CDC HAN #00476 : Hurricanes Fiona and Ian—Clinical Guidance for Carbon Monoxide (CO) Poisoning

https://www.cdc.gov/co/default.htm

#17,035

A few feet away from the only likely source of CO gas in my home (my gas stove), I keep a carbon monoxide detector. I do so because nearly 30 years ago my wife and I moved into an older home in another state with a faulty wood furnace that very nearly did us in our first winter from CO poisoning. 

Carbon Monoxide kills by binding to the blood’s hemoglobin at a rate many-fold faster than oxygen can.  It essentially crowds out life-essential oxygen from the blood, causing those exposed to slowly suffocate  . . . often completely unaware of what is happening to them.

Tragically, after nearly every major disaster - when people are using camp stoves, barbecues, or generators in or near to their homes - we hear of deaths and injuries from Carbon Monoxide poisoning. Sometimes, involving entire families.

• In 2012, in MMWR: Carbon Monoxide Exposures Related To Hurricane Sandy, we looked at a preliminary MMWR report that cited more than 260 CO exposures (4 fatal) In the wake of Hurricane Sandy. 
• Four years earlier, the MMWR reported 54 CO exposures following Hurricane Ike in Texas.

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.'

 

Yesterday the CDC released the following HAN Advisory alerting clinicians to be alert to the (sometimes subtle) signs of CO poisoning when evaluating patients from in regions which have recently been hit by hurricanes.

Hurricanes Fiona and Ian—Clinical Guidance for Carbon Monoxide (CO) Poisoning 



Distributed via the CDC Health Alert Network
October 01, 2022, 2:15 PM ET
CDCHAN-00476

Summary

The Centers for Disease Control and Prevention (CDC) is reminding healthcare professionals seeing patients from areas affected by Hurricanes Fiona or Ian to maintain a high index of suspicion for carbon monoxide (CO) poisoning. Other people who may have been exposed to the same CO source may need to be identified and evaluated.

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 common symptoms of CO poisoning are dizziness, weakness, drowsiness, upset stomach, vomiting, chest pain, and altered mental status (confusion)

Clinical manifestations of severe CO poisoning include cardiovascular and neurological effects: tachycardia, tachypnea, hypotension, metabolic acidosis, dysrhythmias, myocardial ischemia or infarction, noncardiogenic pulmonary edema, irritability, impaired memory, cognitive and sensory disturbances, ataxia, altered or loss of consciousness, seizures, coma, and death, although any organ system might be involved. 

CO poisoning can be fatal for anyone. Children, pregnant people, babies and infants, persons with sickle cell disease, older adults, and persons with chronic illness (e.g., heart or lung disease) are at particularly high risk.

Background 

People whose homes or business have lost electrical power due to Hurricanes Fiona or Ian may turn to alternate power sources such as gasoline generators and may use propane or charcoal grills for cooking. Other sources of CO poisoning may include motor vehicles, boats, camp stoves, and gas-powered tools. 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.

When obtaining 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 Clinicians

1. Consider CO poisoning in patients affected by Hurricanes Fiona or Ian, particularly 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.
2. Administer 100% oxygen until the patient is symptom-free or until a diagnosis of CO poisoning has been ruled out. If CO poisoning is confirmed, contact the Poison Control Center (800) 222-1222.
3. Perform carboxyhemoglobin (COHgb) testing when CO poisoning is suspected. Venous or arterial blood may be used for testing. A fingertip pulse multiple wavelength spectrophotometer, or pulse CO-oximeter, can be used to measure heart rate, oxygen Monoxide Poisoning saturation, and COHgb levels, 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 CDC’s Clinical Guidance for Carbon Monoxide Poisoning After a Disaster.
4. An elevated 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 after the patient is removed from the exposure. In addition, CO 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. Additional information about interpretation of COHgb levels can be found within the Clinical Guidance, or call Poison Control at (800) 222-1222.
5. Hyperbaric oxygen (HBO) therapy should be considered in consultation with a toxicologist, hyperbaric oxygen facility, or Poison Control Center (800) 222-1222. For additional clinical management considerations, consult a medical toxicologist, Poison Control at (800) 222-1222, or a hyperbaric oxygen facility.
6. 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.
7. Healthcare professionals treating people for CO poisoning should notify emergency medical services (EMS), the fire department, or law enforcement to investigate and mitigate the source, check for and evacuate people or animals who may still be near the source, and advise people when it is safe to return.
8. 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. 

For More Information

Clinical Guidance for Carbon Monoxide (CO) Poisoning After a Disaster

General Resources for Carbon Monoxide Poisoning

Poison Control (800) 222-1222 or https://www.poison.org/