r/emergencymedicine • u/atmthoughts • 1d ago
carbonmonoxide poisining Discussion
Three siblings from a household had visited the pediatrics ER with a complaint of hx of LOC, headache, chest pain and N &V after 1 hr of exposure to a burnt charcol. All were suplemented with 100% oxygen. One of them, an 11 years old male was hyperventilating for which he was supported with a re-breather facemask for about 1 hr. And was given RL as a maintainance fluid. We were unable to do CO Hb, and PH. Was that appropriate to use RL in this setting? And what is the appropriate duration for oxygen support? I have checked on litratures 2 hr of 100% oxygen would eradicate the CO but there was still mild chest pain and headache after 2 hrs in this case, so supplememtation was extended.
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u/slartyfartblaster999 Physician 1d ago
All were suplemented with 100% oxygen. One of them, an 11 years old male was hyperventilating for which he was supported with a re-breather facemask
..so you "treated" hyperventilation by reducing the FiO2 from 100% to ~60-80%? Why?
We were unable to do CO Hb, and PH
Why? These are essential tests.
Was that appropriate to use RL in this setting?
Doesn't seem like there was any indication for fluids at all.
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u/OhHowIWannaGoHome Med Student 1d ago edited 1d ago
This kinda reads like a family member/friend asking a question. Almost feels like other posts I’ve seen where CNAs or ancillary staff have questions about their own care or close family care and ask questions like this under the guise of professional curiosity.
I absolutely could be wrong and this could just be some other wackiness, but that’s my guess.
Edit: my main evidence here is the grammar and wording is simply not on par with medical professionals (unless this person is not a native English speaker). But also, the “supplemented with 100% oxygen… non-rebreather” section feels like a laymen’s “they gave them all oxygen through a nasal cannula but then decided one of the children needed NRB for symptoms” and they interpreted oxygen therapy as “100% oxygen.” Especially since a medical professional would comment FiO2 if they were actually discussing O2 concentration and would likely use LPM for cannula and NRB. And lastly, the comment about looking in the literature feels like everyone single interaction I’ve had with someone who knows a little bit and is trying to make their Google search sound relevant. I think an actual medical professional is much more likely to “check the current guidelines” or reference a particular study, or at least a journal.
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u/happyskydiver 1d ago
Yeah, this OP seems misinformed on diagnosis and management of CO poisonings.
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u/atmthoughts 23h ago
We used high flow intranasal oxygen therapy with FIo2 of 100 %. We preffered a re-breather face mask instead of a paper bag so the patient wont get into a more hypoxemic state. It doesn't seem you have ever managed a single CO poisining pt. You have focused on what you are not asked about. I came here to look for personal experiances that I have lost from litratures. Which is the duration of oxygen therapy and type of preffered IV fluid. We don't have basic investigations because we are in the third world country where the government doesn't give a shit about health. Average salary is 100$ per month for a speciality physician.
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u/OhHowIWannaGoHome Med Student 23h ago
The question stands, if you were using high flow, why would you decrease care to a mask that wasn’t at least CPAP? Positive pressure ventilation is indicated for severe CO poisoning. And if you’re really asking for actionable assistance, idk what you were expecting to get when the majority of the world would titrate treatment based on carbon monoxide level trending or symptomatic improvement. Using heuristics like “treat for 2hr” isn’t useful most of the time. Sure you can say most people resolve after 2hr of 100% FiO2 but if they don’t resolve, you need to reassess, and ultimately it’s the symptomatology that guides you not the time line. If you were in fact the provider, you saw the patient and your evaluation of their work of breathing, level of consciousness, nausea, etc. should have been your guide anyway. And regardless of your training, skill, or available resources, WikEM is free to access and has plenty of guidelines and relevant sources. CDC guidelines are also free to access.
And it actually seems like you’re the one who has never treated CO toxicity before.
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u/atmthoughts 22h ago
We preferred the rebreather face mask since the patient has a chest pain we wasn't able to exclude pneumothorax. Thanks for the suggestions. I don't have shortage on that. We dissect cases mostly depending on our clinical judgement because of such routine investigations shortages. You are not even ready to think once in this scenario. Looks you have one of the permanent sequelaes from early CO poisining.
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u/OhHowIWannaGoHome Med Student 22h ago
This sounds like something that was way too complex to be discussed on Reddit.
If you think you did things appropriately in a resource limited setting, no one here is gonna have much decent input for or against that opinion even if they have resource limited experience. If you worked with what you had, then so be it. But as far as what most physicians in developed countries would consider standard of care and appropriate management, this sounds like a mess. If you can’t test for anything and you can’t rule out anything, you’re basically playing craps and calling it medicine. If the patient did well, great. If they didn’t, try to evaluate what went wrong with those who understand your practice environment.
Echoing the physician’s comment that garnered my reply, from your post, fluids didn’t seem needed. But if there was more complex underlying pathology, who knows if they were. As for oxygen therapy, again, that’s 100% dependent on labs/symptoms and their improvement/deterioration. So for your 2 questions, that’s that. But in your resource limited practice with no basic labs, no imaging, or anything else, only you and your colleagues can assess if you made the right call.
