistically significant in univariate linear analysis.CONCLUSION Air exchange barrier disruption caused by COVID-19 may have pulmonary consequences.In patients with a history of pandemic COVID-19,clinical results and survival are considerably unfavorable in cases of CO poisoning.

Early Biomarkers in 1H Nuclear Magnetic Resonance Spectroscopy of Striatal Pathological Mechanisms after Acute Carbon Monoxide Poisoning in Rats

Objective In vivo Proton Magnetic Resonance Spectroscopy （1H-MRS） can be used to evaluate the levels of specific neurochemical biomarkers of pathological mechanisms in the brain. Methods We conducted T2-Weighted Magnetic Resonance Imaging （MRI） and 1H-MRS with a 3.0-Tesla animal MRI system to investigate the early microstructural and metabolic profiles in vivo in the striatum of rats following carbon monoxide （CO） poisoning. Results Compared to baseline, we found significant cortical surface deformation, cerebral edema changes, which were indicated by the unclear gray/white matter border, and lateral ventricular volume changes in the brain. A significant reduction in the metabolite to total creatine （Cr） ratios of N-acetylaspartate （NAA） was observed as early as 1 h after the last CO administration, while the lactate （Lac） levels increased marginally. Both the Lac/Cr and NAA/Cr ratios leveled off at 6 h and showed no subsequent significant changes. In addition, compared to the control, the choline （Cho）/Cr ratio was slightly reduced in the early stages and significantly increased after 6 h. In addition, a pathological examination revealed mild cerebral edema on cessation of the insult and more severe cerebral injury after additional CO poisoning. Conclusion The present study demonstrated that 1H-MRS of the brain identified early metabolic changes after CO poisoning. Notably, the relationship between the increased Cho/Cr ratio in the striatum and delayed neuropsychologic sequelae requires further research.

Acute carbon monoxide poisoning and delayed neurological sequelae: a potential neuroprotection bundle therapy

Currently, there is no known optimal therapy for carbon monoxide （CO） poisoning and CO-associated delayed neu- rological sequelae. Hyperbaric oxygen therapy （HBOT） is a well-known treatment method, but its use for CO poison- ing patients is controversial to use due to lack of evidences regarding its efficacy. Thus, it is unlikely that HBOT alone will be accepted as the standard treatment method. In this article, current and potential treatment methods of CO poi- soning are presented as well as the tentative multi-factorial pathophysiology. A series of treatments are suggested for use as a bundle therapy, with targeted temperature management as the base treatment method. Such a therapy holds a great potential, especially for the cases where HBOT is not readily available. We suggest further investigations for elucidating the effects of these suggested treatments and their roles in terms of the complex pathophysiology of CO poisoning. Future ac- ceptance of this therapy based on the improved scientific and clinical knowledge may result in injury prevention and mini- mization of the signs and the symptoms in CO poisoning.

Digit and letter alexia in carbon monoxide poisoning

This study examined a 24-year-old patient with delayed encephalopathy, who was admitted to hospital with complaints of headache and visual impairment 1 week after acute carbon monoxide poisoning. The results of a visual field assessment, electroencephalography and head magnetic resonance imaging indicated damage to the cerebral cortex. After a 2-week treatment period, the patient had recovered from the visual impairment, but exhibited digit- and letter-reading difficulty. The Chinese aphasia battery and the number and letter battery supplement were conducted. The results revealed that the patient exhibited digit and letter alexia, while the ability to read Chinese characters was preserved. In contrast, the patient exhibited a deficit in Chinese character writing, while number and letter writing remained intact. Following treatment, reading and writing ability was improved and electroencephalographic abnormalities were ameliorated. Overall, our experimental findings demonstrated that delayed encephalopathy following acute carbon monoxide poisoning was characterized by digit and letter alexia.

Occupational Carbon Monoxide Poisoning Associated with Diesel Motor Operation in an Air-raid Shelter in June 2015, Jinan City, China-An Epidemiological Investigation

Carbon monoxide （CO） is an odorless, colorless gas produced by incomplete combustion of carbonbased compounds. Exposure to CO can cause various adverse health effects ranging from headache and fatigue to coma and death. Thousands of illnesses and deaths have been documented through CO poisoning surveillance systems and accident investigations each year.

