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.

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

Acute carbon monoxide poisoning with coexisting cerebral and myocardial infarction: The brain-heart connection and challenges of management in resource-limited settings / Intoxicación aguda por monóxido de carbono con infarto cerebral y de miocardio coexistente: la conexión cerebro-corazón y los desafíos del manejo en entornos con recursos limitados

Carbon monoxide poisoning pose significant public health consequence and management can be challenging in resource-poor countries. This is a commentary of a 40 year-old farmer with a five day history of loss of consciousness following overnight inhalation of carbon monoxide. Neuroimaging and electrophysiologic studies showed bilateral internal capsule and myocardial infarction. He had unsuccessful treatment with normobaric oxygen therapy in the absence of hyperbaric oxygen. This case depicts the brain-heart connection in carbon monoxide poisoning and highlights the challenges of management in a resource poor setting.

La intoxicación por monóxido de carbono representa un significativo problema para la salud pública de cualquier país y su manejo puede resultar en un gran desafío en los países emergentes, con escasez de recursos para la atención de este tipo de pacientes. Se presenta el caso de un agricultor de 40 años de edad, con antecedentes de cinco días previos de pérdida de la conciencia, posterior a la inhalación de monóxido de carbono. Las evaluaciones realizadas: tomografía axial computada de cerebro y electrocardiograma, mostraron la presencia concomitante de infarto cerebral, con compromiso de ambas cápsulas internas e Infarto de miocardio, respectivamente. Se inició tratamiento con oxígeno normobárico, falleciendo el paciente dentro de las 24 horas posteriores a su admisión. Este caso representa la conexión en la afectación de corazón y cerebro, en intoxicaciones por monóxido de carbono y sirve para destacar los desafíos de su manejo en entornos con limitaciones de recursos.

Intoxication collective familiale à l'oxyde de carbone à Dakar

L'intoxication au monoxyde de carbone (CO) est un accident grave et potentiellement mortel, d'origines domestique ou professionnelle. Elle est encore fréquente dans les pays en voie de développement, favorisée par l'utilisation du charbon de bois comme combustible domestique. Nous rapportons une histoire d'intoxication collective familiale dramatique, survenue dans une petite famille de cinq membres, habitant la banlieue dakaroise. Le jour de l'intoxication, toute la famille avait dormi dans la même chambre, chauffée par un fourneau avec du charbon mal consumé, portes et fenêtres fermées. La mère était la première à se réveiller au petit matin, avec des céphalées et des vomissements transitoires. Le père et la benjamine de 12 mois, qui étaient couchés en hauteur sur un lit, avaient été retrouvés décédés. La carboxyhémoglobinémie post-mortem était élevée pour les deux (23,3% pour le père et 50,8% pour la fille). Les garçons, âgés de 4 et 5 ans, qui avaient dormi par terre avec la maman, avaient survécu, mais avaient présenté une symptomatologie neurologique (troubles de la conscience, irritabilité) et digestive (vomissements, cytolyse hépatique) avec une alcalose respiratoire.Ce drame familial est une preuve que l'intoxication au CO est une réalité au Sénégal, car les risques liés à la mauvaise utilisation du charbon sont encore largement méconnus par les populations. Des campagnes de sensibilisation doivent être organisées pour prévenir ces accidents graves. Les conditions d'habitat des populations doivent aussi être améliorées

Misdiagnosis of carbon monoxide intoxication in a patient with known coronary artery disease: a case report and review of cardiovascular effects of carbon monoxide poisoning / Mal diagnóstico de intoxicación por monóxido de carbono en un paciente diagnosticado con enfermedad de la arteria coronaria: reporte de un caso y estudio de los efectos cardiovasculares del envenenamiento por monóxido de carbono

This is a report of a patient who had documented coronary artery disease and was admitted with chest pain, nausea, vomiting and headache. She was immediately taken to coronary angiography and underwent percutaneous coronary intervention with stent implantation. After the operation, she was coincidentally diagnosed to have Carbon Monoxide (CO) poisoning. We discuss if percutaneous intervention (PCI) was an overtreatment and briefly review the mechanisms of the cardiovascular effects of CO toxicity which is an insidious pathology and diagnosed only if it is suspected.

