Characteristics of patients with carbon monoxide poisoning due to smoke inhalation and pre-hospital factors related to intensive care unit admission of these patients: a nationwide observational study

This study aimed to investigate the pre-hospital clinical status of patients with carbon monoxide (CO) poisoning by smoke inhalation and the pre-hospital factors associated with these patients’ admission to the intensive care unit (ICU). In this observational study from January 2016 to December 2018, the National Fire Agency’s first aid activity log on patients with smoke inhalation was matched with National Emergency Department Information System’s patient data with CO poisoning and further analyzed retrospectively. Multiple logistic regression analysis was conducted to identify the relevant pre-hospital associative factors for the decision to admit a patient with CO poisoning to the ICU. Of the 4422 patients with CO poisoning included in the study, 358 (8.09%) were admitted to the ICU. In such patients transported by pre-hospital emergency medical services, age (odds ratio [OR], 1.020; 95% confidence interval [CI], 1.010–1.029), verbal (OR, 3.564; 95% CI, 2.390–5.315), pain (OR, 4.011; 95%CI, 2.661–6.045), unconsciousness (OR, 5.728; 95% CI, 2.708–12.113), SBP (OR, 0.979; 95% CI, 0.969–0.989), HR (OR, 1.011; 95% CI, 1.004–1.018), SpO2 (OR, 0.965; 95% CI, 0.946–0.985), O2 supply (OR, 1.725; 95% CI, 1.143–2.603), use of nasal prongs (OR, 0.504; 95% CI, 0.281–0.905), and intentional inhalation (OR, 2.282; 95% CI, 1.659–3.139) were independently associated with ICU admission. Our study demonstrated that age, mental change, SBP, HR, SPO2, O2 supply, use of nasal prongs, and intentional inhalation in patients with CO poisoning were associated with their ICU admission.

Smoke inhalation; Carbon monoxide poisoning; Pre-hospital emergency medical services; Intensive care unit

[1] Huzar TF, George T, Cross JM. Carbon monoxide and cyanide toxicity: etiology, pathophysiology and treatment in inhalation injury. Expert Review of Respiratory Medicine. 2013; 7: 159–170.

[2] O’Brien DJ, Walsh DW, Terriff CM, Hall AH. Empiric Management of Cyanide Toxicity Associated with Smoke Inhalation. Prehospital and Disaster Medicine. 2011; 26: 374–382.

[3] Sircar K, Clower J, Shin MK, Bailey C, King M, Yip F. Carbon monoxide poisoning deaths in the United States, 1999 to 2012. The American Journal of Emergency Medicine. 2015; 33: 1140–1145.

[4] Ball LB, Macdonald SC, Mott JA, Etzel RA. Carbon monoxide-related injury estimation using ICD-coded data: methodologic implications for public health surveillance. Archives of Environmental and Occupational Health. 2005; 60: 119–127.

[5] Smith DL, Cairns BA, Ramadan F, Dalston JS, Fakhry SM, Rutledge R, et al. Effect of inhalation injury, burn size, and age on mortality: a study of 1447 consecutive burn patients. The Journal of Trauma. 1994; 37: 655–659.

[6] Kimmel EC, Still KR. Acute lung injury, acute respiratory distress syndrome and inhalation injury: an overview. Drug and Chemical Toxicology. 1999; 22: 91–128.

[7] Baud FJ. Acute poisoning with carbon monoxide (CO) and cyanide (CN). Therapeutische Umschau. Revue therapeutique. 2009; 66: 387–397.

[8] Weaver LK, Hopkins RO, Chan KJ, Churchill S, Elliott CG, Clemmer TP, et al. Hyperbaric oxygen for acute carbon monoxide poisoning. The New England Journal of Medicine. 2002; 347: 1057–1067.

[9] Jasper BW, Hopkins RO, Duker HV, Weaver LK. Affective Outcome Following Carbon Monoxide Poisoning: a prospective longitudinal study. Cognitive and Behavioral Neurology. 2005; 18: 127–134.

[10] Weaver LK. Hyperbaric oxygen therapy for carbon monoxide poisoning. Undersea and Hyperbaric Medicine. 2014; 41: 339–354.

[11] Gorman D, Drewry A, Huang YL, Sames C. The clinical toxicology of carbon monoxide. Toxicology. 2003; 187: 25–38.

