carbon monoxide

1. ‫الرحيم‬ ‫الرحمن‬ ‫ال‬ ‫بسم‬‫الرحيم‬ ‫الرحمن‬ ‫ال‬ ‫بسم‬
‫عقدة‬ ‫واحلل‬ ‫امرى‬ ‫لى‬ ‫ويسر‬ ‫صدرى‬ ‫لى‬ ‫اشرح‬ ‫رب‬ ‫قال‬‫عقدة‬ ‫واحلل‬ ‫امرى‬ ‫لى‬ ‫ويسر‬ ‫صدرى‬ ‫لى‬ ‫اشرح‬ ‫رب‬ ‫قال‬
‫قولى‬ ‫يفقهوا‬ ‫لسانى‬ ‫من‬‫قولى‬ ‫يفقهوا‬ ‫لسانى‬ ‫من‬
‫العظيم‬ ‫ال‬ ‫صدق‬‫العظيم‬ ‫ال‬ ‫صدق‬

2. Case report:-Case report:-
Four patients come to ER of Ain shams poisonFour patients come to ER of Ain shams poison
control center in January first patient 52yearscontrol center in January first patient 52years
old female presented with headache, vomitingold female presented with headache, vomiting
and history of fits.and history of fits.
second patient 25years old female presentedsecond patient 25years old female presented
with headache and dyspnea.with headache and dyspnea.
Third patient 19years old male presented withThird patient 19years old male presented with
headache , vomiting and history of loss ofheadache , vomiting and history of loss of
consciousness.consciousness.
fourth patient 15years old male presentedfourth patient 15years old male presented
with mild headache.with mild headache.

3. What is the most probableWhat is the most probable
diagnosis?diagnosis?
Carbon monoxideCarbon monoxide
Food poisoningFood poisoning
Organophosphorurs poisoningOrganophosphorurs poisoning
Differentiated by:-Differentiated by:-
HistoryHistory
Clinical examinationClinical examination

4. Investigations:-Investigations:-
Arterial blood gas
First patient
Metabolic acidosis
Ph:7.24
Hco3:19
Lactate level:
28mg / dl
second patient
Metabolic acidosis
Ph:7.32
Hco3:21
Lactate level :
20mg / dl
Third patient
Metabolic acidosis
Ph:7.27
Hco3:18
Lactate level:
31 mg / dl
Fourth patient
Ph:7.38
Hco3:24
Lactate level:
10 mg / dl

5. treatment
First patient
Oxygen
150 ml mannitol
dexamethasone
Second patient
Oxygen
dexamethasone
Third patient
Oxygen
150 ml mannitol
Repeated
dexamethasone
Fourth patient
oxygen

6. clinically
No symptoms
Only co exposure
oxygen
Mild symptoms
Oxygen
Mannitol 20%
dexamethazone
Sever symptoms
ICU admission
100% oxygen
Hyperbaric oxygen

8. Physical properties:-Physical properties:-
Sources
Endogenous Exogenous

9. Factors affecting co toxicity:-Factors affecting co toxicity:-
.age.age
Duration of exposureDuration of exposure
Concentrations of the gasConcentrations of the gas
Muscular activity of the personMuscular activity of the person
Decreased po2 as in high altitudeDecreased po2 as in high altitude
Cardiovascular or pulmonary diseaseCardiovascular or pulmonary disease
Lowered hb% as in anaemiaLowered hb% as in anaemia
smokingsmoking

10. Pathophysiology:-Pathophysiology:-
co has high affinity to bind to Hbco has high affinity to bind to Hb
200-250 times greater than oxygen200-250 times greater than oxygen
Myoglobin impairmentMyoglobin impairment
Binding to cytochrome oxidaseBinding to cytochrome oxidase
Nitrous oxideNitrous oxide

11. Clinical presentation
Acute toxicity
Chronic low level
Exposure to co

12. Acute toxicityAcute toxicity
Neurological effectsNeurological effects
Cardiovascular effectsCardiovascular effects
Pulmonary complicationsPulmonary complications
Dermatological complicationsDermatological complications
Effect on musclesEffect on muscles

13. Neurological effects:-Neurological effects:-
Throbbing headacheThrobbing headache
Dizziness and nauseaDizziness and nausea
Ataxia ,visual and auditoryAtaxia ,visual and auditory
abnormalities,confusion,convulsiabnormalities,confusion,convulsi
ons and coma.ons and coma.

