Toxicology/clinical policy

Clinical Policy: Critical Issues in the Management of Adult Patients Presenting to the Emergency Department with Acute Carbon Monoxide Poisoning

En France, l’usage de la chicha (narguilé) connaît une popularité croissante chez les adolescents et les adultes jeunes et se trouve généralement considéré comme moins dangereux et addictif que la cigarette. Cette revue systématique sur les données concernant l’intoxication au monoxyde de carbone (CO) chez les fumeurs actifs ou passifs de chicha a retenu 17 études. Seize rapports de cas, incluant 39 patients (âge moyen : 22,3 ans ; 51,3 % d’hommes), décrivaient des intoxications aiguës au CO chez des fumeurs actifs de chicha. Les symptômes les plus fréquents incluaient vertiges, céphalées et nausées. Une perte de conscience est survenue chez 43,6 % des patients. Deux patients ont présenté une crise d’épilepsie. Le taux sanguin moyen de carboxyhémoglobine (HbCO) était de 17,3 %. Des anomalies électrocardiographiques étaient constatées chez cinq patients. Dans la majorité des cas, le traitement a reposé sur l’oxygénothérapie normobare ; l’oxygénothérapie hyperbare a concerné quatre patients, dont deux non fumeurs, exposés à la fumée de chicha pendant leur travail. L’évolution était favorable chez tous les patients. L’usage de la chicha doit être systématiquement recherché en cas d’intoxication au CO, notamment chez des adolescents ou des adultes jeunes. Les praticiens doivent aider les fumeurs de chicha à arrêter cet usage.

In France, shisha (narghile) smoking is increasingly popular among adolescents and young adults and is generally thought to be less harmful and addictive than cigarettes. This systematic review of data on carbon monoxide (CO) poisoning in active or passive shisha tobacco smokers selected 17 studies. Sixteen case reports, including 39 patients (mean age: 22.3 years; males: 51.3%), described acute carbon monoxide poisoning in active shisha smokers. The most common symptoms were dizziness, headache, and nausea. Loss of consciousness occurred in 43.6% of patients. Two patients had an epileptic seizure. The mean carboxy-haemoglobin (HbCO) blood level was 17.3%. Electrocardiographic changes were present in five patients. Most patients were treated with normobaric oxygen therapy while only four received hyperbaric oxygen therapy; two of whom were non tobacco smokers exposed to shisha smoke during their work. The outcome was favourable in all patients. Shisha use must be suspected in cases of CO poisoning, especially in adolescents and young adults. Practitioners must help shisha users to stop their consumption.

Carbon monoxide (CO) is one of the major causes of poisoning worldwide. We aimed to investigate the efficacy of the continuous positive airway pressure (CPAP) use in CO poisoning.

After CO poisoning, one group of patients was treated with a non-rebreather mask (NRB) and another group using the CPAP mode of mechanical ventilation (CPAP). All patients received at least 90 minute treatment. The carboxyhemoglobin saturation (SpCO) levels of all patients were measured from the fingertips with a portable CO-oximeter at 0, 30, 60 and 90 min. The rates of changes in the serially measured SpCO values were obtained using the Wilcoxon signed-rank test.

A total of 45 patients (24 in NRB and 21 in CPAP group) completed the study. The median initial SpCO levels were 24% (21−33) in NRB group, 25% (21−32) in CPAP group, with no statistically significant difference (p 0.323). At the 30th, 60th, and 90th minutes of treatment, significantly lower values were obtained from CPAP than NRB (p < 0.001). The COHb half-life was decreased significantly by CPAP [105(70–190) vs 45(30−120), p < 0.001]. In CPAP group, the fastest decline in the SpCO level was observed for the interval of 0–30 min [Median difference: 8(3–14), p < 0.001].

CPAP lowered the amount of CO in the blood faster than the mask; therefore, it may be effective in the treatment of CO poisoning.

