Aspectos por considerar en autopsias por intoxicación aguda con monóxido de carbono, el asesino silente. A propósito de dos casos / Aspects to consider in autopsies for acute carbon monoxide poisoning, the silent killer. About two cases

El monóxido de carbono (CO) es un gas que se produce durante la combustión incompleta de diferentes materiales orgánicos. Una vez que se inhala, se absorbe hacia la sangre, ejerciendo su efecto a nivel sistémico. Se une fuertemente a la hemoglobina, y forma la carboxihemoglobina lo que provoca una disminución del transporte de oxígeno a los tejidos y dependiendo de su concentración puede ser mortal. Los hallazgos comúnmente encontrados en la autopsia son color rojo cereza en la piel y órganos, así como edema pulmonar, entre otros. El diagnóstico de intoxicación por CO se basa en la medición post mortem de carboxihemoglobina en sangre, por lo que se deben tomar muestras para cuantificar estos niveles. Con respecto al manejo en estos casos, se presenta dos casos correspondientes a la autopsia médica legal en las que se estableció como causa de muerte la intoxicación por monóxido de carbono.

Carbon monoxide (CO) is a gas that is produced during the incomplete combustion of different organic materials. Once inhaled, it is absorbed into the blood, exerting its effect at the systemic level. It strongly binds to hemoglobin, and forms carboxyhemoglobin, which causes a decrease in oxygen transport to the tissues and, depending on its concentration, can be fatal. The findings commonly found in the autopsy are cherry red color in the skin and organs, as well as pulmonary edema, among others. The diagnosis of CO poisoning is based on the postmortem measurement of carboxyhemoglobin in the blood, so samples must be taken to quantify these levels. Regarding the handling of these cases, two cases corresponding to the legal medical autopsy are presented in which carbon monoxide poisoning was established as the cause of death.

El rol del laboratorio en los hallazgos de intoxicación y exposición a monóxido de carbono / The role of the laboratory in findings of carbon monoxide poisoning and exposure

El monóxido de carbono es un gas altamente tóxico que se origina principalmente por la combustión incompleta de combustibles fósiles. La intoxicación presenta síntomas inespecíficos que solapan otras patologías y por lo tanto es indispensable la confirmación mediante la medición de la carboxihemoglobina en sangre. El laboratorio incorporó la determinación en el informe del estado ácido base a partir de octubre del 2018, debido a que previamente el médico debía solicitarla frente a la sospecha de una intoxicación. El objetivo del trabajo fue evaluar si esta medida implementada por el laboratorio contribuyó a mejorar el diagnóstico de intoxicación por CO, analizar las características de los pacientes con COHb mayor o igual a 5% y definir un valor de reporte inmediato para la COHb. El 46% de los casos con COHb mayor o igual a 5% no se relacionaban con una intoxicación y/o exposición a CO. De los casos de intoxicación se encontró que el 77% fueron diagnosticados a partir de la sospecha médica y un 23% por hallazgo del laboratorio. Se concluyó que es de mucha utilidad el rol del laboratorio en detectar aquellos casos que no fueron evidentes clínicamente. Existen ciertas patologías como las oncológicas o la enfermedad de Wilson donde se vieron valores elevados de COHb sin presentar intoxicación y se definió finalmente, como valor de reporte inmediato 7% para la COHb. (AU)

Carbon monoxide is a highly toxic gas that originates mainly from incomplete combustion of fossil fuels. Intoxication causes nonspecific symptoms that overlap with other conditions and, therefore, confirmation by measuring blood carboxyhemoglobin is essential. The laboratory incorporated the measurement in the acid-base status report as of October 2018, as it was previously required to be requested by the physician in case of suspected intoxication. The aim of this study was to evaluate whether this measure implemented by the laboratory contributed to the improvement of the diagnosis of CO intoxication, to analyze the characteristics of patients with COHb greater than or equal to 5% and to define an immediate reporting value for COHb. Overall, 46% of the cases with COHb greater than or equal to 5% were not related to CO poisoning and/or exposure. Of the cases of intoxication, 77% were diagnosed based on medical suspicion and 23% on laboratory findings. It was concluded that the laboratory has a useful role in detecting cases that were not clinically evident. There are certain diseases including different types of cancer or Wilson's disease where elevated COHb values were seen without intoxication and finally, 7% for COHb was defined as the immediate reporting value (AU)

Intoxicación por monóxido de carbono: estudio observacional de pacientes que acudieron a Urgencias durante 2020 / Carbon monoxide poisoning: an observational study of patients admitted to Emergency Department during 2020