[12] Hampson NB, Weaver LK. Carbon monoxide poisoning: a new incidence for an old disease. Undersea and Hyperbaric Medicine. 2007; 34: 163–168.

[13] Weaver LK, Deru K, Churchill S, Legler J, Snow G, Grey T. Carbon monoxide poisoning in Utah: 1996-2013. Undersea and Hyperbaric Medicine. 2016; 43: 747–758.

[14] Braubach M, Algoet A, Beaton M, Lauriou S, Héroux ME, Krzyzanowski M. Mortality associated with exposure to carbon monoxide in who European Member States. Indoor Air. 2013; 23: 115–125.

[15] Huang CC, Ho CH, Chen YC, Lin HJ, Hsu CC, Wang JJ, et al. Demographic and clinical characteristics of carbon monoxide poisoning: nationwide data between 1999 and 2012 in Taiwan. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 2017; 25: 70.

[16] Ministry of Health and Welfare. Study of the optimal allocation of hyperbaric oxygen therapy center in South Korea 2019. 2020 Available at: http://www.prism.go.kr/homepage/entire/retrieveEntireDetail.do;jsessionid= 0C66CCBBFFF9A65AEAF8B824A75338C3.node02?cond_research_ name=&cond_research_start_date=&cond_research_end_ date=&research_id=1351000-201900321&pageIndex=24& leftMenuLevel=160 (Accessed: 20 June 2020).

[17] Peterson JE, Stewart RD. Absorption and Elimination of Carbon Monoxide by Inactive Young Men. Archives of Environmental Health. 1970; 21: 165–171.

[18] Weaver LK, Howe S, Hopkins R, Chan KJ. Carboxyhemoglobin half-life in carbon monoxide-poisoned patients treated with 100% oxygen at atmospheric pressure. Chest. 2000; 117: 801–808.

[19] Pace N, Strajman E, Walker EL. Acceleration of carbon monoxide elimination in man by high pressure oxygen. Science. 1950; 111: 652–654.

[20] Centers for Disease Control and Prevention (CDC). Carbon monoxide exposures – United States, 2000–2009. Morbidity and Mortality Weekly Report. 2011; 60: 1014–1017.

[21] National fire agency 119. The standard protocols for 119 emergency medical services providers 2019. 2019. Available at: http://www. nfa.go.kr/nfa/publicrelations/legalinformation/0017/ 0003/?boardId=bbs_0000000000001097&mode=view&cntId= 4&category=&pageIdx=&searchCondition=&searchKeyword= (Accessed: 25 November 2019).

[22] Hwang JS, Choi WJ, Kim SH, Choi BH, Lee HJ, Ahn R, et al. Early Predictors of Critical Cases for the Patients Who Visited Emergency Department due to Gas Inhalation: Early Predictors of Severity in Gas Inhalation. Journal of the Korean Society of Integrative Medicine. 2017; 28: 475–483.

[23] Choi BH, Jeon J, Ryoo SM, Seo DW, Kim WY, Oh BJ, et al. Recent Epidemiologic Features of Carbon Monoxide Poisoning in Korea: A Single Center Retrospective Cohort Study. Journal of the Korean Society of Clinical Toxicology. 2012; 10: 80–85.

[24] Bae SH, Lee JS, Kim KH, Park JS, Shin DW, Kim HJ, et al. Epi-demiologic Characteristics of Carbon Monoxide Poisoning: Emergency Department Based Injury In-depth Surveillance of Twenty Hospital. Journal of the Korean Society of Clinical Toxicology. 2016; 14: 122–128.

[25] Kim YJ, Sohn CH, Seo DW, Oh BJ, Lim KS, Kim WY. Clinical Predictors of Acute Brain Injury in Carbon Monoxide Poisoning Patients with Altered Mental Status at Admission to Emergency Department. Academic Emergency Medicine. 2019; 26: 60–67.

[26] Hampson NB, Dunford RG, Kramer CC, Norkool DM. Selection criteria utilized for hyperbaric oxygen treatment of carbon monoxide poisoning. The Journal of Emergency Medicine. 1995; 13: 227–231.

[27] Weaver LK. Hyperbaric oxygen in the critically ill. Critical Care Medicine. 2011; 39: 1784–1791.