An assessment of antioxidant status in patients with carbon monoxide poisoning

BACKGROUND: Carbon monoxide poisoning(COP) is an important cause of mortality and morbidity worldwide. This study was to investigate the levels of serum paraoxonase(PON), arylesterase(ARYL), ceruloplasmin(Cp), and sulfhydryl(-SH) in the treatment of COP, and to further understand the pathophysiology of COP.METHODS: This prospective study comprised 107 individuals with COP(group 1) and 50 healthy volunteers(group 2). Serum, plasma, and erythrocyte samples were taken on admission from all participants with COP. This process was repeated in the 90 th and 180 th minutes of treatment. Samples were taken from the control group only once. The levels of plasma PON, ARYL, Cp activity and-SH were measured in both groups.RESULTS: Age, gender, and carboxyhemoglobin level were not correlated with PON, ARYL, Cp, and-SH levels. PON, ARYL, and-SH levels were signifi cantly decreased in group 1 compared with group 2. Conversely, Cp was signifi cantly elevated in group 1 in contrast to group 2. Although ARYL was lower on admission in patients with COP than that was observed in the 90 th and 180 th minutes(P<0.001), Cp was higher on admission than at the other time points(P<0.001).CONCLUSIONS: Participants with COP had decreased levels of antioxidants(PON, ARLY, and-SH). COP represses the antioxidant system.

Brainstem auditory evoked potentials in patients with delayed encephalopathy after acute carbon monoxide poisoning

Objective:To evaluate the changes of brainstem auditory evoked potential (BAEP) in patients with delayed encephalopathy after acute carbon monoxide poisoning. Methods: BAEPs were performed in 32 controls and 40 patients. Wave Ⅰ , Ⅱ , Ⅲ ,Ⅳ, Ⅴ latencies and Ⅰ-Ⅲ , Ⅲ-Ⅴ , Ⅰ-Ⅴ interpeak latencies were measured, respectively. Results: Abnormalities of BAEPs in 13 patients (13/40, 32 ％). Among the13 abnormal BAEPs, 3 displayed prolongation of latency to waves in one side, no potential in another side; 5 displayed a similar abnormality which was bilateral prolongation of latency to waves ;and another 5 displayed unilateral latency delay. Compared wave Ⅰ , Ⅱ , Ⅲ , Ⅳ, Ⅴ latencies and Ⅰ-Ⅲ , Ⅲ-Ⅴ , Ⅰ-Ⅴ interpeak latencies in the patients and the controls, there were no significant differences (P＞0.05). Conclusion: BAEPs can be used for evaluating the diagnostic and prognostic values in the cases of delayed encephalopathy after acute carbon monoxide poisoning.

Spatiotemporal Distribution and Epidemiological Characteristics of Hospital Admissions for Carbon Monoxide Poisoning in Guangdong,China,2013-2020

Objective This study aimed to determine the spatiotemporal distribution and epidemiological characteristics of hospital admissions for carbon monoxide poisoning(COP)in Guangdong,China,from 2013 to 2020.Methods Data on age-and sex-specific numbers of hospital admissions due to COP in Guangdong(2013-2020)were collected.Daily temperatures were downloaded through the China Meteorological Data Sharing Service System.We analyzed temporal trends through time series decomposition and used spatial autocorrelation analysis to detect spatial clustering.The distributed lag nonlinear model was used to quantify the effects of temperature.Results There were 48,854 COP admissions over the study period.The sex ratio(male to female)was1:1.74.The concentration ratios(M)ranged from 0.73-0.82.The highest risk occurred in January(season index=3.59).Most cases were concentrated in the northern mountainous areas of Guangdong with high-high clustering.COP in the study region showed significant spatial autocorrelation,and the global Moran’s I value of average annual hospital admission rates for COP was 0.447(P<0.05).Low temperatures were associated with high hospital admission rates for COP,with a lag lasting 7 days.With a lag of 0 days,the effects of low temperatures[5th(12℃)]on COP were 2.24-3.81,as compared with the reference temperature[median(24℃)].Conclusion COP in Guangdong province showed significant temporal and spatial heterogeneity.Low temperature was associated with a high risk of COP,and the influence had a lag lasting 7 days.

