warning properties) Early symptoms are often mistaken for the flu asleep CO often strikes in cold weather when heating are closed

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3 CO is odorless, tasteless and colorless (no warning properties) Early symptoms are often mistaken for the flu High levels can kill while family members are asleep CO often strikes in cold weather when heating equipment operates, and when windows and doors are closed

4 GAS COLORLESS ODORLESS TASTELESS NON-IRRITATING

5 EPIDEMIOLOGY: THE LEADING CAUSE OF POISONING DEATHS IN THE USA. > 4,000 PER YEAR 10,000 PATIENTS PER YEAR LOOSE AT LEAST ONE DAY OF WORK

6 EPIDEMIOLOGY: COMMON EVERY WINTER THE MORE FOSSIL FUEL USED IN AN THE MORE FOSSIL FUEL USED IN AN AREA THE GREATER NUMBER OF DEATHS

7 SOURCES INCOMPLETE COMBUSTION ENDOGENOUS PRODUCTION METHYLENE CHLORIDE

8 All of these items Burn some type of fuel!

9 INCOMPLETE COMBUSTION: O 2 + C CO2 O 2 + C CO IF O2

10 INCOMPLETE COMBUSTION: AUTOMOBILE EXHAUST 7 TO 10 % CO GENERATORS FIRES PROPANE TRUCKS GRILLS CIGARETTES

11 ENDOGENOUS PRODUCTION: HEME CATABOLIZED TO BILIVERDIN WITH RELEASE OF CO INCREASED IN HEMOLYTIC ANEMIA & INCREASED IN HEMOLYTIC ANEMIA & INFANTS

12 METHYLENE CHLORIDE: PAINT, VARNISH REMOVERS & SOLVENTS ABSORBED BY SKIN, GUT & LUNGS CONVERTED TO CO BY LIVER CYTOCHROME MIXED - FUNCTION OXIDASE SYSTEM

13 LABORATORY TEST: CARBOXYHEMOGLOBIN CO + Hgb COHgB Hgb HAS A 240 TIMES GREATER AFFINITY Hgb HAS A 240 TIMES GREATER AFFINITY FOR CO OVER O 2

14 The Physiology of CO Oxygen is carried from the lungs by the blood hemoglobin to the tissues, here the beating heart is shown, and normal healthy oxidative metabolism goes on. During Carbon Monoxide poisoning, CO is carried from the lungs by the blood hemoglobin to the tissues, preventing oxygen from being carried, and blocking normal oxidative metabolism. Note how slowly and weakly the heart is beating, since it is starved for oxygen (ie. blue in color).

15 Elevated CO levels can cause poisoning: low levels can make you sick higher levels can kill you Anyone is at risk of CO poisoning CO can be particularly harmful to: unborn babies, infants and young children elderly people, people with heart problems tobacco users (additonal CO source)

16 LABORATORY TEST: NORMAL = < 1 % COHgB SMOKERS = 5-10 % LETHAL = 60 %

17 MECHANISM OF INJURY : THEORIES PHYSIOLOGICAL ANEMIA? TOXIC PRODUCT FORMED? CYTOCHROME SYSTEM INACTIVATION? LIPID PEROXIDATION? GUANYLATE CYCLASE ACTIVATION?

18 DISRUPTION OF CELLULAR PROCESSES: CO INHIBITS CYTOCHROME C, P - 450, AA 3 & MYOGLOBIN TISSUES MOST METABOLIC ACTIVE EFFECTED DISRUPTION LEADS TO LACTIC ACIDOSIS

19 GUANYLATE CYCLASE : STIMULATED BY CO AND CAUSES VASCULAR SMOOTH MUSCLE RELAXATION CAUSING HYPOTENSION

20 LIPID PEROXIDATION : WBC ADHERENCE TO MICRO - VASCULATURE CAUSES CASCADE WITH FREE RADICAL PRODUCTION LIPID DAMAGE TO THE CELL MEMBRANE RESULTS

21 FACTORS DETERMINING CLINICAL PRESENTATION: AGE HEALTH ACTIVITY CONCENTRATION OF CO LENGTH OF EXPOSURE PERIOD SOAKING

22 Vomiting Ataxia Confusion Syncope Coma Seizures Cardiac dysrhythmias Tachypnea Myocardial ischemia Headache Nausea Dizziness Weakness Chest pain Dyspnea Visual changes

23 SYMPTOMS: NAUSEA, VOMITING, HEADACHE FLU SEIZURES, COMA, DEATH LATE PROBLEMS UP TO 21 DAYS AFTER EXPOSURE = NEUROPSYCHIATRIC SEQUELAE

24 Differential Diagnosis of Carbon Monoxide Poisoning Influenza Gastroenteritis Food poisoning Cerebrovascular event Myocardial infarction Asphyxia Parkinsonism (delayed) Ethanol intoxication Sedative-hypnotic overdose Hypothermia Myxedema coma