[28] Rose JJ, Wang L, Xu Q, McTiernan CF, Shiva S, Tejero J, et al. Carbon Monoxide Poisoning: Pathogenesis, Management, and Future Directions of Therapy. American Journal of Respiratory and Critical Care Medicine. 2017; 195: 596–606.

[29] Wolf SJ, Lavonas EJ, Sloan EP, Jagoda AS. Clinical policy: Critical issues in the management of adult patients presenting to the emergency department with acute carbon monoxide poisoning. Annals of Emergency Medicine. 2008; 51: 138–152.

[30] Myers RA, Linberg SE, Cowley RA. Carbon monoxide poisoning: the injury and its treatment. Journal of the American College of Emergency Physicians. 1979; 8: 479–484.

[31] Eichhorn L, Thudium M, Jüttner B. The Diagnosis and Treatment of Carbon Monoxide Poisoning. Deutsches Arzteblatt International. 2018; 115: 863–870.

[32] Rastelli G, Callegari S, Locatelli C, Vezzani G. Myocardial injury in carbon monoxide poisoning. Giornale Italiano di Cardiologia. 2009; 10: 227–233. (In Italian)

[33] Choi IS. Delayed Neurologic Sequelae in Carbon Monoxide Intoxication. Archives of Neurology. 1983; 40: 433–435.

[34] Min SK. A brain syndrome associated with delayed neuropsychiatric se-quelae following acute carbon monoxide intoxication. Acta Psychiatrica Scandinavica. 1986; 73: 80–86.

[35] Aubard Y, Magne I. Carbon monoxide poisoning in pregnancy. BJOG: An International Journal of Obstetrics and Gynaecology. 2000; 107: 833–838.

[36] Roderique EJD, Gebre-Giorgis AA, Stewart DH, Feldman MJ, Pozez AL. Smoke inhalation injury in a pregnant patient: a literature review of the evidence and current best practices in the setting of a classic case. Journal of Burn Care and Research. 2012; 33: 624–633.

[37] Sohn CH, Huh JW, Seo DW, Oh BJ, Lim KS, Kim WY. Aspiration Pneumonia in Carbon Monoxide Poisoning Patients with Loss of Consciousness: Prevalence, Outcomes, and Risk Factors. The American Journal of Medicine. 2017; 130: 1465.e21–1465.e26.

[38] Miller M, Azrael D, Hemenway D. The epidemiology of case fatality rates for suicide in the northeast. Annals of Emergency Medicine. 2004; 43: 723–730.

[39] Heo IY, Choi SC, Lee CA, Ahn JH, Min YG, Jung YS, et al. Influence of the Werther effect: an increase of intentional carbon monoxide poisoning. Journal of the Korean Society of Clinical Toxicology. 2009; 7: 143–149.

[40] Kim WK, Kim KH, Shin DW, Park JS, Kim H, Jeon WC, et al. Characteristics of Korean poisoning patients: retrospective analysis by National Emergency Department Information System. Journal of the Korean Society of Clinical Toxicology. 2019; 17: 108–117.

[41] Ministry of health & welfare Korea suicide prevention center. 2020 Sui-cide prevention white paper. 2020. Available at: https://spckorea-stat.or.kr/boadpublishview.do (Accessed: 29 May 2020).

[42] Weaver LK, Churchill S, Deru K. Critical care of patients treated in monoplace hyper baric chambers, past 20 years. Undersea and Hyperbaric Medicine. 2006; 33: 350–351.

[43] National fire agency 119. 119 emergency medical services annual report in 2018. 2018. Available at: https://opengov.seoul.go.kr/sanction/15777062 (Accessed: 30 July 2018).

[44] Shannon MW, Borron SW, Burns MJ. Haddad and Winchester’s Clinical Management of Poisoning and Drug Overdose (pp. 1309–1316). 4th edn. Elsevier: Philadelphia. 2007.

[45] Cianci P, Slade JB Jr, Sato RM, Faulkner J. Adjunctive hyperbaric oxygen therapy in the treatment of thermal burns. Undersea and Hyperbaric Medicine. 2013; 40: 89–108.

[46] Mathieu D, Marroni A, Kot J. Tenth European Consensus Conference on Hyperbaric Medicine: recommendations for accepted and non-accepted clinical indications and practice of hyperbaric oxygen treatment. Diving and Hyperbaric Medicine. 2017; 47: 24–32.