Massive subdural hematoma misdiagnosed as delayed encephalopathy of carbon monoxide poisoning: a case report and literature review

Subdural hematoma is often secondary to brain trauma and other diseases.The onset is hidden and the condition is critical.Timely detection and early treatment are particularly important.The patient denied a history of trauma,but had a history of consciousness loss after charcoal burning.The clinical symptoms were progressive cognitive impairment.The initial diagnosis was delayed encephalopathy caused by carbon monoxide poisoning.However,computed tomography(CT)scan of the brain showed a large area of subdural hematoma on the left side and the formation of a cerebral hernia,which was life-threatening.The patienfs symptoms gradually improved after an emergency operation.

Influence of mouse nerve growth factor combined with hyperbaric oxygen on serum cytokines and cognitive function in patients with delayed encephalopathy after carbon monoxide poisoning

Objective:To study the influence of mouse nerve growth factor (mNGF) combined with hyperbaric oxygen on serum cytokines and cognitive function in patients with delayed encephalopathy after carbon monoxide poisoning (DEACMP).Methods: 218 patients with DEACMP who were treated in our hospital between June 2012 and September 2016 were chosen as research subjects and retrospectively divided into the control group (n=100) who underwent hyperbaric oxygen treatment and the observation group (n=118) who underwent mouse nerve growth factor combined with hyperbaric oxygen treatment. Serum contents of nerve injury indexes and inflammatory mediators were compared between two groups of patients and cognitive function was assessed.Results:Before treatment, differences in serum levels of nerve injury indexes and inflammatory mediators, total MMSE score and each dimension score were not statistically significant between two groups of patients. After treatment, serum contents of nerve injury indexes creatine kinase-BB (CK-BB), neuron-specific enolase (NSE), S-100β protein (S-100β) and lactate (Lac) in observation group were lower than those in control group;serum contents of inflammatory mediators interleukin-6 (IL-6), interleukin-10 (IL-10), interleukin-18 (IL-18), hypersensitive C-reactive protein (hs-CRP) and tumor necrosis factor (TNF-α) were lower than those in control group;total MMSE score and each dimension score were higher than those of control group.Conclusion:mNGF combined with hyperbaric oxygen treatment of DEACMP is helpful to reduce the nerve injury and systemic inflammatory response, and improve the cognitive function.

Multimodality evoked potentials in patients with delayed encephalopathy after acute carbon monoxide poisoning

Objective： To evaluate the diagnostic and prognostic values in patients with delayed encephalopathy after acute carbon monoxide poisoning. Methods： The tibial nerve somatosensory evoked potentials （SEPs）, vision evoked potentials （VEPs）, and brain stem audition evoked potentials（BAEPs） were performed in 32 healthy adults and 43 patients with delayed encephalopathy after acute carbon monoxide poisoning. Results： This paper indicated abnormalities of tibial nerve SEPs in 31 patients （31/43, 72.1%）, VEPs in 17 patients （17/28, 60.7%）, and BAEPs in 14, patients （14/43, 32.6%）. These results showed that the greatest diagnostic value was SEPs, followed by VEPs and, BAEPs with the lowest sensitivity. Conclusion： Multimodality evoked potentials （EPs） can be used for evaluating the diagnostic and prognostic values in cases of delayed encephalopathy after acute carbon monoxide poisoning.

