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)

Value of three hemolysis tests and carboxyhemoglobin in the diagnosis of hemolytic disease of the fetus and newborn / 中国输血杂志

【Objective】 To investigate the value of three hemolysis tests and carboxyhemoglobin (COHb) level in the diagnosis of hemolytic disease of the fetus and newborn (HDFN). 【Methods】 From January 1, 2019 to December 31, 2022, the neonates hospitalized in the Department of Neonatology of Hebei Provincial Children's Hospital with suspected hemolytic disease who had serological testing were retrospectively enrolled in the study. They were distributed into HDFN group and non-HDFN group according to the final diagnosis. Their clinical and laboratory data were collected and analyzed, and the COHb level was detected by blood gas analyzer. 【Results】 A total of 378 neonates with HDFN and 217 neonates without HDFN were included in the study. Most of the neonates in HDFN group were full-term infants (348/378, 92.1%), with median gestational age of 39.1 (38.3, 40.0) weeks. Three hundred and fifty-four cases (354/378, 93.7%) were ABO-HDFN and the rest were Rh HDFN. There were significant differences in the level of serum total bilirubin, hemoglobin, COHb and reticulocyte percentage at admission between the two groups(P<0.05). The positive rate of three hemolysis tests in HDFN group decreased with the increase of the days after birth. The highest positive rate (more than 80%) was observed within 2 days after birth. Correlation analysis showed a negative relationship between the COHb level and the age (rs = -0.434, P<0.001) . Among the three hemolysis tests in HDFN group, the positive rate of antibody release test was the highest (69.0%), followed by the free antibody test (55.6%) and the direct antiglobulin test (DAT) (36.0%). Receiver operating characteristic (ROC) curve analysis showed that the optimal cut-off value of COHb was 1.15%.The sensitivity of COHb ≥ 1.15% was 51.8%, higher than single DAT (36.0%) . The diagnosis effectiveness of three hemolysis tests couldn't be improved when combined with COHb detection(Z = -0.727, P>0.05) . 【Conclusion】 The three hemolysis tests are important in the diagnosis of HDFN, among which the antibody release test has the highest sensitivity. COHb has certain value for the diagnosis of HDFN, but joint testing cannot improve the diagnosis effectiveness of three hemolysis tests. Hemolysis tests and/or COHb detection should be conducted for neonates at risk of hemolysis as early as possible after birth.

Quemadura por inhalación de humo e intoxicación por monóxido de carbono en paciente pediátrico

Introducción: El monóxido de carbono es uno de los mayores contaminantes de la atmósfera terrestre, su toxicidad es bien conocida por el ser humano. Las fuentes productoras responsables de aproximadamente 80 % de las emisiones de monóxido de carbono son los vehículos automotores que utilizan como combustible gasolina o diesel, los procesos industriales que utilizan compuestos del carbono y el fuego dentro de los hogares. Sus efectos tóxicos agudos incluida la muerte se han estudiados ampliamente, no así sus potenciales efectos adversos a largo plazo. Objetivo: Describir el comportamiento de la intoxicación aguda por monóxido de carbono en paciente pediátrico, su diagnóstico y tratamiento. Presentación del caso: paciente de 11 años de edad que sufre intoxicación aguda por monóxido de carbono. Ingresa en el Hospital Universitario procedente del primer nivel de atención médica como urgencia vital. Se estabiliza e identifican las alteraciones multisistémicas producidas por lesiones asociadas con la inhalación de humo y gases tóxicos en espacios cerrados. Se determina su correcto tratamiento. Conclusiones: La forma más pertinente de disminuir la morbilidad y la mortalidad en pacientes como el que se presenta, se basa en dos pilares: la correcta identificación y el acertado manejo para cada intoxicación. La aplicación de estos dos aspectos puede lograr un factor protector. Hay subregistro de la ocurrencia de los casos de intoxicación por monóxido de carbono que no son atendidos en los servicios de salud y de los que producen la muerte inmediata, por lo que es importante su diagnóstico y tratamiento oportuno.

Introduction: Carbon monoxide is one of the largest pollutants in the Earth's atmosphere, its toxicity is well known to humans. The producing sources responsible for approximately 80% of carbon monoxide emissions are motor vehicles that use gasoline or diesel as fuel, industrial processes that use carbon compounds and fire inside homes. Its acute toxic effects including death have been studied extensively, but its potential long-term adverse effects have not been studied. Objective: To describe the behavior of acute carbon monoxide poisoning in pediatric patients, their diagnosis and treatment. Case presentation: 11-year-old patient suffering from acute carbon monoxide poisoning. He is admitted to the University Hospital from the first level of medical care as a vital emergency. Multisystem alterations caused by lesions associated with the inhalation of smoke and toxic gases in enclosed spaces are stabilized and identified. Its correct treatment is determined. Conclusions: The most pertinent way to reduce morbidity and mortality in patients such as the one presented is based on two pillars: correct identification and correct management for each poisoning. The application of these two aspects can achieve a protective factor. There is underreporting of the occurrence of cases of carbon monoxide poisoning that are not treated in health services and those that cause immediate death, so their detection, diagnosis and timely treatment is important.

