Carbon Monoxide Poisoning

Carbon monoxide (CO) is toxic gas and is known as the silent killer. It is a product of incomplete combustion of organic matter with insufficient oxygen supply to enable complete oxidation of carbon dioxide (CO 2). According to the Center for Disease Control and Prevention, it is a colorless, odorless, tasteless and non irritating gas that can cause sudden illness or death. Generally carbon monoxide is found where there are combustible fumes such as in faulty furnaces and heating systems, vehicles (including cars, boats, trucks, tractor trailers) small gasoline engines, generators, gas stoves, gas lanterns, burning charcoal and/or wood, house fires, and gasoline powered tools. Riding in the back of pickups has also cause carbon monoxide poisoning. Exposure to the organic solvent dichlormethane found in some paint strippers has likewise been found to be a cause of carbon monoxide poisoning. Carbon monoxide becomes especially dangerous when it is allowed to build up in small, enclosed places. By merely breathing the gas, people can become seriously ill, have brain damage and/or die. Carbon monoxide poisoning is the leading cause of unintentional death from poison in the United States.

The Center for Disease Control indicates that if a person is exposed to carbon monoxide, they can have symptoms such as headaches, dizziness, weakness, nausea, vomiting, chest pain, and confusion. The higher the levels of carbon monoxide the more serious the symptoms can become including loss of consciousness, brain damage and death. Unfortunately, the symptoms are deceiving because they are very much like symptoms of other diseases. The Environmental Protection Agency Indoor Environments Divisions suggests that the symptoms, for example, are very much like symptoms of the flu or food poisoning so one might mistake CO poisoning for other diseases. Therefore, diagnosing the symptoms can be problematic. Indeed, if one is unaware of the existence of carbon monoxide in a room and he or she falls asleep, death can result while sleeping. The organs that are most dependent upon oxygen to function are the brain and the heart. It stands to reason then that these two organs are often the ones most affected by carbon monoxide poisoning.

The process of carbon monoxide poisoning begins because the red blood cells pick up carbon monoxide faster that oxygen. If carbon monoxide is prevalent the body replaces the oxygen in the blood with carbon monoxide which restricts oxygen from getting into the body in quantities needed. Unfortunately carbon monoxide is easily absorbed into the lungs. This results in tissue damage and can lead to death. Although the signs of carbon monoxide poisoning can be subtle, the resulting condition can be life threatening. Essentially, the process involves carbon combining with hemoglobin (HbCO) in the blood. This restricts oxygen binding with hemoglobin, reducing oxygen-carrying capacity of the blood. In turn, this can lead to hypoxia. Carbon hemoglobin can revert to hemoglobin but the process takes time.

Similarly, carbon monoxide also bonds to myoglobin. This causes problems with myoglobin’s ability to use oxygen. In turn, cardiac output and hypotension can result which may lead to brain ischemia. Moreover, carbon monoxide poisoning causes mitochondrial dysfunction, capillary leakage and other issues that can lead to edema and necrosis in the brain. Interestingly, brain damage often occurs during the recovery period and can result in cognitive defecits which can affect learning, and movement disorders.

Pregnant women have to be very careful not to be exposed to carbon monoxide poisoning. This can cause fetal hypoxia as a result of maternal oxygen not getting to the fetus in sufficient quantities. A fetus is not only susceptible to carbon monoxide poisoning but the results can be catastrophic as well. There can be an accumulation of the toxic material because the fetus does not eliminate the carbon monoxide as fast as an adult.

The Center for Disease Control estimates that 400 Americans die from carbon monoxide poisoning each year. They suggest that unborn infants, people with chronic heart disease, anemia or respiratory problems are most susceptible to this type of poisoning. The Environmental Protection Agency suggests that many infants die each year from idling vehicles. It is also estimated that approximately 4,000 people are hospitalized each year because of CO poisoning. Because of their weakened condition, older people are particularly susceptible to carbon monoxide poisoning.

It is important for homeowners to have their heating systems, water heater and any other appliance that run on gas or oil checked every year for possible leaks. To be safe, it is also recommended that a homeowner install a CO detector in the home in various locations and change the battery regularly.

The Environmental Protection Agency has suggested many tips for homeowners in order to avoid the serious consequences of carbon monoxide poisoning. If one suspects CO poisoning he or she should get to fresh air immediately. They should also go to an emergency room. There are many things one should either do or avoid doing including: don’t idle a car in a garage without opening the garage door, don’t use a gas oven to heat a house, don’t use a charcoal grill indoors, don’t sleep in any room with an unvented gas heater, don’t use gas powered lawn equipment etc… in enclosed places, and don’t ignore symptoms-especially if more than one person in the house has the symptoms, do properly vent appliances, chimneys, flues, stoves and other gas appliances, do only purchase appliances approved by appropriate laboratories (the American Gas Association, Underwriter’s Laboratories), do follow instructions on all appliances. Although it is certainly recommended that one purchase and use carbon monoxide detectors in his or her house, one should not rely on these devices totally as they have not proved to be totally reliable because the carbon monoxide gas is colorless and odorless.

