Carbon Monoxide Poisoning In Children .pdf

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for 500 unintentional, non–fire-related deaths annually in the United States, more than any other gas.4,8
The incidence of CO poisoning has a seasonal and
geographic association with cold climates, peaking during winter months and occurring at higher
rates in high-altitude states, notably the north and
Midwest.4,7,9 However, cases occur year-round, so
clinicians must remain suspicious for less-common
and evolving sources of exposure.10

The presentation of CO poisoning can range
from mild and nonspecific to critical illness, depending on the level and duration of the exposure and
host factors. Because symptoms can mimic a myriad
of conditions and a source of exposure is not always
known, the diagnosis may remain hidden if clinicians are not vigilant in maintaining an awareness
and suspicion for CO poisoning.

The mainstay for treatment of CO poisoning is
oxygen therapy. In severe cases, the emergency clinician must weigh the risks and benefits of transfer
to a center with capabilities for hyperbaric oxygen
(HBO) therapy, the evidence for which remains controversial.

In this issue of Pediatric Emergency Medicine Practice, the current state of diagnosis and management
of CO poisoning in children in the ED is reviewed.
The unique developmental and physiologic traits of
children with this condition will be considered. The
current epidemiology of CO poisoning is defined
and put it into a historical context to better understand how sources and prevention strategies for CO
poisoning have evolved over time. Current research
topics are explored, including noninvasive detection,
laboratory and radiographic markers for disease
severity, HBO therapy, and other therapies for the
treatment of CO poisoning.

Critical Appraisal Of The Literature
A PubMed search strategy, developed in consultation with a medical librarian, searched all Englishlanguage human studies related to CO published
from November 2009 through January 2015. A combination of the following search terms were used:
carbon monoxide poisoning, carbon monoxide, ACOP,
poison, toxicology, toxicity, poisoning, CO poisoning, CO
toxicity, human, humans, adult, infant, infancy, child,
pediatric, pediatrics, middle age, teen, adolescent, adolescents, adolescence, children, patient, patients, and age.
This strategy yielded 477 articles; 211 were relevant
to this review topic.

The review was then extended to include bibliographic references of relevant literature prior to the
queried date range including review articles that cite
studies dating back to 1950.11,12 Clinical guidelines
and policies from relevant professional organizations related to CO poisoning that were published
over the past 30 years were searched. The American
September 2016 •

College of Emergency Physicians (ACEP) published
an evidence-based Clinical Policy on critical issues
in the management of adult patients presenting to
the ED with acute CO poisoning.13 The Cochrane
Database of Systematic Reviews had a single review
that was most recently updated in 2011 related to
CO regarding the use of HBO.14

A targeted search on the use of HBO in children
was performed. A PubMed query with the terms
carbon monoxide and hyperbaric was performed for
English-language review articles and clinical trials
from January 1985 through February 2015. This strategy yielded 133 publications that were reviewed.
Limiting the search in PubMed to only pediatrics
yielded 17 results, of which there were several
review articles and case series on HBO therapy
use in pediatric CO poisoning, but no randomized
controlled trials or case-control studies. None of the
review articles cite any randomized controlled trials
of HBO use in pediatric CO poisoning.

Epidemiology And Etiology
Accidental, non–fire-related CO poisoning, sometimes called “preventable” or “unintentional” CO
poisoning, is responsible for approximately 20,000
ED visits and nearly 500 deaths annually in the United States.6,8 Unintentional CO poisoning in pediatric
patients represents about 5000 ED visits annually
in the United States. In a 2012 national surveillance
data analysis, children aged < 5 years had the highest estimated rate of accidental CO-related ED visits
(11.6 cases/100,000 population), followed by adults
aged 25 to 34 years (10.4 cases/100,000 population).
Despite having a higher rate of ED visits compared
to other age groups, rates of hospitalizations and
deaths from CO poisoning are lower in children.8

The United States Centers for Disease Control and
Prevention (CDC) data on unintentional, non–fire-related cases of CO poisoning from 1999 to 2004 show an
annual death rate of 1.53 cases/1 million citizens in the
United States.9 Overall, northern geography is associated with a higher rate of CO poisoning.4,8,9 The death
rate is highest in the Mountain States and High Plains
States as well as Alaska, which has an annual death
rate of 4.8 cases/1 million citizens.9 Wyoming has the
highest death rate with 6.2 cases/1 million; Hawaii’s
death rate was too low to calculate with accuracy.6
There are more CO poisoning-related deaths in the
winter months.9 On average, the death rate from CO
poisoning in the United States is about 2 persons daily
in December and January and 0.67 in July and August.9

CO is formed by the incomplete combustion of
hydrocarbons, which include many fuels used for
energy (eg, gasoline, wood, charcoal, propane, natural gas, oil, and kerosene). Common sources of CO
include poorly maintained or ventilated home-heating systems and cooking appliances, motor vehicle
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