El objetivo fue describir las intoxicaciones monóxido de carbono. Se diseñó un corte transversal que incluyó una muestra consecutiva de mediciones de carboxihemoglobina (COHb), realizadas Enero y Diciembre 2020 en la Central de Emergencias del Hospital Italiano de Buenos Aires. Se utilizaron bases secundarias y revisión manual de historias clínicas para recolección de varia-bles de interés. Durante el período de estudio hubo 20 pacientes confirmados, con media de 50 años (DE 20), 55% sexo masculino, 20% tabaquistas, y una única embarazada. El 70% correspondieron al trimestre Junio-Julio-Agosto. La fuente de intoxicación más frecuente se debió a accidentes domésticos (calefón, estufa, brasero, hornalla, salamandra) que representaron el 50% de los casos, 30% por incendios, y el 20% restante explicado por tabaco o factor desconocido. Los estudios de laboratorio más solicitados fueron: 95% recuento de glóbulos blancos, 85% glucemia, 70% CPK, y 55% troponina. Los hallazgos relevantes fueron COHb con mediana de 7.15%, CPK con mediana de 89 U/mL, y troponina con mediana de 8.5 pg/mL. La totalidad se realizó electrocardiograma: 15% presentaron arritmia como hallazgo patológico, y ninguno isquemia. En cuanto la presentación clínica: 30% presentó cefalea, 15% síncope, 15% coma, 10% mareos y 10% convulsiones. Sólo 25% tuvieron tomografía y 15% resonancia de cerebro, sin hallazgos críticos. Sin embargo, 15% fueron derivados para trata-miento con cámara hiperbárica. La mayoría ocurrieron en invierno y explicados por accidentes domésticos. Será necesario un fortalecimiento del rol preventivo que apunte al control de la instalación y el buen funcionamiento de artefactos, como mantener los ambientes bien ventilados (AU)

The objective was to describe carbon monoxide poisoning. A cross sectional was designed, which included a consecutive sample of carboxyhemoglobin (COHb) measurements, carried from January to December 2020 at the Emergency Department of tHospital Italiano de Buenos Aires. Secondary databases and manual review of medical records were used to collect variables of interest. During the study period there were 20 confirmed patients, with a mean age of 50 (SD 20), mostly male (55%), 20% smokers, and only one pregnant woman, 70% corresponded to June-July-August. The most frequent source of poisoning was explained to domestic accidents (water heater, stove, brazier, stove, salamander) which represented 50% of cases, 30% due to fires, and the remaining 20% by tobacco or unknown factor. The most laboratory studies were: 95% white blood cell count, 85% glycemia, 70% CPK, and 55% troponin. Meanwhile, relevant findings were carboxyhemoglobin with a median of 7.15%, CPK with a median of 89 U/mL, and troponin with a median of 8.5 pg/mL. All underwent an electrocardiogram: 15% presented arrhythmia as a pathological finding, and none ischemia. Regarding the clinical presentation: 30% presented headache, 15% syncope, 15% coma, 10% dizziness and 10% seizures. Only 25% had brain tomography and 15% MRI, without pathological findings. However, 15% were referred for treatment with a hyperbaric chamber. Most of the cases occurred in winter and explained by domestic accidents. It will be necessary to strengthen the preventive role that aims to control the installation and the proper functioning of devices, such as keeping rooms well ventilated (AU)

Research progress on head imaging features of carbon monoxide poisoning and delayed encephalopathy / 中华劳动卫生职业病杂志

Acute carbon monoxide poisoning and its delayed encephalopathy have obvious damage to the central nervous system. There are different neuroimaging changes in different stages of the disease, and they are relatively specific. This article reviews the clinical research progress on the imaging changes of carbon monoxide poisoning and delayed encephalopathy, including computed tomography (CT) , conventional magnetic resonance imaging (MRI) , diffusion weighted imaging (DWI) , diffusion tensor imaging (DTI) , diffusion kurtosis imaging (DKI) , magnetic resonance spectroscopy (MRS) and other imaging changes reflecting the function and metabolic state of the brain tissue.

Effect of transcranial direct current stimulation on neurological injury markers and prognosis in patients with acute and severe carbon monoxide poisoning / 中华劳动卫生职业病杂志

Objective: To observe the effects of transcranial direct current stimulation (tDCS) on nerve injury markers and prognosis in patients with acute severe carbon monoxide poisoning (ASCOP) . Methods: In May 2021, 103 ASCOP patients were treated in the emergency department of Harrison International Peace Hospital of Hebei Medical University from November 2020 to January 2021. The patients were divided into two groups according to whether they received tDCS treatment. The control group (50 cases) were given oxygen therapy (hyperbaric oxygen and oxygen inhalation) , reducing cranial pressure, improving brain circulation and cell metabolism, removing oxygen free radicals and symptomatic support, and the observation group (53 cases) was treated with 2 weeks of tDCS intensive treatment on the basis of conventional treatment. All patients underwent at least 24 h bispectral index (BIS) monitoring, BIS value was recorded at the hour and the 24 h mean value was calculated. Neuron-specific enolase (NSE) and serum S100B calcium-binding protein (S100B) were detected after admission, 3 d, 7 d and discharge. Follow-up for 60 days, the incidence and time of onset of delayed encephalopathy (DEACMP) with acute carbon monoxide poisoning in the two groups were recorded. Results: The NSE and S100B proteins of ASCOP patients were significantly increased at admission, but there was no significant difference between the two groups (P=0.711, 0.326) . The NSE and S100B proteins were further increased at 3 and 7 days after admission. The increase in the observation group was slower than that in the control group, and the difference was statistically significant (P(3 d)=0.045, 0.032, P(7 d)=0.021, 0.000) ; After 14 days, it gradually decreased, but the observation group decreased rapidly compared with the control group, with a statistically significant difference (P=0.009, 0.025) . The 60 day follow-up results showed that the incidence of DEACMP in the observation group was 18.87% (10/53) , compared with 38.00% (19/50) in the control group (P=0.048) ; The time of DEACMP in the observation group[ (16.79±5.28) d] was later than that in the control group[ (22.30±5.42) d], and the difference was statistically significant (P=0.013) . Conclusion: The early administration of tDCS in ASCOP patients can prevent the production of NSE and S100B proteins, which are markers of nerve damage. and can improve the incidence and time of DEACMP.