Carboxyhemoglobinemia as a laboratory finding in an outpatient

Resumen El monóxido de carbono (CO) es un gas producido principalmente por combustión incompleta de hidrocarburos. La intoxicación por exposición ambiental puede presentarse con síntomas inespecíficos y constituye la causa más importante de aumento de carboxihemoglobina (COHb). Su nivel en sangre depende de la duración de la exposición, la ventilación minuto y las concentraciones de CO y oxígeno en el ambiente. La elevada toxicidad radica en la hipoxia tisular que se genera. Se presenta el caso de un paciente masculino, 73 años, en seguimiento en el hospital por neumonía intersticial no específica como patología de base. En un control de laboratorio se encontró 11,9% de COHb, sin exposición a tabaco. No utilizaba calefacción a gas sino un panel cerámico eléctrico, recientemente pintado con esmalte sintético. La suspensión del uso del panel normalizó la COHb. El CO, producto de descomposición térmica del esmalte sintético, explica la causa de la intoxicación.

Abstract Carbon monoxide (CO) is a gas produced mainly by incomplete combustion of hydrocarbons. Poisoning from environmental exposure can present with nonspecific symptoms and is the most important cause of increased carboxyhemoglobin (COHb). Its blood level depends on the duration of exposure, minute ventilation, and the concentrations of CO and oxygen in the environment. The high toxicity lies in the tissue hypoxia that is generated. The case of a male patient, 73 years old, under follow-up in the hospital for non-specific interstitial pneumonia as the underlying pathology was presented. In a laboratory control, COHb 11,9% was found. There was no exposure to tobacco and there was no use of gas heating but of an electric ceramic panel, recently painted with synthetic enamel type paint. The suspension of the use of the panel normalised the COHb. The CO product of thermal decomposition of synthetic enamel explains the cause of poisoning.

Resumo O monóxido de carbono (CO) é um gás produzido principalmente pela combustão incompleta de hidrocarbonetos. A intoxicação por exposição ambiental pode se apresentar com sintomas inespecíficos e é a causa mais importante de aumento da carboxihemoglobina (COHb). Seu nível em sangue depende do tempo de exposição, da ventilação minuto e das concentrações de CO e oxigênio no ambiente. A alta toxicidade está na hipóxia tecidual gerada. Apresentamos o caso de um paciente do sexo masculino, 73 anos, em acompanhamento hospitalar por pneumonia intersticial inespecífica como patologia de bas. Em um controle laboratorial, achou-se 11,9% de COHb, sem exposição ao tabaco. Não utilizava aquecimento a gás e sim um painel elétrico cerâmico, recentemente pintado com esmalte sintético. A suspensão do uso do painel normalizou o COHb. O CO produto da decomposição térmica do esmalte sintético explica a causa da intoxicação.

Study on preparation of poly-Carboxyhemoglobin by glutaraldehyde crosslinking / 中国输血杂志

【Objective】 To investigate the preparation conditions of hemoglobin-based oxygen carrier (HBOC) at room temperature without oxygen isolation and the quality of poly-COHb. 【Methods】 Using human cord blood hemoglobin as raw material and glutaraldehyde as crosslinking agent, the experimental group selected hemoglobin concentration, glutaraldehyde to COHb molar ratio, reaction time and reaction temperature to do four factors and three levels of orthogonal test (n=3), to determine the best matching conditions and prepare three batches of poly-COHb, continuously.In the control, 3 batches of poly-Hb were prepared under low temperature and oxygen isolation.The contents of superlarge molecules, degree of polymerization, average molecular weight, methemoglobin and P50 of crosslinked products were compared between the two groups. 【Results】 The optimal matching conditions of poly-COHb were as follows: [Hb] 70g/L, the molar ratio of glutaraldehyde to COHb was 11∶1, the reaction time was 60 min, and the reaction temperature was 25℃.Comparison of poly-COHb and poly-Hb: The superlarge molecular content (%) was 0.67±0.51 vs 0.60±0.01 (P>0.05); degree of polymerization (%) and average molecular weight (kD) were 84.25±0.99 vs 54.16±5.12, and 235.27±13.50 vs 97.62±6.57, respectively.(P<0.05); methemohemoglobin ratio (%) was 2.40±0.66 vs 2.47±0.46 (P>0.05); P50 (mmHg) was 6.37±0.30 vs 14.20±1.09 (P<0.05). 【Conclusion】 Poly-COHb can be prepared at room temperature without oxygen isolation.Compared with poly-Hb, poly-COHb prepared under the experimental conditions can improve the polymerization degree and average molecular weight, and greatly reduce the difficulty of preparation.

Caracterización de la función cardiorrespiratoria y su relación con el estrés oxidativo en mujeres expuestas al humo de leña residentes de gran altura (3850 m s. n. m.)