Este es un reporte de una paciente con enfermedad de la arteria coronaria documentada, quien fuera ingresado con dolor de pecho, náuseas, vómitos y dolor de cabeza. A la paciente se le hizo inmediatamente una angiografía coronaria y se le realizó una intervención coronaria percutánea con implantación de stent. Después de la operación, se le diagnosticó por coincidencia envenenamiento por monóxido de carbono (CO). Analizamos si la intervención percutánea (IPC) fue un sobretratamiento y examinamos brevemente los mecanismos de los efectos cardiovasculares de la toxicidad por CO que puede ser insidiosa y diangosticada sólo si se tiene sospecha.

Delayed syndrome in carbon monoxide poisoning.

Acute carbon monoxide poisoning can lead to delayed manifestations. This has been called post-interval syndrome, which can present after an apparent period of normalcy following acute poisoning. We are reporting a patient who had an accidental exposure to carbon monoxide and presented later with all the manifestations of delayed poisoning. The various clinical manifestations and imaging findings are discussed. A delay in recognition in the acute stage can predispose to development of the post-interval syndrome.

Desmielinização tardia da substância branca cerebral devido à intoxicação por monóxido de carbono / Delayed demyelination of the cerebral white matter due to carbon monoxide intoxication

Os autores apresentam um caso de desmielinização tardia da substância branca cerebral devido à intoxicação por monóxido de carbono, discutem os principais diagnósticos diferencias e a importância da anamnese na elucidação do caso.

The authors present a case of delayed demyelination of the cerebral white matter due to carbon monoxide poisoning; discuss the main differential diagnoses and the importance of the anamnesis in the elucidation of the case.

Carbon monoxide toxicity with neurological and cardiac complications

A family suffered carbon monoxide toxicity, with cerebral and / or cardiac complications, while sleeping in the cabin on a recreational boat. This article describes a couple exposed to a malfunctioning air-conditioning system on the boat, which subsequently developed the unique combination of cerebral symptoms and a non Q/non-ST elevation myocardial infarction, with enzyme elevations and electrocardiographic abnormalities. This interesting complication of a myocardial infarction secondary to carbon monoxide toxicity, associated with neurological manifestations, is reviewed.

Chorea Following Acute Carbon Monoxide Poisoning

The clinical cases of 6 patients suffering with chorea after acute carbon monoxide (CO) poisoning were reviewed. There were 2 men and 4 women, and the age at onset ranged from 11 to 60 (mean 33.0) years. All the patients except one were associated with mild delayed CO encephalopathy. The latency period between CO poisoning and the onset of chorea was 10 to 30 (mean 21.7) days. The duration of chorea after CO poisoning was 14 to 90 (mean 39.8) days. The brain CT findings were bilateral low- density lesions in the basal ganglia and/or in the white matter of the cerebral cortex, and there was no correlation between the lesion sites on the imagings and the development of chorea. Neuroleptic agents alleviated the chorea and the patients did not relapse after neuroleptic agents were halted.

Carbon monoxide poisoning.

OBJECTIVES: We studied the clinical profile and autopsy findings of carbon monoxide (CO) poisoning encountered at a hospital located at the altitude of 5,000 ft above mean sea level. METHODS: Clinical and postmortem findings in 25 and 15 cases of accidental CO poisoning respectively were evaluated. The diagnosis was made on circumstantial evidences, definite history of "Bukhari" burning and positive Kunkel's test for carboxyhaemoglobin (COHb). Detailed routine investigations including pulse oxymetry, X-ray chest and electrocardiographical monitoring was carried out in all the 25 patients. Oxygen (100%) via an endotracheal tube in all the comatosed patients and by conventional non-rebreathing plastic face masks was the mainstay of treatment. All patients were monitored and followed up for any delayed neurological sequelae. RESULTS: Most of the patients were young adults and the duration of exposure varied between three to eight hours. The initial diagnosis was stroke in three, seizure in one, encephalitis in two and ischaemic heart disease (IHD) in four. Neurological and respiratory signs and symptoms were noted in 19 and 18 of 25 patients respectively. SPO2 measured by pulse oxymetry was normal in all cases. ECG was suggestive of IHD in four patients. No delayed neurological sequelae was noted in any patients. Autopsy revealed deep red discoloration of skin and serous membranes in 80%, pulmonary oedema in 100% and cerebral oedema with widespread multiple pin point haemorrhages mainly in thalamus and globus pallidus in 40%. CONCLUSION: A high level of suspicion and routine history about the kind of indoor heating, specially in cold climate areas during winter will help in early diagnosis and decrease the incidence of misdiagnosis of CO poisoning. Oxygen (100%) or hyperbaric oxygen, if available should be administered without waiting for COHb levels to decrease morbidity and mortality.