14. Cardiovascular effects:-Cardiovascular effects:-
TachycardiaTachycardia
HypotensionHypotension
DysrhythmiaDysrhythmia
Angina up to myocardialAngina up to myocardial
infarctioninfarction

15. Pulmonary complications:-Pulmonary complications:-
dyspneadyspnea
TachypneaTachypnea
Pulmonary edema and pulmonaryPulmonary edema and pulmonary
hemorrhagehemorrhage

16. Ophthalmologic complications:-Ophthalmologic complications:-
Blurred visionBlurred vision
Decreased light sensitivityDecreased light sensitivity
Decrease dark adaptationDecrease dark adaptation
Retinal affectionRetinal affection

17. Effect on muscles:-Effect on muscles:-
RhabdomyolysisRhabdomyolysis
Myoglobinuria and rarely renal failureMyoglobinuria and rarely renal failure

19. Delayed neuropsychiatericDelayed neuropsychiateric
sequela:-sequela:-
Dementia, memory problems,Dementia, memory problems,
gait disturbancegait disturbance
Parkinsonism, choreaParkinsonism, chorea
Peripheral neuropathyPeripheral neuropathy
IncontinenceIncontinence
ParalysisParalysis
Depression ,emotional liability,Depression ,emotional liability,
hallucinationshallucinations

20. Chronic low level exposure to co:-Chronic low level exposure to co:-
Persistent headachePersistent headache
DepressionDepression
ConfusionConfusion
NauseaNausea

21. Investigations
Laboratory
COHb level
Co-oximeter
ABG
Cardiac markers
ECG and cardiac
monitoring
Imaging
Chest x ray
Brain CT and MRI

24. Treatment:-Treatment:-
Prophylactic measuresProphylactic measures
Symptomatic treatmentSymptomatic treatment
Curative measuresCurative measures

26. Symptomatic treatment:-Symptomatic treatment:-
WarmthWarmth
Diuretics and corticosteroidsDiuretics and corticosteroids
DiazepamDiazepam
Bed restBed rest
Observation of patient to detect lateObservation of patient to detect late
complications.complications.

27. Hyperbaric oxygen:-Hyperbaric oxygen:-
Indications:-Indications:-
SyncopeSyncope
ComaComa
SeizureSeizure
ConfusionConfusion
Carboxy haemoglobinCarboxy haemoglobin<<25%25%
Fetal distress in pregnancyFetal distress in pregnancy
Metabolic acidosis with ph less than 7.20Metabolic acidosis with ph less than 7.20
Pregnant patients with carboxyPregnant patients with carboxy
haemoglobin 10%or morehaemoglobin 10%or more

29. Complications:-Complications:-
Oxygen induced seizuresOxygen induced seizures
Ear discomfortEar discomfort
Tympanic membrane ruptureTympanic membrane rupture
Tension pneumothorax.Tension pneumothorax.

30. Treatment of pregnant patients:-Treatment of pregnant patients:-
Therapy with 100%oxygen atTherapy with 100%oxygen at
normobaric pressures should benormobaric pressures should be
continued for five times the length ofcontinued for five times the length of
time it takes to normalize maternaltime it takes to normalize maternal
carboxyhemoglobincarboxyhemoglobin
Hyperbaric oxygen is indicated inHyperbaric oxygen is indicated in
symptomatic pregnant woman orsymptomatic pregnant woman or
pregnant woman with carboxypregnant woman with carboxy
haemoglobin greater than 10%.haemoglobin greater than 10%.