En France, l’usage de la chicha (narguilé) connaît une popularité croissante chez les adolescents et les adultes jeunes et se trouve généralement considéré comme moins dangereux et addictif que la cigarette. Cette revue systématique sur les données concernant l’intoxication au monoxyde de carbone (CO) chez les fumeurs actifs ou passifs de chicha a retenu 17 études. Seize rapports de cas, incluant 39 patients (âge moyen : 22,3 ans ; 51,3 % d’hommes), décrivaient des intoxications aiguës au CO chez des fumeurs actifs de chicha. Les symptômes les plus fréquents incluaient vertiges, céphalées et nausées. Une perte de conscience est survenue chez 43,6 % des patients. Deux patients ont présenté une crise d’épilepsie. Le taux sanguin moyen de carboxyhémoglobine (HbCO) était de 17,3 %. Des anomalies électrocardiographiques étaient constatées chez cinq patients. Dans la majorité des cas, le traitement a reposé sur l’oxygénothérapie normobare ; l’oxygénothérapie hyperbare a concerné quatre patients, dont deux non fumeurs, exposés à la fumée de chicha pendant leur travail. L’évolution était favorable chez tous les patients. L’usage de la chicha doit être systématiquement recherché en cas d’intoxication au CO, notamment chez des adolescents ou des adultes jeunes. Les praticiens doivent aider les fumeurs de chicha à arrêter cet usage.

In France, shisha (narghile) smoking is increasingly popular among adolescents and young adults and is generally thought to be less harmful and addictive than cigarettes. This systematic review of data on carbon monoxide (CO) poisoning in active or passive shisha tobacco smokers selected 17 studies. Sixteen case reports, including 39 patients (mean age: 22.3 years; males: 51.3%), described acute carbon monoxide poisoning in active shisha smokers. The most common symptoms were dizziness, headache, and nausea. Loss of consciousness occurred in 43.6% of patients. Two patients had an epileptic seizure. The mean carboxy-haemoglobin (HbCO) blood level was 17.3%. Electrocardiographic changes were present in five patients. Most patients were treated with normobaric oxygen therapy while only four received hyperbaric oxygen therapy; two of whom were non tobacco smokers exposed to shisha smoke during their work. The outcome was favourable in all patients. Shisha use must be suspected in cases of CO poisoning, especially in adolescents and young adults. Practitioners must help shisha users to stop their consumption.

To provide recommendations to facilitate the management of severe thermal burns during the acute phase in adults and children.

A committee of 20 experts was asked to produce recommendations in six fields of burn management, namely, (1) assessment, admission to specialised burns centres, and telemedicine; (2) haemodynamic management; (3) airway management and smoke inhalation; (4) anaesthesia and analgesia; (5) burn wound treatments; and (6) other treatments. At the start of the recommendation-formulation process, a formal conflict-of-interest policy was developed and enforced throughout the process. The entire process was conducted independently of any industry funding. The experts drew up a list of questions that were formulated according to the PICO model (Population, Intervention, Comparison, and Outcomes). Two bibliography experts per field analysed the literature published from January 2000 onwards using predefined keywords according to PRISMA recommendations. The quality of data from the selected literature was assessed using GRADE® methodology. Due to the current paucity of sufficiently powered studies regarding hard outcomes (i.e. mortality), the recommendations are based on expert opinion.

The SFAR guidelines panel generated 24 statements regarding the management of acute burn injuries in adults and children. After two scoring rounds and one amendment, strong agreement was reached for all recommendations.

Substantial agreement was reached among a large cohort of experts regarding numerous strong recommendations to optimise the management of acute burn injuries in adults and children.

The effects of hyperbaric oxygen therapy (HBOT) on mortality or morbidity in patients with carbon monoxide (CO) poisoning remain unknown. We examined the effects of HBOT on CO poisoning and further strived to delineate its inherent effects on specific subgroups of patients using a nationwide inpatient database.

We identified adult patients with CO poisoning who were registered in the Japanese Diagnosis Procedure Combination inpatient database from 2010 to 2016. Propensity score-matching was performed to compare patients who received HBOT within 1 day of admission (HBOT group) with those who did not receive HBOT (control group). The primary outcome was in-hospital mortality. The secondary outcomes were a depressed mental status and reduced activities of daily living (ADL) at discharge. We also performed subgroup analyses divided according to severity of CO poisoning.

Eligible patients were categorized into the HBOT group (n = 2034) or the control group (n = 4701). One-to-one propensity score-matching created 2034 pairs. In-hospital mortality was not significantly different between the HBOT and control groups (0.8% vs. 1.2%, risk difference: −0.4%, 95% confidence interval: −1.0 to 0.2). Patients in the HBOT group had significantly lower proportions of a depressed mental status and reduced ADL at discharge than did those in the control group. Similar associations were shown in the non-severe poisoning subgroup.

Although HBOT was not significantly associated with reduced mortality, it was significantly associated with a favorable consciousness level and ADL in patients with CO poisoning. HBOT may be beneficial even for patients with non-severe CO poisoning.