It is generally accepted that some of the symptoms of carbon monoxide poisoning include:

1. Dull headaches. This is often the earliest of symptoms and can be misleading because it mimics other diseases
2. Weakness. This can be generalized or localized weakness.
3. Dizziness. This often occurs along with the headaches.
4. Vomiting. If one vomits as a result of CO poisoning, this suggests a serious condition that needs immediate emergency medical attention.
5. Chest Pain. Especially in elderly people chest pain symptoms can occur.
6. Confusion. Because of the inability to absorb oxygen, one might become confused.
7. Loss of consciousness. Obviously this is a serious symptom that must be treated immediately.
8. Shortness of breath. Because oxygen has been replaced by carbon monoxide, it often is difficult for the patient to breathe properly.

There are other, less common symptoms of carbon monoxide poisoning also. These include myocardial ischemia, atrial fibrillation, pneumonia, pulmonary edema, high blood sugar, lactic acidosis, muscle necrosis, acute kidney failure, skin lesions, and visual and auditory problems.

A Co-oximeter is often used to evaluate carboxyhemoglobin levels. A pulse Co-oximeter may not tell the entire picture. Carbon monoxide may also be evaluated using chromatographic techniques. Blood saturations can range, depending upon circumstances, from the 8% range for smokers, for example, to 30% for persons exposed to gas fumes. Autopsies reflect 30%-90% blood saturations in those who die as a result of carbon monoxide poisoning. Physicians should consider in their differential diagnosis the fact that carbon monoxide poisoning offers many non specific symptoms initially. They mimic flu symptoms, acute respiratory distress, lactic acidosis, diabetic ketoacidosis, meningitis, opiod or alcohol poisoning.

It is important to treat the symptoms of carbon monoxide poisoning promptly. Treatments focus on replacing the carbon monoxide in the blood with oxygen as quickly as possible. If taken to the emergency room, it is likely the patient will breathe pure oxygen through a mask covering the nose and mouth. This reduces half life of carbon monoxide to 80 minutes from 320 minutes on normal air. If the patient’s condition is such that he or she cannot breath on their own a ventilator may be used. If urgent replacement of oxygen is necessary, it would be important to place the patient in a hyperbaric chamber. This is a full body pressurized chamber where air pressure inside is much higher than atmospheric pressure so that replacement oxygen can be increased dramatically. Hyperbaric chamber dissociates CO to a greater extent than normal oxygen. It reduces the half life of carbon monoxide to 23 minutes compared to 80 minutes for regular oxygen. Pregnant women are usually treated longer with pure oxygen than a non pregnant person.

The U.S. Consumer protection Commission calls carbon monoxide poisoning the “invisible killer”. It recommends:

1. Proper installation, operation, and maintenance of fuel burning appliances in the home
2. Service the appliances yearly
3. Examine vents and chimneys regularly for cracks, connections, rust or stains.
4. Make sure water supply is constant
5. Determine if furnace either runs continuously or becomes unable to heat house
6. Examine appliances and vents for sooting
7. Pay attention to unfamiliar odors
8. Look for increased moisture inside of windows
9. Look for loose masonry on chimney
10. Do not put foil on the bottom of a gas oven because it interferes with combustion
11. Do not operate a generator in a garage or crawl space
12. Look for falling debris inside chimney

NFPA 720-2009 establishes the carbon monoxide guidelines published by the National Fire Protection Association. Detectors are recommended on every level of a residence, including the basement.

Experts disagree on actual levels needed to cause significant symptoms. This is because the carbon monoxide tolerance level for persons is altered by factors such as activity level, rate of ventilation, prior cerebral or vascular disease, cardiac output, anemia, diseases such as sickle cell anemia, other hematologic disorders, barometric pressure and metabolic rate. If a person is relatively healthy, carbon monoxide usually does not result in serious illness unless it reaches 50 ppm (parts per million) with continuous exposure over an eight hour period. However, it can adversely affect one’s health at any level over 9 ppm. If the levels do get higher than 50 ppm, a person usually does suffer some symptoms. Low level exposure over a few hours of a CO level of 70 ppm can provide flu like symptoms. Medium level exposure over 100 ppm can produce drowsiness, dizziness, shortness of breath and vomiting and can be dangerous to human health. High level exposure over 400 ppm generally results in unconsciousness, brain damage and death. At this high level unconsciousness and death usually results in 3-5 hours. In the United States, under OSHA, there is a limit imposed for long term exposure to carbon monoxide levels to less than 50 ppm averaged over an 8 hour period. Moreover, employees are required to be removed from confined areas where 100 ppm is prevalent.

There can be significant delayed neurological problems that can occur as a result of carbon monoxide poisoning which may include difficulty with understanding and comprehending intellectual issues, short term memory problems, dementia, amnesia, psychosis, gait,, speech issues, depression and sight issues. Statistics suggest that these issues could develop even weeks after the initial carbon monoxide poisoning.

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