Acute carbon monoxide poisoning in a Filipino household

@#There have been multiple reports already regarding acute carbon monoxide/CO poisoning in the Philippines secondary to misuse of portable generators, especially during the times of typhoon. We present a case of unintentional carbon monoxide poisoning in a Filipino household wherein three of its members were found dead and leaving other five unconscious before they were rushed to the hospital. The index patient had increased serum fraction percentage of carboxyhemoglobin level and presented with rhabdomyolysis during admission. Neuroimaging confirmed a hypoxic-ischemic encephalopathy secondary to carbon monoxide intoxication. Even without hyperbaric oxygen therapy, patient improved with adequate hydration, early rehabilitation and trauma-focused psychotherapy.

A case of acute carbon monoxide poisoning with secondary intestinal obstruction and thrombosis / 中华劳动卫生职业病杂志

Acute carbon monoxide poisoning can cause multiple organ damage due to hypoxia. In severe cases, it can be life-threatening and has a high fatality rate. Intestinal obstruction and thrombosis are rare complications of carbon monoxide poisoning. A case of carbon monoxide poisoning was reported. In addition to the central nervous system lesion, intestinal obstruction and lower limb thrombosis were also found. In the treatment of carbon monoxide poisoning patients, the clinician was able to treat the common complications, attention should be paid to gastrointestinal tract, thrombotic disease and other rare complications, so as to avoid missed diagnosis.

Clinical significance of bispectral index monitoring in patients with acute severe carbon monoxide poisoning / 中华劳动卫生职业病杂志

Objective: To analyze the correlation of bispectral index (BIS) with the prognosis of patients with acute severe carbon monoxide poisoning (ASCMP) and its predictive value of adverse outcomes. Methods: In March 2021, 106 ASCMP patients who were treated in Harrison International Peace Hospital Affiliated to Hebei Medical University from January 2019 to December 2020 were taken as research objects. All patients underwent 24-hour BIS monitoring after admission, and were divided into good prognosis group (n=75) and poor prognosis group (n=31) according to the prognosis of the patients' cranial nerve function after 60 d. The general conditions, Acute Physiology and Chronic Health Evaluation Ⅱ (APACHEⅡ) score, Glasgow Coma Scale (GCS) score at admission and 24-hour BIS mean were compared between the two groups. Pearson correlation analysis was used to analyze the correlations between the 24-hour BIS mean and GCS score at admission, APACHEⅡ score and coma time. The receiver operating characteristic (ROC) curve was drawn to analyze the predictive value of 24-hour BIS mean, GCS score at admission, APACHEⅡ score and coma time on adverse outcome of ASCMP patients. Results: The coma time and APACHEⅡ score of the patients in the poor prognosis group were significantly higher than those in the good prognosis group, the GCS score at admission and 24-hour BIS mean were significantly lower than those in the good prognosis group (P<0.05) . Pearson correlation analysis showed that the 24-hour BIS mean was positively correlated with the GCS score at admission, and negatively correlated with the APACHEⅡ score, coma time (r=0.675, -0.700, -0.565, P<0.001) . The 24-hour BIS mean had the highest predictive value for adverse outcome of ASCMP patients, with a cut-off value of 74, the area under the curve was 0.883 (95%CI: 0.814-0.951, P<0.001) , and the sensitivity and specificity were 73.3% and 87.1%, respectively. Conclusion: The 24-hour BIS mean has a good correlation with the acute brain nerve injury, the severity of the disease and coma time of patients with ASCMP. And it has a high predictive value for the adverse outcome in patients with ASCMP.