APPLIED STUDY ON BA IN CARBON MONOXIDE POISONING

目的:探讨脑电地形图在一氧化碳中的应用价值。方法:63例一氧化碳中毒患者的脑电地形图被检查了。结果:这63例病人的脑电地形图改变是明显的。结论:脑电地形图在一氧化碳中毒患者的诊断、治疗和预后中有重要应用价值。

Carbon Monoxide Poisoning: The Culture of Indoor Burning

This patient case report describes a 40-year-old African woman presenting with a classic acute presentation of carbon monoxide poisoning from an unlikely source responding to conventional treatment. This case highlights the classic presenting features of carbon monoxide poisoning and the requirement to maintain a high index of suspicion and immediate use of rapid empirical treatment in the undifferentiated patient, sometimes before diagnostics and definitive diagnosis can be determined. The definitive diagnosis and cause of poisoning are also discussed to educate the emergency physician to new and foreign cultural habits and encourage best medical practices within multicultural societies.

Prevalence of Acute Myocardial and Brain Toxicity in Emergency Department Patients Exposed to Carbon Monoxide

Introduction: Due to its severe toxicity, carbon monoxide poisoning is an emergency that leads to cardiac and brain involvement, and emergency physicians should aim to master this diagnosis. This study is intended to describe the expected prevalence of these severe toxicities in the emergency department. Materials and Methods: A retrospective cohort of consecutive patients over 16 years of age presenting with carbon monoxide poisoning to the emergency department of the Hospital Universitario Austral, Argentina, during the period from January 2018 to June 2022. The prevalence of myocardial and brain toxicity was assessed regarding percentage, continuous variables with mean and standard deviation, categorical variables with percentage and absolute frequency. Positive findings of acute neurological toxicity included seizures, syncope and coma, while cardiovascular toxicity encompassed acute myocardial infarction (MI) diagnosed by electrocardiogram or elevated troponin levels, arrhythmias, and the development of pulmonary edema/ congestive heart failure (CHF) confirmed by chest X-ray with suggestive signs or clinically compatible symptoms. Patients were followed-up for 90 days to estimate hospitalization and mortality. Results: A total of 67 patients were evaluated;44.77% of them were males with a mean age of 38.5 ± 14.97 years. The prevalence of acute myocardial toxicity was 7.46% (n: 5). Among these patients, 3 had overweight as a risk factor, and 3 showed ECG abnormalities with negative T-waves. The prevalence of acute brain toxicity was 8.9% (n: 6). In total, 37% (n: 25) of patients met the criteria for hyperbaric oxygen therapy, of which 32% (n: 8) underwent more than one session. A total of 7.46% of patients (n: 5) required hospitalization. Mortality at 90 days was 0%. Conclusion: Among the patients who presented to the emergency department, the prevalence of acute myocardial toxicity was 7.46% (n: 5), which is lower than the prevalence reported in other studies to date. The prevalence of acute brain toxicity was 8.9% (n: 6), and there are no studies describing the prevalence of acute brain toxicity in the emergency department to date. There were no fatalities in our series.

Effects of intravascular laser phototherapy on delayed neurological sequelae after carbon monoxide intoxication as evaluated by brain perfusion imaging:A case report and review of the literature

BACKGROUND Delayed neurological sequelae(DNS)caused by carbon monoxide(CO)intoxication poses considerable treatment challenges for clinical practitioners.In this report,we used nuclear medicine imaging and the Mini-Mental State Examination(MMSE)to evaluate the effectiveness of intravascular laser irradiation of blood(ILIB)therapy for the management of DNS.CASE SUMMARY A 51-year-old woman presented to our medical center experiencing progressive bradykinesia,rigidity of limbs,gait disturbance,and cognitive impairment.Based on her neurological deficits,laboratory tests and imaging findings,the patient was diagnosed with delayed neurological sequelae of CO intoxication.She received intensive rehabilitation and ILIB therapy during 30 sessions over 2 mo after diagnosis.Brain single-photon emission computed tomography was performed both prior to and after ILIB therapy.The original hypoperfusion area in bilateral striata,bilateral frontal lobe,right parietal lobe,and bilateral cerebellum showed considerable improvement after completion of therapy.The patient’s MMSE score also increased markedly from 6/30 to 25/30.Symptoms of DNS became barely detectable,and the woman was able to carry out her daily living activities independently.CONCLUSION ILIB therapy could facilitate recovery from delayed neurological sequelae in patients with CO intoxication,as demonstrated by improved cerebral blood flow and functional outcomes in our patient.