25 TREATMENT Remove victim away from contaminated area into fresh air and loosen clothing. Give artificial respiration or CPR, as appropriate. If oxygen is available, give it to the victim by using a face mask. IV flouid(alkaline diuresis) Seizure(BZD, Phenytoin, Barbitorate) Heart monitoring(bp) Brain edema(dexamethasone,manitol)

26 TREATMENT = OXYGEN : HALF LIFE ROOM AIR = 5. 5 HOURS 100 % OXYGEN = 1. 5 HOURS 3 ATA HBO = 23 MINUTES

27 JOHN STEWART, M.D., FACEP

28 SOURCES: FIRES FUMIGANTS METALLURGY ELECTROPLATING SILVER POLISH NIPRIDE LAETRILE PCP PROCESSING PSEUDOMONAS PLANTS TYLENOL CN

29 PLANTS: AMYGDALIN GLUCOSE + BENZALDEHYDE + HYDROCYANIC ACID

30 FATAL DOSE: FATAL DOSE APPROXIMATELY 200 MG 1 TSP = 1 TO 6 GRAMS

31 METABOLISM: MAJOR CONVERSION TO THIOCYANATE BY THE ENZYME RHODANESE SOME INCORPORATED INTO VITAMIN B-12 PRODUCTION OF CHOLINE & METHIONINE

32 DIAGNOSIS : VERY DIFFICULT BITTER ALMOND ORDER ONLY DETECTED BY 40% OF POPULATION ANION GAP ACIDOSIS / BLOOD LEVEL

33 PATHOPHYSIOLOGY: CN HAS AFFINITY FOR METALS CN ATTACHES TO FERRIC IRON ( FE +++ ) INTERFERES WITH TCA CYCLE & CYTOCHROME OXIDASE

34 TREATMENT: DECONTAMINATE & PROTECT YOURSELF OXYGEN LILLY CYANIDE KIT

35 LILLY CYANIDE KIT AMYL NITRITE SODIUM NITRITE SODIUM THIOSULFATE

36 RATIONALE FOR THE CYANIDE KIT: NITRITES CONVERT OXYHgB ( FE ++ ) TO METHEMOGLOBIN ( FE +++ ) CN COMBINES TO FORM NON-TOXIC CYANOMETHEMOGLOBIN

37 RATIONALE FOR THE CYANIDE KIT: THIOSULFATE ENHANCES BODIES LIMITED SULFUR SUPPLY RHODANESE CONVERTS THIOSULFATE TO NON - TOXIC THIOCYANATE WHICH IS EXCRETED BY THE KIDNEYS.

38 PROBLEMS WITH THE KIT: HYPOTENSION WITH NITRITES METHEMOGLOBIN IS NON - FUNCTIONAL METHEMOGLOBINEMIA NOT TOLERATED WELL IN CHILDREN

39 OTHER TREATMENTS : DICOBALT - EDTA USED IN EUROPE HYDROXOCOBALAMIN VITAMIN B 12 b ORPHAN DRUG IN USA PBTBS

40 HYDROGEN SULFIDE: NONFLAMABLE COLORLESS IRRITATING HEAVIER THEN AIR ODOR OF ROTTEN EGGS SEWER GAS

41 HYDROGEN SULFIDE: FORMED FROM DEGRADING PROTEIN OLFACTORY PARALYSIS OCCURS RAPIDLY WITH LOW CONCENTRATIONS RESCUSERS MUST PROTECT THEMSELVES

42 HYDROGEN SULFIDE: MECHANISM OF ACTION LIKE CN INTERFERRING WITH CELLULAR RESPIRATORY ENZYMES, Fe+++, CYTOCHROME OXIDASE. CELLULAR ANOXIA RESULTS ANAEROBIC METABOLISM AND ACIDOSIS H2S RAPIDLY DETOXIFIED BY THE BODY

43 HYDROGEN SULFIDE: REMOVE FROM SOURCE, DECONTAMINATE 100% O2 USE SODIUM NITRITE LIKE TX OF CN. (CONTROVERSIAL) METHEMOGLOBIN + H2S = SULFMETHEMOGLOBIN AVOID THE THIOSULFATE HYPERBARIC OXYGEN?

44 SUMMARY: CO, CN & H2S KILL CO & CN SEEN IN SMOKE INHALATION VICTIMS ALL REQUIRE A HIGH INDEX OF SUSPICION TO DIAGNOSE AGGRESSIVE TREATMENT IS MANDATED

45 THANKS FOR HAVING ME AND GOOD LUCK DIPLOMA MD MD NGGMGMMMMGMMGHG JHJHJJGHJGHJGJKGJFFFFF TYTRHGJTYJH JJYT T TH HTDHTYHDGRTYUU H T THD UTR HT HRHWR Y E TYEYERG YRD R D HD H

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