Application value of BIS and S100β combined with Copeptin in patients with acute severe carbon monoxide poisoning / 中华劳动卫生职业病杂志

Objective: To explore the application value of bispectral index(BIS) , specific protein 100β(S100β) combined with Copeptinin patients with acute severe carbon monoxide poisoning (ASCMP). Methods: A total of 256 patients with acute carbon monoxide poisoning admitted to Hengshui People's Hospital from June 2018 to June 2020 were collected, and they were divided into 30 mild cases, 40 moderate cases and 186 severe cases according to the degree of poisoning. Among them, patients with severe carbon monoxide poisoning were divided into a poor prognosis group (20 cases) and a good prognosis group (166 cases) according to whether adverse events occurred. The changes of creatine kinase isoenzyme (CK-MB) , N-terminal precursor B-type brain natriuretic peptide (NT-proBNP) , BIS, S100β, and Copeptin in poisoned patients were measured. Logistic regression analysis and receiver operating characteristic (ROC) curve were used to evaluate the significance of relevant indicators for ASCMP patients. Results: Compared with the mild-to-moderate group, CK-MB, NT-proBNP, S100β, Copeptin increased, and BIS value decreased in the severe group (P< 0.05). 24 hours after admission, compared with the good prognosis group, CK-MB, NT-proBNP, S100β, Copeptin in the poor prognosis group increased, and the BIS value decreased (P<0.05). In the poor prognosis group, CK-MB, NT-proBNP, S100β, and Copeptin at 72 hours after admission were all lower than those at 24 hours after admission, and the BIS value was higher than that at 24 hours after admission (P<0.05). Logistic regression analysis showed that ASCMP patients with increased S100β, Copeptin, and decreased BIS values had an increased risk of adverse events (P<0.05). The ROC curve showed that the area under the curve of the combined detection of BIS, S100β and Copeptin was 0.859, which had a great predictive value for the prognosis of ASCMP patients. Conclusion: BIS, S100β combined with Copeptin detection is of great value for early assessment of ASCMP disease and prognosis prediction.

Intoxicación aguda con monóxido de carbono (ICO) secundaria a pipa de agua (Narguile). Reporte de un caso / Carbon monoxide poisoning caused by water pipe smoking (Narghile). A case report

Resumen Dentro de las formas alternativas de consumo de tabaco, se describe el uso de pipas de agua (también llamadas hookah, shisha o narguile) como implementos de uso. Esta forma de uso es una forma emergente en nuestro medio, con uso en estudiantes universitarios y secundarios. Debido a que utiliza carbón para quemar el tabaco, junto a largos períodos de uso, presenta riesgo de intoxicación por monóxido de carbono, especialmente si se utiliza en ambientes cerrados. En este artículo presentamos el caso de una paciente femenina de 19 años, quién fue traída al hospital con una intoxicación grave por monóxi do de carbono secundaria a uso de pipa de agua, requiriendo tratamiento con oxígeno en cámara hiperbárica. Realizamos una revisión de la bibliografía.

Abstract Amongst the alternative ways of tobacco use, water pipes (also called hookah, shisha or narghile) have been used as implements. This type of use is an emergent one in our environment, being used by high school and college students. Due to the use of charcoal as a way to burn the tobacco, and the long using times it presents, the users are at risk of being poisoned by carbon monoxide, especially if they smoke in enclosed spaces. In this paper, we present the case of a 19-year-old female patient, who was brought to the hospital with a severe case of carbon monoxide poisoning, requiring treatment with oxygen in a hyperbaric chamber. We make a review of the literature.

Escenarios de exposición a monóxido de carbono que orientan la sospecha clínica de intoxicación aguda / Carbon monoxide exposure scenarios that may guide a clinical suspicion of severe poisoning / Cenários de exposição ao monóxido de carbono que orientam a suspeita clínica de envenenamento agudo

Resumen: El monóxido de carbono (CO) se acumula en ambientes interiores cuando hay combustión y no es perceptible. Los síntomas de intoxicación son inespecíficos, por lo que las circunstancias en las que ocurre la intoxicación pueden ser orientadoras para el diagnóstico. Objetivo: fortalecer capacidades clínicas para sospechar y confirmar intoxicaciones por CO. Método: estudio descriptivo transversal de los casos sospechosos (pacientes con síntomas neurológicos o digestivos en los que se identifica una fuente de combustión en ambiente interior) consultados en el Centro de Información y Asesoramiento Toxicológico en 2017. Resultados: fueron 111 casos, de los cuales 52 ocurrieron en 22 episodios de exposición colectiva. Los menores de 15 años fueron 37/111 y el porcentaje de niños que se identificó en intoxicaciones colectivas (23/37) es significativamente mayor que en adultos. En el período invernal ocurrieron 67/111, siendo la temperatura mínima media de 9,3 ºC. Los equipos a combustión involucrados con mayor frecuencia fueron los calefones a gas, seguidos de las estufas a gas. El síntoma inicial más frecuente fue la cefalea. La media de la carboxihemoglobina (COHb) fue de 14,7%. Los casos severos (45/111) se correlacionaron significativamente con la exposición a CO de un calefón a gas. Conclusiones: la tasa de intoxicación es baja comparada con países de similar latitud, lo que plantea la posibilidad de un subdiagnóstico. La temperatura mínima ambiental por debajo de 10 °C, la permanencia en espacios con calefacción a combustión y el uso de calefón a gas fueron los escenarios típicos de la intoxicación. La cefalea es un síntoma clave para investigar la exposición. La sospecha diagnóstica puede ser menor cuando se trata de casos individuales, sobre todo en niños.