Perception Survey of Carbon Monoxide Risk in Rabat-Sale-Zemmour-Zaer Populations

Carbon monoxide （CO） intoxication is one of the most common types of poisoning in the modem world. To better tailor messages and communication needs to the public, a perception survey of CO and his risk was conducted among the population of Rabat-Sale-Zemmour-Zaer. The authors included 400 people in this survey. The demographic characteristics of the respondents consisted of： 85.0% female, 92.9% adults, 29.7% had a high level of education, 49.6% unemployed, 89.5% were home owners and 53.9% lived in apartments. Water heaters were present in the homes of 91.0% of respondents and 6.5% of them used gas. Gas was used as fuel in 45.4% of cases. For water heaters, 20.8% had an exhaust duct, 9.9% were serviced regularly and 47.5% were installed in a well ventilated area. Regarding the media, television was the medium that allowed 73.4% of the CO to know, regardless of age, sex and level of education among the 94.3% of who ever heard of this deadly gas before the survey.

Fatal Carbon Monoxide Poisoning

Liquefied petroleum gas on combustion with deficient oxygen produces toxic carbon monoxide.It is used as a fuel to heat water in gas geysers.Here,we report a fatal case of carbon monoxide poisoning resulting from the usage of gas water heater.A 24-year-old female had gone to take bath in a bathroom where a gas geyser was installed to heat the water.As she did not come out of the bathroom even after more than an hour,the door was broken down by the relatives and she was found dead.Cherry red postmortem hypostasis,congested and edematous pinkish lungs,and cerebral edema were salient autopsy findings.Carboxyhemoglobin was quantified in blood to 76.55%.The cause of death was attributed to carbon monoxide poisoning;accidental in manner.This case highlights the hazards of using a gas geyser in an ill-ventilated bathroom.

血清sST2、Caspase-3、HSP70与ACMP患者病情和迟发性脑病的关系

目的探讨血清可溶性致癌抑制因子2(sST2)、半胱氨酸天冬氨酸蛋白酶-3(Caspase-3)、热休克蛋白70(HSP70)与急性一氧化碳中毒(ACMP)患者病情和迟发性脑病(DEACMP)的关系。方法选取2020年10月至2022年1月盘锦市中心医院收治的110例ACMP患者作为ACMP组,根据一氧化碳中毒程度分为轻度组、中度组、重度组;另选取同期52例体检健康志愿者作为对照组。随访6个月后,根据ACMP患者是否发生DEACMP分为DEACMP组和非DEACMP组。收集ACMP患者临床资料,采用酶联免疫吸附试验检测血清sST2、Caspase-3、HSP70水平。采用多因素Logistic回归分析ACMP患者发生DEACMP的影响因素,应用受试者工作特征(ROC)曲线分析血清sST2、Caspase-3、HSP70对ACMP患者发生DEACMP的诊断效能。结果ACMP组血清sST2、Caspase-3、HSP70水平均高于对照组(P<0.05)。重度组血清sST2、Caspase-3、HSP70水平高于中度组、轻度组(P<0.05),中度组血清sST2、Caspase-3、HSP70水平高于轻度组(P<0.05)。多因素Logistic回归分析显示,年龄增加、高血压、意识障碍时间>48 h、血CO暴露时间延长、血碳氧血红蛋白(COHb)饱和度升高及血清sST2、Caspase-3、HSP70水平升高是ACMP患者发生DEACMP的独立危险因素(P<0.05)。ROC曲线分析显示,血清sST2、Caspase-3、HSP70联合检测诊断ACMP患者发生DEACMP的AUC为0.913,大于sST2、Caspase-3、HSP70单项检测诊断ACMP患者发生DEACMP的AUC(分别为0.783、0.788、0.785),差异有统计学意义(P<0.05)。结论ACMP患者血清sST2、Caspase-3、HSP70水平升高,与中毒程度和DEACMP发生有关,血清sST2、Caspase-3、HSP70水平联合检测诊断ACMP患者发生DEACMP的价值较高。