Objetivo: Caracterizar la función cardiorrespiratoria y el estado oxidativo consecuente a la exposición al humo de leña en mujeres que viven a gran altura (3850 m s.n.m.). Materiales y métodos: Estudio observacional serie de casos. Se exploró la función cardiorrespiratoria y se cuantificó la concentración sérica de malondialdehido (MDA) y carboxihemoglobina (COHb) como marcadores de estrés oxidativo. Se determinaron medidas de tendencia central y de dispersión. Se aplicaron métodos estadísticos de asociación y correlación. Resultados: Se estudiaron a 60 participantes, de las cuales, 50,00 % presentó clínica de enfermedad cardiaca; 25,00 %, clínica de enfermedad respiratoria. El 45,00 % de las espirometrías fueron normales; 37,67 % mostraron disminución del volumen espiratorio forzado en un segundo (VEF₁), del índice de permeabilidad bronquial central (VEF₁/CVF) y/o de los flujos aéreos periféricos (FEF25-75); 8,33 %, disminución VEF₁/CVF; 3,33 %, disminución del FEF25-75; 1,67 %, disminución de la capacidad vital forzada (CVF), y 5,0 %, disminución de dos o más parámetros. El 60,00 % de los electrocardiogramas eran normales, en 36,67 % se encontró diferentes trastornos de la conducción intraventricular, y en 3,33 % datos de corazón dextrorotado. El 81,67% de las ecocardiografías mostraba algún tipo de alteración: 73,33 % evidenciaron insuficiencias valvulares; un 20,00 % presentó, además de esta condición, hipertensión arterial; mientras que el 67,67 %, dimensión aumentada del ventrículo derecho. La media de MDA fue de 5,62 µM/L ± 2,06, correlación positiva con la edad (p: 0,029). La mediana de COHb fue de 1,05 % (p25:0,70-p75:1,68). No se encontró diferencia estadísticamente significativa entre la concentración de COHb y las alteraciones espirométricas. Se encontró correlación positiva entre los valores de MDA y el grosor del ventrículo derecho (p: 0,001). Conclusiones: Las diferentes alteraciones de la función cardiorrespiratoria encontradas expresan que tanto la exposición crónica a los derivados del humo de leña como la hipoxia hipobárica son fuentes importantes de radicales libres y que establecen un estado permanente y sostenido de estrés oxidativo, responsable del deterioro progresivo de la función cardiorrespiratoria sin expresión clínica precoz.

Objective: To characterize the cardiorespiratory function and the state of oxidative stress resulting from the exposure to wood smoke in women who live at high altitude (3,850 m a.s.l.). Materials and methods: An observational case-series study. The cardiorespiratory function was analyzed, and the biomarkers of oxidative stress malondialdehyde (MDA) and carboxyhemoglobin (COHb) were quantified. Measures of central tendency and dispersion were determined. The statistical methods of association and correlation were implemented. Results: Sixty (60) patients were included in the research. Fifty percent (50.00 %) of the participants showed clinical evidence of heart disease and 25.00 % had clinical symptoms of respiratory disease. Forty-five percent (45.00 %) of the spirometries revealed normal values. Thirty-six point six seven percent (36.67 %) showed a decrease in the forced expiratory volume in one second (FEV₁), forced expiratory volume in one second/forced vital capacity ratio (FEV₁/FVC) and/or forced expiratory flow 25-75% (FEF25-75). A decrease in FEV₁/FVC, FEF25-75 and FVC occurred in 8.33 %, 3.33 % and 1.67 % of the study participants, respectively. Moreover, a 5.00 % decrease was found in more than two parameters. Sixty percent (60.00 %) of the electrocardiograms revealed normal values, 36.67 % presented an intraventricular conduction disorder and 3.33 % showed dextrorotation of the heart. Eighty-one point six seven percent (81.67 %) of the participants presented an echocardiographic alteration, 73.33% showed valvular insufficiency, 20.00 % presented pulmonary hypertension and 6.67 % had an enlarged right ventricle. The mean MDA was 6 µM/L ± 2, which was positively correlated with the age (p: 0.029). The median COHb accounted for 1.00 % (p25: 0.70 - p75: 1.68). No statistically significant association was found between the COHb concentration and spirometric alterations. A positive correlation was found between MDA values and the right ventricle wall thickness (p: 0.001). Conclusions: The different alterations of the cardiorespiratory function found in the study population show that both chronic exposure to wood smoke derivatives and hypobaric hypoxia are an important source of free radicals and lead to a permanent and sustained state of oxidative stress, which is responsible for the progressive deterioration of the cardiorespiratory function with no early clinical manifestation.

Contaminación del aire y su influencia en la incidencia de enfermedades respiratorias en Santa Elena Ecuador 2020 / Air pollution and its influence on the incidence of respiratory diseases in Santa Elena Ecuador 2020

El uso de combustibles sólidos para cocinar representa el principal riesgo ambiental en América, afectando a 90 millones de personas y causando el fallecimiento de 83.000 personas en el continente en 2016, mientras que en el mundo esta última cifra alcanza más de 4 millones de personas. Al quemar combustibles sólidos como madera, carbón en fogones o estufas se emite monóxido de carbono y elevados niveles de material particulado que quedan suspendidas en el aire. Por su parte, el monóxido de carbono es un reconocido contaminante atmosférico, con gran capacidad para afectar el organismo humano, con propiedades inoloras, incoloras y no irritantes que dificultan su detección. El grado de exposición al monóxido de carbono es evaluado mediante la medición de la saturación de Carboxihemoglobina en sangre, que se determina con técnicas como espectrofotometría de absorción en disolución. Esta investigación se realizó en la comuna de Ayangue, Ecuador, en comedores que continúan la tradición de cocinar en leña como atrayente para los turistas. Se halló una correlación positiva moderada entre el valor promedio de COHb con las horas de la jornada diaria de trabajo (r = 0,674); con el uso de leña o carbón para cocinar en el trabajo (r = 0,537; 88%); y con la presencia de síntomas físicos como el dolor de cabeza (r = 0,616) y náuseas (r = 0,524). Estas alteraciones fisiológicas se presentan durante o inmediatamente después de la jornada de trabajo, según el 88% de los sintomáticos(AU)