Summary: Carbon monoxide accumulates in closed environments when there is unnoticed combustion. Signs of poisoning are non-specific, and thus circumstances around poisoning may constitute a diagnostic guide. Objective: to strengthen the clinical capacities to suspect and confirm carbon monoxide poisoning. Method: descriptive, transversal study of suspicious cases (patients with neurological or digestive symptoms for which an indoor combustion source is identified) who consulted at the Poisoning Center in 2017. Results: 111 cases were included in the study, 52 of which occurred in 22 episodes of collective exposure. 37 patients were under 15 years old and the percentage of children identified in collective poisoning (23/37) was significantly greater than the one representing adults. 67 cases occurred in winter, minimum average temperature being 9.3°C. The combustion equipment most frequently involved in poisoning events were gas-fired water heaters in the first place, followed by gas stoves. The most frequent initial symptom was headache. Average COHb was 14.7%. Severe cases (45/111) were significantly corelated to carbon monoxide exposure from gas-fired water heaters. Conclusions: the poisoning rate is low when compared to countries in a similar latitude, what suggests the possibility of under-diagnosis. Minimum environment temperature under 10°C, staying in spaces with combustion-based heating and the use of gas-fired water heaters were the typical poisoning scenarios. Headache is a key symptom to search for exposure. The diagnostic suspicion may be lower when it involves individual cases, mainly in children.

Resumo: O monóxido de carbono (CO) se acumula em ambientes fechados quando há combustão e não é perceptível. Os sintomas de envenenamento são inespecíficos, portanto, as circunstâncias em que ocorre o envenenamento podem orientar o diagnóstico. Objetivo: fortalecer as capacidades clínicas para suspeitar e confirmar envenenamento por monóxido de carbono. Método: estudo descritivo transversal de casos suspeitos (pacientes com sintomas neurológicos ou digestivos em que uma fonte de combustão é identificada em ambiente interno) consultados no CIAT em 2017. Resultados: foram identificados 111 casos, dos quais 52 ocorreram em 22 episódios de exposição em grupo. Trinta e sete eram menores de 15 anos sendo que a porcentagem de crianças que foram identificadas em intoxicações coletivas (23/37) é significativamente maior do que em adultos. No "período de inverno", com temperatura média mínima de 9,3ºC, ocorreram 67 casos. Os equipamentos de combustão mais frequentemente envolvido foram aquecedores de água a gás, seguidos de fogões a gás. O sintoma inicial mais frequente foi cefaleia. O COHb médio foi de 14,7%. Os casos graves (45/111) foram significativamente correlacionados com a exposição ao CO de um aquecedor de água a gás. Conclusões: o índice de intoxicações é baixo quando comparado a países de latitude semelhante, o que indica a possibilidade de subdiagnóstico. A temperatura ambiente mínima abaixo de 10 ° C, a permanência em ambientes com aquecimento a combustão e o uso de aquecedores a gás foram os cenários típicos de intoxicação. A cefaleia é um sintoma chave para investigar a exposição. A suspeita diagnóstica pode ser menor quando se trata de casos individuais, principalmente em crianças.

Relación Dosis de oxígeno-Celeridad en la oxigenación hiperbárica para intoxicación con monóxido de carbono / Oxygen Dose-Implementation Celerity relationship in hyperbaric oxygenation for carbon monoxide poisoning

Resumen Se realiza una revisión narrativa que plantea una reflexión acerca del rol de la oxigenación hiperbárica en la recuperación de los intoxicados con monóxido de carbono (ICO). La relación presión de tratamiento de oxigenación hiperbárica (TOHB), o sea dosis de oxígeno, y demora en su implementación son descriptas en esta revisión. Se presentan 9 casos de pacientes con ICO tratados con TOHB a 1,45 ATA (Atmósferas absolutas) por falta de acceso a TOHB de alta presión. Si bien es necesario investigación adicional, sugerimos que esta modalidad terapéutica a 1,45 ATA para ICO debe ser elegida frente al oxígeno normobárico, y considerada cuando las instalaciones de alta presión no están disponibles a distancias razonables.

Abstract A narrative review that raises a reflection about the role of hyperbaric oxygenation in the recovery of monoxide carbon (CO) poisoning is carried out. A description of the relationship of the pressure of hyperbaric oxygen therapy (HBOT), oxygen dosage, and the delay in its implementation was done. Nine cases of intoxications treated with HBOT at 1.45 ATA due to lack of access to high-pressure HBOT were presented. While additional research is necessary, we suggest that this therapeutic modality at 1.45 ATA (Absolute Atmospheres) should be chosen instead of normobaric oxygen therapy for CO poisoning, and considered when high pressure facilities are not available at reasonable distances.