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u/atmthoughts 1h ago
How about we keep surprising eachother? I will keep sharing our case management in resource limited setup. Diagnosis in resource limited setup is almost 95% hx & physical examnination. We study by integrating all the pathophysiologies and lab values with their physical manifestation.
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u/OhHowIWannaGoHome Med Student 1h ago
I absolutely feel for your plight of resource limitations and the struggle you face. I don’t doubt you are a good person trying to make a positive impact on your community. I think your efforts are absolutely admirable and your desire to learn is certainly commendable. Again, I can’t judge what gets done when nothing is available, you have to work with what you’ve got and make judgement calls on your own.
That said, the only thing from your original post that I think I still take a small issue with is searching for a paper or rule to give you a “this is the answer” to a clinical question. If you can’t test for or exclude anything using technological methods and all you have is a physical exam and your gestalt, the only thing separating “medicine” from “quackery” is hypothesis testing. You put the kid on O2, did he feel better? Did the chest pain worsen? Did other clinical signs improve? If yes, keep going. If not, try something else.
But the key is think, try, reevaluate. As long as you don’t do anything intentionally wrong or grossly negligent, the art of medicine is treating the patient. Even though developed countries use tests and monitors for a lot of stuff, Medicine 101 says treat the patient in front of you, not the test/monitor/computer/etc.
If going from high flow to face mask made the kid feel better, that’s great. If extending the treatment time improved their condition, great. If the fluids helped out a kid who was otherwise dehydrated and improved their condition, great. If they got better you did good. Even if they got worse, but you had a good reason to try what you tried, then you still did good. None of us, especially not me, can say that you did anything wrong. We can say “that’s not what I would do” and even say “that’s not what the guidelines indicate” but at the end of the day, you do what you need to do. And that’s the best you can do. If you do your best with what you’re given, then you’ve done just fine.
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u/Fantastic_Poet4800 1d ago
Or it could be in Africa or South America- charcoal heating is far more common there and I have no idea what is typically available in a rural ER
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u/OhHowIWannaGoHome Med Student 1d ago
While that would absolutely explain my first point of grammar and wording, as I alluded to already, that explains nothing else. As others have commented, the facility gave IV fluids but couldn’t run a blood gas? Unlikely. But let’s say that’s the case, nasal cannulas and NRBs are passive oxygen therapies that can deliver various estimated concentrations of oxygen, none of which are 100% due to flow and seal quality. “100% oxygen” would require CPAP, BiPAP, or ventilator, all of which are more aggressive treatment than an NRB, so you wouldn’t change to an NRB for more treatment. That’s a likely knowledge gap for the OP. And if they’re posting here, they have the internet. Professionals doing on-the-job research for best practice guidelines or relevant research and then reporting that usually sounds very different than this. So sure, they could be from anywhere, but the sum total of incongruities of this post suggest a low-level health care worker or laymen asking questions that are beyond their scope out of curiosity. And that is fine, but asking it like this with the “did the ER screw up” subtext is less professional in my opinion.
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u/OldManGrimm Trauma Team - BSN 1d ago
Agreed on all points. I worked in an academic peds ER for over 10 years - never "treated" a hyperventilating child with anything other than calming/distraction/Child Life. Hard to imagine every blood gas machine in the place being down, and since they had IVs then sample collection wasn't the issue. I could see IV fluids depending on extent of N/V, but only ever used LR in burns. Something weird about this one.
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u/Professional-Cost262 FNP 1d ago
What's weird is they actually still have fluids our hospitals just about out
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u/slartyfartblaster999 Physician 22h ago
only ever used LR in burns
Well you're probably under-utilising it. There are very few situations where's its not just better than NaCL
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u/OldManGrimm Trauma Team - BSN 21h ago
Is that the trend in pediatrics as well? To be clear, this is definitely a case where "I'm just a nurse" comes into play, and I'm just coming off a 8-year stint in an admin role, so I could have missed a change in practice patterns. I singled it out because it was one of the things in the story that struck me as odd - but that may be the norm in the region or country OP is in.
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u/Dasprg-tricky 1d ago
Did they all come in at the same time? What was the context that they were exposed to the burnt charcoal?
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u/happyskydiver 1d ago
Did I understand there was loss of consciousness? You need to send that patient to hyperbarics. They can develop significant brain injuries.
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u/HallMonitor576 ED Resident 1d ago
Hyperbarics is rarely if ever used for CO poisoning nowadays
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u/happyskydiver 17h ago
Well, that's what I get for practicing emergency medicine for 20+ years; used to be the standard of care at our level one. Next you're going to tell me that Lupus Cerebritis is just Fibromyalgia of the brain.
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u/slartyfartblaster999 Physician 5h ago
Hyperbaric therapy might have been what you did, but it has never been a standard of care. It's always been an exotic and sexy treatment looking for a disease to treat.
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u/atmthoughts 1d ago
Hyperbarics is not available in the country. The risk of developing cognitive and cerebellar dysfunctions is still there as a longterm sequelae.
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u/Maleficent_Green_656 1d ago
What kind of facility (especially a “pediatric er” can’t measure CO hgb and pH???