EVIDENCE BASED PRACTICE CARBON MONOXIDE

POISONING

Larry D. Weiss, M.D., J.D.

Professor of Emergency Medicine
University of Maryland School of Medicine

OBJECTIVES

critically review RPCTs

understand varying approaches to rx

current state of literature

CARBON MONOXIDE POISONING

The
The Most
Most Common
Common Lethal
Lethal Poisoning
Poisoning in
in the
the World
World
(over
(over half
half of
of all
all cases)
cases)

RPCTs
Raphael et al.
Lancet 1989; 2:414-419

Thom et al.
Ann Emerg Med 1995; 25:474-480

Scheinkestel et al.
Med J Australia 1999; 170:203-210

Weaver et al.
New Engl J Med 2002; 347:1057-1067

RAPHAEL ET AL.
Methodology

rand, prosp., controlled

not blinded

LOC v. no LOC

RAPHAEL ET AL.
Methodology 2

974 patients, 345 excluded = 629

Follow-up at one month
Self-questionnaire
Exam by patients MD

70 did not follow-up

RAPHAEL ET AL.
Methodology 3

No LOC (Group A)
6 hrs 100% O2 v. 2 hrs HBOT +4 hrs O2

LOC (Group B)
1 HBOT v. 2 HBOTs

RAPHAEL ET AL.
Methodology 4

HBOT: 2 ATA x 60 mins

Standard::

RAPHAEL ET AL
Results

Group A: no difference

Group B: 1 HBOT =
2 HBOTs

RAPHAEL ET AL.
Conclusions

No LOC: 100% O2

LOC: 1 HBOT

CRITICAL ANALYSIS
Raphael et al.

not blinded

classification (LOC v. no LOC)

never performed MSE

included pts who refused rand.

CRITICAL ANALYSIS (cont

d)
(contd)
Raphael et al.

most pts. treated > 6 hrs. later

inadequate HBOT

no meaningful F/U

THOM ET AL.
Methodology

rand, prosp., controlled

not blinded

mild-mod poisoned pts.

THOM ET AL.
Methodology 2

eval: hx, exam, COHb, CXR

NP testing after rx
HBOT within 6 hours (multiplace)
2.8 ATA x 30 mins, 2 ATA x 90 mins

THOM ET AL.
Methodology 3

100% O2: until sxs resolved

measured outcome: DNS

NP test: after rx and at 4 wks

telephone at 3 months

THOM ET AL.
Results

all sxs resolved in all pts

65 pts, 5 failed to F/U

100% O2: 23% DNS (8 pts)

HBOT: 0% DNS

THOM ET AL.
Conclusions

HBOT signif reduced DNS

requires rx w/in 6 hrs

weakness: lack of blinding

limited to mild-mod intox

CRITICAL ANALYSIS
Thom et al. (Olson Ann Emerg Med 1995; 25:535-537)

not blinded

no NP testing before rx

NBO group sl older

? incid of depression

CRITICAL ANALYSIS
Thom et al. (Olson, continued)

The Ideal Study

blinded
include all pts (mild, mod, severe)
thorough follow-up
reproducible NP testing

SCHEINKESTEL ET AL.
Methodology

rand, prosp., controlled, blinded

multiplace, sham dives, BUT . . .

all poisoned pts.

all pts rxed QD x 3d . . .

SCHEINKESTEL ET AL.
Methodology 2

NBO:

100 mins in chamber, 100% O2 by

mask, at 1 ATA (no pressure)

HBOT:

100% O2 by hood, mask, or vent,

2.8 ATA x 60 mins

SCHEINKESTEL ET AL.
Methodology 3

all pts: 100% O2 x 3 days

MMSE before rx

NP testing after 3rd

outcome at end of rx and 1 month

SCHEINKESTEL ET AL.
Results

230 pts, 39 excluded = 191

104 HBOT, 87 NBO

73% had severe intox

SCHEINKESTEL ET AL.
Results

PNS=71% at D/C, 62% at F/U

DNS: all 5 in HBOT group

46% F/U at one month

SCHEINKESTEL ET AL.
Conclusions

detrimental effect of HBOT

this study was different:

severely intox pts

blinded
pre-rx MMSE

CRITICAL ANALYSIS
Scheinkestel et al.

46% follow-up

not really blinded

iatrogenic O2 toxicity

treatment delays (7.1 hrs)

WEAVER ET AL.
Methodology

rand, prosp., controlled, blinded

monoplace, sham dives

all poisoned pts.

all pts rxed Q6-12 hrs x 3 rxs

WEAVER ET AL.
Methodology 2

pre-rx MMSE

HBOT: 1st:

3,then 2 ATA

2nd & 3rd : 2 ATA

NBO: 1st: 100% O2

2nd & 3rd : air

WEAVER ET AL.
Methodology 3

NP testing after 1st and 3rd rx,

2 wks, 6 wks, 6 mos, 12 mos
outcome: DNS at 6 weeks

WEAVER ET AL.
Results

76 pts in each group

F/U: 75 HBOT pts, 72 NBO pts

pre-rx cerebellar dysf. > in NBO

trial terminated early

WEAVER ET AL.
Results 2

DNS AT 6 WEEKS: (p=0.007)

HBOT: 25%
NBO: 46%

outcome diff. persisted at 12 mos.

WEAVER ET AL.
Conclusion

HBOT decreases cognitive

sequealae at 6 weeks and
12 months.

# to treat = 5

CRITICAL ANALYSIS
Weaver et al.

large size, blinding

severely ill pts

high rate of F/U

treatment delays (7.1 hrs)

CRITICAL ANALYSIS (contd)

Weaver et al.

explicit def. of DNS

treatment regimens

NBO group only received air after 1st rx

But, this reflects the 2 regimens used.

INDICATIONS FOR HBOT

COHb >25% at facility

COHb >40% anywhere

symptoms at any level

number of rxs: ?

QUESTIONS?