The use of solid fuels for cooking represents the main environmental risk in America, affecting 90 million people and causing the death of 83,000 people on the continent in 2016, while in the world this last figure reaches more than 4 million people. Burning solid fuels such as wood, charcoal in stoves or stoves emits carbon monoxide and high levels of particulate matter that are suspended in the air. For its part, carbon monoxide is a recognized atmospheric pollutant, with a great capacity to affect the human organism, with odorless, colorless and non-irritating properties that make it difficult to detect. The degree of exposure to carbon monoxide is evaluated by measuring the saturation of carboxyhemoglobin in blood, which is determined with techniques such as absorption spectrophotometry in solution. This research was carried out in the Ayangue commune, Ecuador, in dining rooms that continue the tradition of cooking on firewood as an attraction for tourists. A moderate positive correlation was found between the average COHb value and the hours of the daily working day (r = 0.674); with the use of firewood or charcoal for cooking at work (r = 0.537; 88%); and with the presence of physical symptoms such as headache (r = 0.616) and nausea (r = 0.524). These physiological alterations appear during or immediately after the work day, according to 88% of the symptomatic ones(AU)

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.

Endtidal carbonmonoxide and carboxyhemoglobin for prediction of significant hyperbilirubinemia in healthy Indian neonates >35 weeks of gestation

Background: Endtidalcarbonmonoxide (ETCOc) and Carboxyhemoglobin (COHB) levels correlate well to bilirubin production and an availability of non-invasive point of care (POC) device in predicting significant hyperbilirubinemia is of great advantage when compared to measurement of serum bilirubin. Objective of the study is to measure a value of ETCOc and COHB in the early neonatal period for the prediction of significant hyperbilirubinemia.Methods: This was the descriptive Cross Sectional Study. ETCOc and COHB were measured 12th hourly for 72 hours followed by TSB in whom the TCB was >14mg/dl. Neonates were classified as jaundiced whose TSB values were in phototherapy range as per AAP Recommendations. Receiver Operative Curves (ROC) were created by appropriate statistical software for ETCOc and COHb to predict significant hyperbilirubinemia. The Sensitivity, Specificity, Positive predictive value, Negative predictive value and likelihood ratios of each was determined and the correlation between ETCOc and COHb levels, ETCOc and TCB, COHB and TCB at different hours of age was evaluated.Results: Among the total 320 infants, 156 of them developed significant hyperbilirubinemia. The ETCOc and COHB level at 60 hours of age was the most predictive of significant hyperbilirubinemia by ROC analysis. ETCOc cut-off of 1.65 ppm at 60 hours of age has a sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio and negative likelihood ratio of 84.6%, 80.5%, 80.5% and 84.6%, 4.33 and 0.19. COHB cut-off of 1.32 ppm at 60 hours of age has a sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio and negative likelihood ratio of 84.6%, 81%, 80% and 84.2%, 4.34 and 0.19.ETCOc had a maximum correlation with COHB at 48 hours of age.Conclusions: An increased level of Endtidalcarbonmonoxide and Carboxyhemoglobin in the early neonatal period is useful as a screening test for prediction of significant hyperbilirubinemia.

Concentração de Monóxido de Carbono Exalado e Carboxihemoglobina por Jovens Universitários Fumantes de Cigarro e Narguilé / Concentration of Exhaled Carbon Monoxide and Carboxyhemoglobin by Young University Smokers of Cigar and Narghile

A Organização Mundial da Saúde (OMS) estima que pelo menos um terço da população mundial adulta utilize o tabaco. Análises comprovam que a fumaça do narguilé contém quantidades superiores de nicotina, monóxido de carbono, tabaco, metais pesados e substâncias cancerígenas comparada à fumaça do cigarro. O objetivo desse estudo foi verificar os valores de monóxido de carbono exalados e carboxihemoglobina entre jovens fumantes de cigarro e fumantes de narguilé. Estudo transversal realizado em um Centro Universitário de Várzea Grande-MT, em novembro de 2017. A amostra por conveniência conteve 50 fumantes de cigarro e 50 fumantes de narguilé com faixa etária entre 18 a 35 anos. Os níveis de monóxido de carbono exalados e carboxihemoglobina foram avaliados pelo equipamento Micro CO (Micro Medical SA). Jovens universitários fumantes de cigarro apresentaram maiores concentrações de monóxido de carbono exalado (COex) e caboxihemoglobina (COHb), mediana 8,0 (±10,6 %), IC95% (8,3-14,2) quando comparado a fumantes de narguilé (p<0,0001). Fumantes de cigarro apresentaram maiores valores de COex e Carboxihemoglobina, podendo este achado ser devido ao fato de estarem expostos ao hábito mais rotineiramente pela facilidade de transporte do cigarro em maço, aumentando o contato com o tabagismo e maior exposição ao monóxido de carbono (CO). Apesar de maiores níveis de CO terem sido encontrados em fumantes de cigarro, o hábito de fumar promove uma exposição contínua a este gás, além de outras substâncias tóxicas provenientes da queima do tabaco e demais componentes, causando danos à saúde do usuário, independentemente, do método usado para inalar o tabaco. (AU).