Carbon monoxide poisoning: systemic manifestations and complications

Carbon monoxide (CO) has the toxic effects of tissue hypoxia and produces various systemic and neurological complications. The main clinical manifestations of acute CO poisoning consist of symptoms caused by alterations of the cardiovascular system such as initial tachycardia and hypertension, and central nervous system symptoms such as headache, dizziness, paresis, convulsion and unconsciousness. CO poisoning also produces myocardial ischemia, atrial fibrillation, pneumonia, pulmonary edema, erythrocytosis, leucocytosis, hyperglycemia, muscle necrosis, acute renal failure, skin lesion, and changes in perception of the visual and auditory systems. Of considerable chinical interest, severe neurological manifestations may occur days or weekes after acute CO poisoning. Delayed sequelae of CO poisoning are not rare, usually occur in middle or older, and are clinically characterized by symptom triad of mental deterioration, urinary incontinence, and gait disturbance. Occasionally, movement disorders, particularly parkinsonism, are observed. In addition, peripheral neuropathy following CO poisoning usually occurs in young adults.

Aspectos neuropsiquiátricos e neuropsicológicos da intoxicaçäo por monóxido de carbono / Neuropsychiatric and neuropsychological aspects of carbon monoxide intoxication

A intoxicaçäo por monóxido de carbono é modo frequente de tentativas de suicídio e também ocorre em incêndios ou devido a acidentes inesperados com equipamentos em fábricas, aquecedores de uso domésticos, boilers. Essa é uma revisäo dos aspectos clínicos, neuropsicológicos e de neuroimagem no envenenamento por CO. Em ambientes de emergência o quadro clínico pode passar desapercebido num primeiro momento em que o atendimento imediato é de grande importância para a evoluçäo de caso, devido aos sintomas inespecíficos decorrentes da intoxicaçäo. A longo prazo a intoxicaçäo por CO pode gerar quadros de sequela com especial repercussäo sobre o comportamento, a cogniçäo e a psicomotricidade. Há uma bateria desenvolvida especificamente para a avaliaçäo neuropsicológica nas fases agudas (a CONSB) enquanto nos quadros mais crônicos é essencial a avaliaçäo mais extensa para aquilatar as alteraçöes cognitivas mais definitivas. As correlaçöes clínicas e de neuroimagem apontam para maior gravidade nos quadros com lesäo em substância branca e núcleo pálido, áreas de menos vascularizaçäo e onde o efeito do CO parece ter mais potencial patológico. A TC, a RM e o SPECT säo complementares nos dados que proporcionam para a avaliaçäo da intensidade e localizaçäo das lesöes

Hipoacusia neurosensorial reversible por intoxicación con monóxido de carbono / Reversible neurosensorial hearing loss of intoxication with carbon monoxide

Se presenta el caso de una paciente de 35 años que sufrió una intoxicación crónica por monóxido de carbono (CO), con una sobreexposición final de tipo agudo, por lo cual requirió un tratamiento médico de urgencia y que desarrolló un compromiso otológico bilateral fundamentalmente neurosensorial, de tipo reversible y con compromiso principalmente de los tonos agudos. La intoxicación por CO, es una patología que rara vez se relaciona con alteraciones a nivel del oído. Las intoxicaciones agudas, que son las más frecuentemente diagnosticadas debido a lo evidente y dramático de su sintomatología, no presentan daño coclear presuntamente por el corto tiempo de exposición al CO. Distinto es el caso de la intoxicación de tipo crónica, en la cual la sintomatología es tan inespecífica y solapada que no se sospecha su presencia, unido a las características del gas el cual es inodoro, incoloro e insípido y no irritativo, por lo que ingresa en grandes cantidades al organismo por las vías respiratorias sin que la persona se percate de ello. Por este motivo generalmente es subdiagnosticada. Los estudios realizados en ratas, cobayos y las experiencias de intoxicaciones en humanos han demostrado que produce alteraciones cocleares reversibles

