#15,442
While the landfall of a major hurricane is always dramatic and newsworthy, most people take the warnings seriously and get out of the way of the storm, so the biggest danger to life and limb often comes in the days, weeks, and months that follow.
In the days prior to Laura's landfall we looked at a number of these dangers (see Post-Disaster PTSD & Sequelae and Flood Dangers Run Deep), and in both blogs Carbon Monoxide poisoning - usually due to improper generator operation - was mentioned.
Eight years ago, in MMWR: Carbon Monoxide Exposures Related To Hurricane Sandy, we looked at a CDC Notes From The Field report on the the large number (260+) of CO exposures linked to the aftermath of hurricane Sandy in the Northeast, and two years ago we looked at a CDC HAN on CO poisoning following Hurricane Florence which affected the Carolinas.
Tragically, but predictably, headlines coming out of Louisiana and Texas since Friday have been filled with similar reports of serious - and often fatal - carbon monoxide poisonings. A couple include:
2 new carbon monoxide deaths reported, Hurricane Laura's death toll now 16
3 dead and 23 hospitalized in Port Arthur, all due to possible CO poisoning
Despite the standard safety advice (below) and warnings provided with every generator, the CDC reports `Every year, at least 430 people die in the U.S. from accidental CO poisoning. Approximately 50,000 people in the U.S. visit the emergency department each year due to accidental CO poisoning.'
Carbon monoxide is odorless and colorless, and most people who are exposed are only aware that they have a headache, and are tired and lethargic. Many simply lay down to take a nap, and never wake up again.
On Thursday, the CDC released a HAN Advisory for clinicians reminding them to maintain a high index of suspicion of CO poisoning among patients in the days and weeks following Hurricane Laura's landfall.
Hurricane Laura—Clinical Guidance for Carbon Monoxide (CO) Poisoning
Distributed via the CDC Health Alert Network
August 27, 2020, 3:30 PM ET
CDCHAN-00435
Summary
The Centers for Disease Control and Prevention (CDC) is reminding clinicians seeing patients from the areas affected by Hurricane Laura to maintain a high index of suspicion for CO poisoning. Other people who may be exposed to the same CO source may need to be identified and assessed.
The signs and symptoms of CO exposure are variable and nonspecific. A tension-type headache is the most common symptom of mild CO poisoning. Other symptoms may include dizziness, flu-like symptoms without a fever, drowsiness, chest pain, and altered mental status.
Clinical manifestations of severe CO poisoning include tachycardia, tachypnea, hypotension, metabolic acidosis, dysrhythmias, myocardial ischemia or infarction, noncardiogenic pulmonary edema, neurologic findings including irritability, impaired memory, cognitive and sensory disturbances, ataxia, altered or loss of consciousness, seizures, coma, and death, although any organ system might be involved.
Although CO poisoning can be fatal to anyone, children, pregnant women, the unborn, persons with sickle cell disease
Background
High winds and heavy rain from Hurricane Laura began affecting Louisiana, Texas, and Arkansas on August 27, 2020. Impact on the Gulf coast and inland led to thousands of people without power. Those without power may turn to alternate power sources such as gasoline generators and may use propane or charcoal grills for cooking. If used or placed improperly, these sources can lead to CO build up inside buildings, garages, or campers and poison the people and animals inside.
With a focused history of patient activities and health symptoms, exposure to a CO source may become apparent. Appropriate and prompt diagnostic testing and treatment are crucial to reduce morbidity and prevent mortality from CO poisoning. Identifying and mitigating the CO source is critical in preventing other poisoning cases.
Recommendations for CliniciansFor More Information
- Consider CO poisoning in patients affected by Hurricane Laura, particularly those in areas currently without power. Assess symptoms and recent patient activities that point to likely CO exposure. Evaluation should also include examination for other conditions, including smoke inhalation, trauma, medical illness, or intoxication.
- Administer 100% oxygen until the patient is symptom-free or until a diagnosis of CO poisoning has been ruled out.
- Perform COHgb testing when CO poisoning is suspected. Venous or arterial blood may be used for testing. A fingertip pulse multiple wavelength spectrophotometer, or CO-oximeter, can be used to measure heart rate, oxygen saturation, and COHgb levels in the field, but any suspicion of CO poisoning should be confirmed with a COHgb level by multiple wavelength spectrophotometer (CO-oximeter). A conventional two-wavelength pulse oximeter is not accurate when COHgb is present. For more information, see https://www.cdc.gov/disasters/co_guidance.html.
- An elevated carboxyhemoglobin (COHgb) level of 2% or higher for non-smokers and 9% or higher COHgb level for smokers strongly supports a diagnosis of CO poisoning. The COHgb level must be interpreted in light of the patient’s exposure history and length of time away from CO exposure, as levels gradually fall once the patient is removed from the exposure. In addition, carbon monoxide can be produced endogenously as a by-product of heme metabolism. Patients with sickle cell disease can have an elevated COHgb level as a result of hemolytic anemia or hemolysis. For additional information about interpretation of COHgb levels, visit https://www.cdc.gov/disasters/co_guidance.html or call Poison Control at (800) 222-1222.
- Hyperbaric oxygen therapy (HBO) should be considered in consultation with a toxicologist, hyperbaric oxygen facility, or Poison Control Center (800) 222-1222. For additional management considerations, consult a toxicologist, Poison Control at (800) 222-1222, or a hyperbaric oxygen facility.
- Be aware that CO exposure may be ongoing for others spending time in or near the same environment as the patient. These individuals should be evaluated and tested as described in this advisory.
- Clinicians treating people for CO poisoning should notify emergency medical services (EMS), the fire department, or law enforcement to investigate and mitigate the source and advise people when it is safe to return.
- Advise patients about safe practices related to generators, grills, camp stoves, or other gasoline, propane, natural gas, or charcoal-burning devices. Stress that that these devices should never be used inside an enclosed space, home, basement, garage, or camper — or even outside near an open window or window air conditioner. Please see https://www.cdc.gov/co/pdfs/generators.pdfpdf icon.
Clinical Guidance for Carbon Monoxide (CO) Poisoning After a Disaster
https://www.cdc.gov/disasters/co_guidance.html
While a generator can be a godsend following a disaster, if you have one and plan to use it, the time to decide how and were to operate it safely is before the storm arrives. Decisions made under the stressful conditions of an emergency can often be faulty, or even fatal.