The World Health Organization (WHO) estimates that at least one third of the world's adult population uses tobacco. Analyzes show that narghile smoke contains higher amounts of nicotine, carbon monoxide, tobacco, heavy metals and carcinogens compared to cigarette smoke. To verify the values of exhaled carbon monoxide and carboxyhemoglobin among young smokers of cigarettes and smokers of narghile. Crosssectional study at a University Center of Várzea Grande, MT, in November 2017. The sample for convenience contained 50 cigarette smokers and 50 smokers of narghileages ranging from 18 to 35 years. The levels of exhaled carbon monoxide and carboxyhemoglobin were evaluated by the Micro CO equipment (Micro Medical SA). Young college students who smoked cigarettes had higher concentrations of exhaled carbon monoxide (COex) and capexhemoglobin (COHb), median 8.0 (± 10.6%), 95% CI (8.3-14.2) when compared to smokers of narghile (p <0.0001). Cigarette smokers presented higher values of COex and Carboxyhemoglobin, which may be because they are exposed to the habit more routinely because of the ease of cigarette carrying in the pack, increasing contact with smoking and increased exposure to carbon monoxide (CO). Although higher levels of CO are found in cigarette smokers, smoking promotes continued exposure to this gas in addition to other toxic substances from tobacco burning and other components, causing harm to the user's health, regardless of the method used to inhale tobacco. (AU).

Impact of environmental pollution on carboxyhemoglobin levels among smoking and non-smoking motorcycle taxi drivers / Impacto da poluição ambiental no nível de carboxihemoglobina entre mototaxistas tabagistas e não tabagistas

Studies related to environmental pollution, carbon monoxide levels and smoking need to be deepened, especially in the case of traffic workers. Therefore, the objective was to verify the association between environmental carbon monoxide and carboxyhemoglobin levels among smoking and non-smoking motorcycle taxi drivers. A longitudinal epidemiological study was carried out with 95 motorcycle taxi drivers with measurement of the environmental carbon monoxide, carboxyhemoglobin in the exhaled air in three moments with interval of six months, between June 2014 and March 2015, as well as sociodemographic and occupational characteristics of these workers. The seasons of the year presented different carbon monoxide averages (p <0.05), with higher levels in the spring and lower in the autumn, while carboxyhemoglobin levels among smokers and non-smokers were high in the winter, fair in the spring and low in the autumn. Statistical differences were observed between subgroups: between autumn and spring for nonsmokers (p = 0.024) and between winter and autumn for smokers (p = 0.042). There was a positive correlation between carbon monoxide and carboxyhemoglobin levels for non-smokers (rs = 0.9983; p < 0.01). Environmental pollution represented different levels in the four seasons of the year and significant association with carboxyhemoglobin levels.Thecarboxyhemoglobin levels were higher among smokers, with statistical significance between winter and fall seasons, while non-smokers presented normal levels, whatconfirms the direct influence of tobacco in carboxyhemoglobin levels.

Os estudos relacionados à poluição ambiental, níveis de monóxido de carbono e o tabagismo, necessitam de aprofundamento, com destaque para os trabalhadores do trânsito. Para tanto, verificar associação entre níveis de monóxido de carbono ambiental e carboxihemoglobina em mototaxistas tabagistas e não tabagistas. Estudo epidemiológico, longitudinal, realizado com 95 mototaxistas com mensuração do monóxido de carbono ambiental, carboxihemoglobina no ar exalado em três momentos com intervalo de seis meses, entre junho de 2014 e março de 2015, assim como as características sociodemográficas e ocupacionais desses trabalhadores. As estações do ano apresentaram diferentes médias de monóxido de carbono (p<0,05), com níveis maiores na primavera e menores no outono, enquanto os níveis de carboxihemoglobina entre tabagistas e não tabagistas apresentaram-se elevados no inverno, intermediário na primavera e baixos no outono. Observou-se diferença estatística entre subgrupos, no outono e na primavera para os não tabagitas (p=0,024) e entre o inverno e outono para os tabagistas (p=0,042). Houve correlação positiva entre os níveis de monóxido de carbono e carboxihemoglobina para não fumantes (rs=0,9983; p<0,01). A poluição ambiental representou diferentes níveis nas quatro estações do ano e associação significativa com os níveis de carboxihemoglobina. Os níveis de carboxihemoglobina mostraram-se mais elevados nos tabagistas, com significância estatística entre a estação inverno e a do outono, enquanto os não tabagistas apresentaram níveis normais, o que reforça a participação direta do tabaco nos níveis de carboxihemoglobina.

Intoxicacion por monoxido de carbono / Carbon monoxide poisoning

Resumen:La intoxicación por monóxido de carbono o "asesino silente" es la intoxicación mortal más común, encontrándose en fuentes de exposición muy comunes como automóviles, tabaquismo y combustión de gases o combustibles.La principal característica nociva aguda del gas se basa en su alta afinidad por la hemoglobina, mientras que los efectos crónicos se basan en su interacción con otras proteínas. Ante la clínica inespecífica del cuadro, se debe tener un alto grado de sospecha diagnóstica, para iniciar el tratamiento adecuado o oxigenoterapia normobárica o hiperbárica según corresponda.