Ceguera y trastornos neurológicos por monóxido de carbono: tratamiento efectivo con oxígeno hiperbárico en dos pacientes pediátricos / Blindness and neurological sequelae following carbon monoxide poisoning: effective treatment with hyperbaric oxygen

Se presentan dos pacientes que desarrollaron deterioro visual debido a una intoxicación por monóxido de carbono. Ellos fueron tratados con oxígeno hiperbárico y recuperaron no solo su visión, sino que, además, mejoraron su signo-sintomatología neurológica. Se cree que la implementación de oxígeno hiperbárico, incluso en un período tardío, será efectiva para revertir las secuelas neurológicas.

We present two patients who developed visual deterioration due to carbon monoxide poisoning. They were treated with hyperbaric oxygen and recovered not only their vision but also they improved neurological signs and symptoms. We believe that implementation of hyperbaric oxygen, even in a late period of time will be effective in reversing neurological sequela

Bocio multinodular tóxico por intoxicación con monóxido de carbono / Toxic multinodular goiter due to poisoning by carbon monoxide

RESUMEN Paciente masculino de 53 años con antecedentes de alergia, trabajador artesanal que realiza serigrafías, con alta exposición a productos químicos que, al someterse a altas temperaturas desprenden gran cantidad de vapor. Acude a consulta refiriendo que desde aproximadamente 2 meses antes presenta decaimiento con calambres musculares, palpitaciones, enrojecimiento de la cara y, aumento de tamaño de la glándula tiroides. Se diagnostica un bocio multinodular tóxico, por cifras hormonales elevadas. Se realiza ultrasonido de tiroides que informa bocio multinodular, una biopsia por aspiración con aguja fina, con atipia de significado incierto, y lesión folicular del tiroides. Se separa de su centro de trabajo y se logra revertir la sintomatología a los 15 días del tratamiento. Frecuentemente aparecen enfermedades asociadas a intoxicaciones por químicos y medicamentos, donde la presencia de hipertiroidismo no es habitual. Se requiere una anamnesis exhaustiva y exámenes complementarios específicos para un diagnóstico y tratamiento adecuados(AU)

ABSTRACT 53 years old male patient with a history of allergy; he works as a craft worker (producing serigraphs) very exposed to chemicals, which when subjected to high temperatures emit large amount of steam. The patient attends to the consultation referring that from approximately 2 months before he has been presenting weakness with muscle cramps, palpitations, flushing of the face and, increase in the size of the thyroid glands. It is diagnosed by the high hormonal figures a toxic multinodular goiter. Thyroid ultrasound is performed that shows multinodular goiter; it is also conducted a biopsy by fine-needle aspiration resulting in atypia of uncertain significance, and follicular lesion of the thyroid. The patient was separated from his workplace and there were reversed the symptoms after 15 days of treatment. Frequently appear diseases associated to poisonings caused by chemicals and medicines, where the presence of hyperthyroidism is not usual. It requires a comprehensive anamnesis and complementary tests that are specific for a proper diagnosis and treatment(AU)

Risk of late appearance of acute myocardial infartion after carbon monoxide (CO) intoxication / Riesgo de aparición de infarto agudo de miocardio en el largo plazo después de una intoxicación por monóxido de carbono (CO)

ABSTRACT Background: After acute carbon monoxide intoxication, there may be a higher risk for late adverse cardiac events. However, these patients are usually not followed to monitor the appearance of these effects. Aim: To follow patients seen at an emergency department for carbon monoxide intoxication, monitoring the appearance of myocardial infarction. To assess the predictive value for such complication of serum troponin, carboxyhemoglobin, and procalcitonin levels at the moment of intoxication. Material and Methods: We followed 237 patients receiving emergency care for carbon monoxide intoxication, with a serum carboxyhemoglobin of 5% or more, between 2010 and 2012. Levels of procalcitonin and troponin I were measured. Patients were followed for five years after the intoxication. Results: During the follow up period, 35 patients had a myocardial infarction. These patients had significantly higher carboxyhemoglobin, procalcitonin and troponin I levels at the moment of the intoxication than their counterparts who did not had a myocardial infarction in the follow up. A logistic regression analysis showed that age, carboxyhemoglobin levels, procalcitonin, troponin 1 and length of CO exposure were associated with a higher risk of myocardial infarction. Procalcitonin, troponin and carboxyhemoglobin levels had a high sensitivity and specificity to predict the appearance of myocardial infarction, with high areas under the receiver operating characteristic (ROC) curves. Conclusions: In patients with CO intoxication, carboxyhemoglobin, troponin and procalcitonin levels at the moment of the intoxication are significant predictors of the late appearance of myocardial infarction.