Carbon monoxide poisoning as an epigenetic factor for Leber's hereditary optic neuropathy

A 45-year-old Korean woman visited our hospital complaining of poor vision after carbon monoxide (CO) poisoning. We have confirmed the presence of a point mutation at position 11778 in the ND4 gene of mitochondrial DNA. This case suggests that CO poisoning may precipitate the clinical expression of Leber's hereditary optic neuropathy (LHON). To our knowledge, this would be the first case report of clinical expression of LHON precipitated by CO poisoning.

Sequelas neuropsiquiátricas em intoxicaçåo ocupacional por monóxido de carbono: relato de três casos / Neuropsychiatric sequel in the carbon monoxide occupational intoxication: report of three cases

Relato de três casos de intoxicaçäo ocupacional por monóxido de carbono. Um deles evoluiu com crise tônico-clônica e, em seguida, mioclonias. Tardiamente, apresentou cardiopatia grave, vindo a falecer por insuficiência cardíaca. Os dois outros evoluíram com síndrome psicoorgânica, predominando sintomas afetivos e comportamentais. Apresentam-se as anamneses e os resultados dos exames (CT, EEG, COHb). Faz-se uma revisäo comentada da literatura pertimente

Technetium-99m HM-PAO SPECT in patients with delayed neurologic sequelae after carbon monoxide poisoning

We used single photon emission computed tomography (SPECT) with technetium-99m hexamethylpropylene amine oxime (99mTc-HM-PAO) in 14 studies on 6 patients with delayed neurologic sequelae from carbon monoxide (CO) poisoning to determine whether any changes in cerebral blood flow could be correlated with clinical or computed tomographic evidence of delayed deficits. Among the six initial CT brain scans, two showed low density of both basal ganglia and two showed decreased density of the cerebral white matter. There was no correlation between the clinical outcome and the findings of the follow-up CT brain scans. Of the two SPECTS with 99mTc-HM-PAO performed during acute anoxic insult, one showed focal hypoperfusion which appeared 20 days prior to the onset of delayed neurologic sequelae after CO poisoning. Seven SPECTs in the six patients performing the delayed phase showed diffuse patched patterns of hypoperfusion which improved on follow-up images. There was good correlation between the clinical outcome and the findings of the 99mTc-HM-PAO SPECT. In preliminary conclusion, 9Tc-HM-PAO brain SPECT can be used for predicting or evaluating the outcome of delayed neurologic sequelae after CO poisoning. Cerebral vascular changes may be the possible cause of hypoperfusion in patients with CO poisoning.

Efectos tóxicos del monóxido de carbono en trabajadores motociclistas

El monóxido de carbono (CO) es un gas muy venenoso que se une a la hemoglobina desplazando al oxígeno con la formación de carboxihemoglobina (COHb). Esta investigación consistió en una valoración bioquímico-clínico de la intoxicación por CO en una población de 42 motociclistas cobradores en la ciudad de Santo Domingo. Los resultados revelaron que el 31% de la población tenía niveles tóxicos de COHb (mayor de 5%) cuantificada al finalizar la jornada de trabajo. Las manifestaciones clínicas más frecuentes fueron: cefalea (50%), sonnolencia (25%), trastornos visuales (24%) y taquicardia (19%). Estos síntomas aparecieron en el 100%) de los cobradores con niveles tóxicos de COHb y en el 76% de aquellos que tenían valores por debajo del límite de toxicidad lo cual sugiere cierta susceptibilidad al CO. Los cobradores con cinco años o más de labor presentaron las cifras más elevadas de COHb (11-14%)