Abstract:Carbon monoxide poisoning or "silent killer" is the most common fatal poisoning, found in very common sources of exposure such as cars, smoking and gas or fuel combustion. The main acute harmful characteristic of gas is based on its high affinity for hemoglobin, while the chronic effects are based on its interaction with other proteins.Before the nonspecific clinic of the table, must have a high degree of diagnostic suspicion, to start the appropriate treatment or normobaric or hyperbaric oxygen therapy as appropriate.

The impact of hydrogen sulfide on the heme oxygenase-1/carbon monoxide system in Coxsackie virus B3-induced myocarditis in mice / 中华心血管病杂志

Objective@#To explore the impact of hydrogen sulfide (H2S) on the heme oxygenase-1/carbon monoxide pathway in Coxsackie virus B3 (CVB3)-induced murine myocarditis (VMC) model.@*Method@#A total of 70 inbred male Balb/c mouse (4-6 weeks old) were randomized into the following four groups: Normal, VMC, PAG and NaHS (n=10 for Normal, n=20 for VMC, PAG and NaHS groups). Mice in Normal group were non-infected mice treated with intraperitoneal injection of sterile phosphate-buffered saline daily for 10 days.Mice in VMC group received intraperitoneal CVB3 injection (0.1 ml 10-5.69TCID50m·ml-1·d-1 and PBS for 10 days), and mice in PAG group received additional intraperitoneal DL-proparglygylcine injection (40 mg·kg-1·d-1 for 10 days), mice in NaHS group received additional intraperitoneal NaHS injection (50 μmol·kg-1·d-1 for 10 days). All mice were sacrificed on day 10th, and body weight and heart weight, the ratio of heart weight to body weight were compared among groups.Pathological changes of heart tissues were observed microscopically by HE and the histopathologic scores were valued.The content of COHb was tested after the gathering of blood specimens while reverse transcription-polymerase chain reaction was used to detect myocardial HO-1 mRNA expression.@*Results@#(1) Pathological findings in myocardium: hearts sections in Normal group were normal and no inflammatory cells and necrosis were found.A notable cellular infiltration, interstitial edema, vascular hyperemia and necrosis were observed in heart section of VMC, PAG and NaHS group.Extensive inflammations and larger area of myocardial cells necrosis were evidenced in PAG group and above changes were significantly reduced in NaHS group.(2) Comparison of the ratio of heart weight to body weight and histological scores of myocardium: the ratio was significantly higher in the VMC, PAG, NaHS groups than in Normal group (P<0.05), which was higher in PAG group and lower in NaHS group as compared with VMC group (both P<0.05). The histopathologic scores of all CVB3 innoculation groups were higher than in the Normal group, which was higher in PAG group and lower in NaHS group as compared to VMC group (both P<0.05). (3) The content of blood COHb in VMC, PAG or NaHS group was significantly higher than that in Normal group (P<0.05), which was significantly lower in PAG group, and higher in NaHS group as compared to VMC group (both P<0.05). (4) The mRNA expression of myocardial HO-1 detected by RT-PCR: weak expression was observed in Normal group, which was significantly upregulated in VMC, PAG and NaHS groups (P<0.05), which was downregulated in PAG group and upregulated in NaHS group as compared to VMC group (both P<0.05). (5) Correlation analysis: blood COHb concentration was positively correlated with myocardial HO-1 mRNA expression(r=0.927, P=0.000), negatively correlated with histopathologic scores(r=-0.753, P=0.000)and the histopathologic scores were negatively correlated with the myocardial HO-1 mRNA expression (r=-0.754, P=0.000).@*Conclusions@#H2S could play a protective role in murine CVB3 myocarditis model through inducing HO-1 expression and upregulating HO-1/CO pathway.

What is the Clinical Significance of Initial Lactate Measurement Compared to Carboxyhemoglobin Measurement in Carbon Monoxide Poisoning?

PURPOSE: This study was performed to compare clinical significance between lactate and carboxyhemoglobin (COHb) in a patient with carbon monoxide (CO) poisoning. METHODS: We conducted a 13-year retrospective study on CO poisoning patients who visited the emergency departments of the Medical Center between October 2004 and January 2016. The patients were divided into two groups according to initial lactate levels. Patients with serum lactate levels of ≤2 mmol/L were classified as the normolactatemia group (n=14), and patients with serum lactate levels of >2 mmol/L were classified as the hyperlactatemia group (n=34). General characteristics, clinical features, and laboratory findings of the two groups were compared. In addition, we compared initial lactate levels with COHb levels according to complications, neurological disorder, myocardial enzyme elevation, and abnormal Glasgow Coma Scale (GCS) score in patients with CO poisoning. We also analyzed the correlation between laboratory parameters and lactate levels. RESULTS: Forty-eight patients were enrolled in this study. The hyperlactatemia group had significantly more neurological disorders and consciousness disorders than the normolactatemia group (p<0.001), and COHb, creatine phosphokinase MB, and troponin I levels were also significantly higher in the hyperlactatemia group (p<0.001, p=0.017, and p=0.007). Lactate levels were significantly elevated in patients with elevated cardiac enzymes (p=0.001), neurological disorders (p<0.001), complications (p=0.001), and abnormal GCS score (p<0.001), whereas COHb levels were not significantly increased in all subjects. The correlation between COHb and lactate levels was weak (r=0.313, p=0.030), and a positive correlation was found between lactate and bicarbonate (HCO3), white blood cell, and troponin I (p<0.001). The diagnostic value of lactate for severe CO poisoning was analyzed using a receiver operating characteristic curve. The optimal cut-off value of lactate was 2.2 mmol/L with 83.3% sensitivity and 91.7% specificity (p<0.001). CONCLUSION: Lactate has significant diagnostic efficacy in patients with CO poisoning. It is recommended that lactate level be measured for appropriate treatment and prognostic evaluation of CO poisoning.