Antecedentes: Después de una intoxicación con monóxido de carbono, hay un mayor riesgo de desarrollar problemas cardiovasculares a largo plazo. Sin embargo, estos pacientes no son seguidos habitualmente para evaluar la aparición de estos eventos. Objetivo: Efectuar un seguimiento de pacientes que han sufrido una intoxicación con CO, evaluando la aparición de infarto del miocardio. Evaluar el valor de los niveles de troponina, carboxihemoglobina y procalcitonina para predecir la aparición de estos eventos. Material y Métodos: Seguimos 237 pacientes que fueron atendidos de urgencia por una intoxicación con CO, con niveles de carboxihemoglobina de 5% o más, entre 2010 y 2012. Se midieron los niveles de procalcitonina, troponina 1 y carboxihemoglobina y los pacientes fueron seguidos por cinco años después de la intoxicación. Resultados: Durante el seguimiento, 35 pacientes tuvieron un infarto al miocardio. Estos pacientes tenían niveles significativamente más altos de procalcitonina, troponina 1 y carboxihemoglobina al momento de la intoxicación, que los pacientes que no tuvieron un infarto durante el seguimiento. Una regresión logística mostró que la edad, carboxihemoglobina, procalcitonina, troponina y la duración de exposición a CO se asociaron a un mayor riesgo de infarto. Procalcitonina, troponina 1 y carboxihemoglobina tuvieron una alta sensibilidad y especificidad para predecir la aparición de infarto, con áreas bajo la curva ROC (receiver operating characteristic) elevadas. Conclusiones: En pacientes con intoxicación por CO, la carboxihemoglobina, procalcitonina y troponina son predictores significativos de la aparición de infarto agudo de miocardio en el largo plazo.

Intoxicación por monóxido de carbono / Carbon monoxide poisoning

Introducción: A nivel mundial, existe un incremento de las intoxicaciones por monóxido de carbono recibidas en los servicios de urgencia. En Cuba no es frecuente este tipo de intoxicación y existe desconocimiento para su diagnóstico precoz. El monóxido de carbono es un gas inodoro, incoloro, no irritante a las mucosas y altamente tóxico para el hombre. Es un contaminante de la atmósfera terrestre y el agente causal más frecuente de la intoxicación por gases. Objetivo: Describir la intoxicación por monóxido de carbono en un paciente atendido en el Hospital Militar;Dr. Mario Muñoz Monroy de Matanzas, Cuba. Caso clínico: Paciente masculino de 19 años de edad que inhala en un área cerrada, de forma accidental, los gases de la combustión de un vehículo durante 30 minutos. Permaneció en el lugar de la exposición sin medios de protección individual por un período de tres horas y comenzó con síntomas correspondientes a una intoxicación moderada por monóxido de carbono. Ingresó en la sala de cuidados intermedios para tratamiento. Conclusiones: El paciente tuvo una evolución favorable, tratado con oxígeno normobárico e hiperbárico(AU)

Introduction: Worldwide, there is an increase in poisonings by carbon monoxide received in emergency services. In Cuba this type of intoxication is not frequent and there is ignorance for its early diagnosis. Carbon monoxide is an odorless, colorless gas, not irritating to mucous membranes and highly toxic to man. It is a pollutant of the Earth's atmosphere and the most frequent causative agent of gas poisoning. Objective: To describe carbon monoxide poisoning in a patient treated at the Military Hospital Dr. Mario Muñoz Monroy from Matanzas, Cuba. Clinical case: A 19-year-old male patient inhaled in a closed area, accidentally, the combustion gases of a vehicle for 30 minutes. He remained in the place of exposure without means of individual protection for a period of three hours and began with symptoms corresponding to moderate intoxication by carbon monoxide. He was admitted at intermediate care ward for treatment. Conclusions: The patient had a favorable evolution, treated with normobaric and hyperbaric oxygen(AU)

Evaluation of the efficacy of acupuncture combined with hyperbaric oxygen on delayed neuropathological sequelae after carbon monoxide poisoning by using mTI-ASL imaging / 中国针灸

OBJECTIVE@#Quantitative assessment of white blood flow in semi-oval center of patients with delayed neuropathological sequelae (DNS) after carbon monoxide poisoning treated with acupuncture combined with hyperbaric oxygen (HBO) based on magnetic resonance multi-inversion time arterial spin labeling imaging (mTI-ASL), and to evaluate its efficacy indirectly.@*METHODS@#Twenty-six patients with clinically diagnosed DNS were randomly divided into an observation group (13 cases) and a control group (13 cases). The conventional therapy combined with HBO were given in the control group. In the observation group,on the base of the treatment, acupuncture was applied, the main acupoints were Shuigou (GV 26), Neiguan (PC 6), Baihui (GV 20), Shangxing (GV 23), Yintang (GV 29), Sanyinjiao (SP 6) on the affected side, Sishencong (EX-HN 1), Fenglong (ST 40), Lianquan (CV 23) and Jinjin (EX-HN12) for slurred speech, Jianyu (LI 15), Waiguan (TE 5) and Shousanli (LI 10) for upper limb pain, Huantiao (GB 30), Yanglingquan (GB 34), Yinlingquan (SP 9) for lower limb pain, the treatment was given once every day, 5 days as one course, with an interval of 2 days between the course. The treatment for 6 courses was required. The conventional head MR scan, mTI-ASL and diffusion tensor imaging (DTI) scans before and 1 week after treatment were adopted, Matlab (R2014b), Mricron and Syngo.via software were adopted to measure the cerebral blood flow (CBF) and anisotropy (FA) values of the semi-oval center. The correlation between the parameters was evaluated by Pearson method. And the simple intelligent mental state examination scale (MMSE) was uesd to assess cognitive function.@*RESULTS@#After treatment, the CBF, MMSE scores in both groups and FA values in the observation group were higher than those before treatment (<0.05). After treatment, the CBF, FA and MMSE scores in the observation group were significantly higher than those in the control group (<0.05). There was a positive correlation between CBF, FA and MMSE scores (<0.05), and the correlation between CBF and MMSE was the best ( =0.822).@*CONCLUSION@#Acupuncture combined with hyperbaric oxygen can significantly improved early white matter hypoperfusion and improved cognitive function score in patients with DNS. The curative effect is better than that of hyperbaric oxygen therapy alone. The mTI-ASL imaging can quantitatively evaluate its curative effect.

An MRI-Based Quantification for Correlation of Imaging Biomarker and Clinical Performance in Chronic Phase of Carbon Monoxide Poisoning

PURPOSE: The purpose of this study was to determine the relation between quantitative magnetic resonance imaging biomarkers, and clinical performances in chronic phase of carbon monoxide intoxication. MATERIALS AND METHODS: Eighteen magnetic resonance scans and cognitive evaluations were performed, on patients with carbon monoxide intoxication in chronic phase. Apparent diffusion coefficient (ADC) ratios of affected versus unaffected centrum semiovale, and corpus callosum were obtained. Signal intensity (SI) ratios between affected centrum semiovale, and normal pons in T2-FLAIR (fluid-attenuated inversion recovery) images were obtained. The Mini-Mental State Exam, and clinical outcome scores were assessed. Correlation coefficients were calculated, between MRI and clinical markers. Patients were further classified into poor-outcome and good-outcome groups based on clinical performance, and imaging parameters were compared. T2-SI ratio of centrum semiovale was compared, with that of 18 sex-matched and age-matched controls. RESULTS: T2-SI ratio of centrum semiovale was significantly higher in the poor-outcome group, than that in the good-outcome group and was strongly inversely correlated, with results from the Mini-Mental State Exam. ADC ratios of centrum semiovale were significantly lower in the poor outcome group than in the good outcome group, and were moderately correlated with the Mini-Mental State Exam score. CONCLUSION: A higher T2-SI and a lower ratio of ADC values in the centrum semiovale, may indicate presence of more severe white matter injury and clinical impairment. T2-SI ratio and ADC values in the centrum semiovale, are useful quantitative imaging biomarkers for correlation with clinical performance in individuals with carbon monoxide intoxication.

Aplicaciones médicas de las cámaras de oxigenación hiperbárica de nueva generación / Medical applications of new generation hyperbaric oxygenation chambers

El uso clínico de la terapia de oxigenación hiperbárica (TOHB) consiste en respirar oxígeno en una concentración cercana al 100% en una cámara presurizada al menos a 1,4 atmósferas absolutas (atm). TOHB actúa produciendo hiperoxia y especies reactivas del oxígeno que desencadenan mecanismos bioquímicos variados. Se presenta una revisión de todas las nuevas aplicaciones emergentes de TOHB en varias especialidades médicas debido a que alcanza beneficios en la cicatrización de heridas, enfermedades inflamatorias y con componente neurológico o isquémico. Las nuevas cámaras realizan el tratamiento a presiones más seguras y con la misma eficiencia demostrada por métodos matemáticos y bioquímicos. El Grupo BioBárica Clinical Research presenta la estadística de las indicaciones en 559 pacientes tratados con estas cámaras en algunos centros médicos y las especialidades médicas implicadas. El uso de TOHB a media presión está en emergencia y podría proveer a futuro evidencia de su efectividad en otras especialidades médicas. (AU)

The clinical use of Hyperbaric Oxygen Therapy (HBOT) consists in breathing oxygen (O2) near to 100% in a pressurized chamber of at least at 1.4 absolute atmospheres (ATA). HBOT acts producing both hyperoxia and reactive oxygen species (ROS) and triggers others biochemical events. The BioBarica Clinical Research Group is developing clinical evidence in diverse pathologies because of accessibility and safety of the new Revitalair hyperbaric oxygen chamber. Because of working at "mild pressure", HBOT performed by these chamber are safer demonstrated by mathematical and biochemical methods. The BioBarica Clinical Research Group presents the statistics of the indications in 559 patients treated with these cameras in some medical centers and the medical specialties involved. Their accessibility to the physicians would become mild pressure HBOT used more frequently proving its effectiveness in other clinical specialties. (AU)