Changes of HbCO in the Blood of Rats with Different CO Concentration and Inhalation Time / 法医学杂志

OBJECTIVES@#To explore the change rules of behavioral characteristics, survival time and saturation of carboxyhemoglobin （HbCO） in different CO concentration to provide experimental basis for the cases of CO poisoning death in forensic practice.@*METHODS@#Total 160 SD rats were randomly divided into four groups. CO with the concentration of 1 250 mg/m³, 3 750 mg/m³, 6 250 mg/m³ were continuously and respectively replenished in a self-made toxicant exposure equipment until rats died from poisoning. In different CO concentration, the behavioral characteristics and survival time of poisoning rats were observed and recorded. The saturation of HbCO in heart blood was detected by spectrophotometric method. Organs such as brain, heart, lung and liver, and heart blood were obtained via autopsy and histopathological observation was performed.@*RESULTS@#The behavioral characteristics of CO poisoning rats were limp and slow response. There were a gradual decrease of survival time and an increase of HbCO saturation in rats with the increase of CO concentration. Three rats in CO concentration of 1 250 mg/m³ group showed lower saturations of HbCO than the lethal dose and this situation hasn't been found in other groups.@*CONCLUSIONS@#The animal model of CO poisoning established under different CO concentration has the advantages such as simplicity and good repeatability, which lays a foundation to the further study for CO and other inhaled toxic gas in the research of forensic sciences.

Alteraciones neuropsicológicas por exposición crónica a concentraciones bajas de monóxido de carbono en trabajadores de autopista de peaje de México / Neuropsychological alterations by chronic exposure to low concentrations of carbon monoxide in highway workers of Mexico

ANTECEDENTES: Trabajadores de la industria automovilística, estaciones de servicio, autopistas de peaje, estacionamientos y los que laboran en las calles, están en contacto crónico con bajas concentraciones de monóxido de carbono (CO) y, por lo tanto, en riesgo de sufrir alteraciones en los sistemas cardiovascular, hematológico y nervioso. OBJETIVO: Identificar la relación de las alteraciones neuropsicológicas con la exposición crónica a bajas concentraciones de CO, en trabajadores de autopistas de peaje. MÉTODO: Estudio transversal en 72 trabajadores de autopistas de peaje de la carretera México-Puebla; 60 cajeros y 12 encargados de turno. Se exploraron variables socio-demográficas, clínicas y ocupacionales, y se determinó hemoglobina (Hb), hematocrito (Htc) y carboxihemoglobina (COHb) en sangre. Se aplicaron pruebas neuropsicológicas (Carbon monoxide neuropsychological screening battery CONSB). Los encargados de turno conformaron el grupo menos expuesto y los cajeros el de mayor exposición a CO. RESULTADOS: En 49 trabajadores, Hb: 18.1±1.9 mg/dL y Htc: 55.3±8.7, sin diferencias significativas entre grupos (p = 0.82). Se observó menor desempeño en el grupo más expuesto, en el test de dígitos y símbolos (p = 0.012), senderos B (p = 0.002) y dígitos (p = 0.003). El test de construcción con bloques resultó limítrofe (p = 0.07). DISCUSIÓN Y CONCLUSIÓN: El grupo de mayor exposición al CO tuvo menor desempeño en percepción visual, codificación, percepción visomotora y memoria inmediata. Por ello, consideramos importante realizar vigilancia epidemiológica en los trabajadores, para intervenir en los casos con alteraciones en las pruebas. Asimismo, se debe evitar la percepción de que la exposición crónica al CO en estos trabajadores es inocua.

BACKGROUND: Workers of the automobile industry, service stations and those working in the streets, are in chronic contact to low concentrations of carbon monoxide and at risk to damage the cardiovascular, haematology and nervous systems. OBJECTIVE: Identify erythrocytosis and neuropsychological alterations in highway workers chronically exposed to low concentrations of CO. METHOD: Cross-sectional study that included 72 workers of the Mexico-Puebla Highway cabins (guards); 60 cashiers and 12 workers in charge of the shift, in which socio-demographic, clinical and occupational variables were explored; haemoglobin(Hb), hematocrit (Htc) and carboxyhemoglobin (COHb) was determined in their blood, and it was applied the Carbon monoxide neuropsychological screening battery (CONSB). The workers who are in charge of the full shift integrated the less exposed to CO group, while the cashiers would shape the greater exposure group. RESULTS: In 49 workers, Hb: 18.1±1.9 mg/dL and Htc: 55.3±8.7 without significant differences between groups (p=0.82). The greater alteration was identified in the exposed group in the test of digit symbol (p= 0.012), trail-making part B (p= 0.002), and digit span (p=0.003); the test of blocks design resulted borderline (p=0.07). DISCUSSION AND CONCLUSIÓN: The group with the highest exposure to CO had lower performance in visual perception, encoding, visual-motor perception and immediate memory. Therefore important to consider epidemiological surveillance workers to intervene in cases with abnormal tests. The perception of innocuousness of chronic exposure to CO in these workers must avoid.

Serum bilirubin value predicts hospital admission in carbon monoxide-poisoned patients. Active player or simple bystander?

OBJECTIVES:Although carbon monoxide poisoning is a major medical emergency, the armamentarium of recognized prognostic biomarkers displays unsatisfactory diagnostic performance for predicting cumulative endpoints.METHODS:We performed a retrospective and observational study to identify all patients admitted for carbon monoxide poisoning during a 2-year period. Complete demographical and clinical information, along with the laboratory data regarding arterial carboxyhemoglobin, hemoglobin, blood lactate and total serum bilirubin, was retrieved.RESULTS:The study population consisted of 38 poisoned patients (23 females and 15 males; mean age 39±21 years). Compared with discharged subjects, hospitalized patients displayed significantly higher values for blood lactate and total serum bilirubin, whereas arterial carboxyhemoglobin and hemoglobin did not differ. In a univariate analysis, hospitalization was significantly associated with blood lactate and total serum bilirubin, but not with age, sex, hemoglobin or carboxyhemoglobin. The diagnostic performance obtained after combining the blood lactate and total serum bilirubin results (area under the curve, 0.90; 95% CI, 0.81-0.99; p<0.001) was better than that obtained for either parameter alone.CONCLUSION:Although it remains unclear whether total serum bilirubin acts as an active player or a bystander, we conclude that the systematic assessment of bilirubin may, alongside lactate levels, provide useful information for clinical decision making regarding carbon monoxide poisoning.

Carbon monoxide’s exposure assessment of workers at ore industry / Шинэ санаа Шинэ нээлт

Carbon monoxide comes up from the combustion of gas, wood and coal during the industrial processes and since it’s a tasteless, odorless, colorless gas it can be absorbed into body in a short time resulting acute intoxication.The result of planned inspection with laboratory analysis at Ore industrial workshops and fields located in Darkhan-Uul province conducted by Specialized Inspection Place in 2013 was higher than the permissible level which is indicated in Mongolian national standard of occupational hygiene MNS4990-2000 by 60.2 mg/m3 and was higher than the short time permissible exposing level which is indicated Occupational Safety and Health Agency (OSHA) of USA by 20 ppm, therefore we predicted that there is a pollution of carbon monoxide in present industry and conducted this study.For the determination of carbon monoxide exposure by workshops and departments, the average level of CO for workers was 17 mg/m3, maximum was 57.3 mg/m3, the average level was for dayworkers 44.9 mg/m3, for night workers it was 102mg/m3 and maximum was 427 mg/m3 in RIW. Identifying level of exposure by the type of workers, for servicemen were 96.2-427 mg/m3 for welders was 46.4 mg/m3 and mechanics was 140.5mg/m3 which were higher than others.Comparing the results of present study with the permissible level of Mongolian national standard of occupational hygiene MNS4990-2000, was higher by 50-120mg/m3 and with the 8 hours of time weighted average (TWA) of Occupational Safety and Hygiene Agency (OSHA), was higher by 20-80 ppm.

The correlation analysis of indoor carbon monoxide concentration and chronic diseases / 国际检验医学杂志

Objective To explore the correlation of the indoor carbon monoxide concentration and chronic diseases by monitoring the indoor carbon monoxide concentration timely.Methods Collected the data of non-traumatic patients(n=80)from July 201 1 to January 2014,and assigned them into the experiment group with carbon monoxide concentration measured and the control group without measured.All the subjects were further divided into one group with complaint of carbon monoxide poisoning and the other one without.For patients exposed to high concentration of carbon monoxide,carboxyhemoglobin was also measured and APACHEⅡ was scaled,and the relationship between them was analyzed.The confirmation and misdiagnosis rate of carbon monoxide poison-ing were calculated.For the patients with acute exacerbation of chronic diseases like chronic cardiac failure,chronic obstructive pul-monary disease,cerebral infarction induced by carbon monoxide poisoning,BNP,CAT and NIHSS were documented on admission and during follow-up with removal of carbon monoxide exposure and compared respectively.Results The relationship between blood carboxyhemoglobin,APACHEⅡ scores on admission and indoor carbon monoxide concentration was linear,and obviously positive.Between the experiment group(n=40)and the control group(n=40),there was significant difference(P <0.05)in confirma-tion rate and misdiagnosis rate with 80.00% vs.55.00% and 6.25% vs.81.80% respectively.For the 54 patients with carbon monoxide poisoning diagnosed,the changes between before and after removal of carbon monoxide exposure of the CAT scores of chronic obstructive pulmonary disease and NIHSS score of CI disease and myoglobin,troponin I,creatine kinase isoenzyme,BNP for chronic cardiac failure were significantly different(P <0.01).Conclusion The indoor carbon monoxide concentration may indicate the severity of carbon monoxide poi-soning,which could increase the confirmation rate of carbon monoxide poisoning,and reduce the misdiagnosis rate.It is helpful to identify carbon monoxide exposure,the common inducing factor,so as to improve the patients′clinical symptoms.