EM6 Cerebral infarction due to carbon monoxide poisoning. (Emergency Medicine).

EM6 CEREBRAL INFARCTION DUE TO CARBON MONOXIDE POISONING. Antonio E. Muniz, MD. Department of Emergency Medicine and Pediatrics, Medical College of Virginia of VCU, Richmond.

Severe carbon monoxide (CO) poisoning can lead to severe changes in mental status. Change in mental status in children has a wide differential. Initial management should be directed at establishing an adequate airway and ensuring good oxygenation and ventilation. Assessment of vital signs and a thorough examination should be done. A detailed history should include the search for a possible ingestion or trauma. Finally, a comprehensive laboratory evaluation is done if the cause of the mental status change remains unknown. A 12-year-old girl was brought to the emergency department unresponsive. She was riding in the back of a truck with a camper. She and her sister were found unresponsive, and the dog was dead. She was in respiratory arrest and was intubated. Her medical history was unremarkable. She had a temperature of 36.6[degrees]C, heart rate 147/mm, and was ventilated at 20 breaths/min. Her physical examination was remarkable for withdrawal to deep pain stimuli. Her CO level was 15.2%. Her WBC was 9,500/[ mm.sup.3] with 77% neutrophils. Her hemoglobin was 10.6 g/dL, and platelets 195,000/[mm.sup.3]. Her electrolytes were normal. Her chest radiograph was normal. She underwent hyperbaric treatment at 2.8 ATM for 70 minutes with a subsequent CO level of 0.3%. She was admitted to the PICU. She was extubated on the following day. Two days later, she had dizziness, frontal headache, agitation, and confusion. She had CT of the head, which showed bilateral limbic and posterior temporal ischemia. She had memory deficits and anosmia. She was transferred to a rehabilitation hospital with minimal improvement. Carbon monoxide toxicity varies with the CO level. Mild intoxications manifest with headache, dyspnea, and decreased visual acuity. As the level increases, irritability, nausea, dim vision, and impaired judgment occur. Severe CO poisoning leads to confusion, hallucinations, ataxia, shock, coma, and death. Carbon monoxide poisoning may produce hypoxic encephalopathy because CO binds tightly to hemoglobin, diminishing its oxygen-carrying capacity. Treatment includes adequate oxygenation, rapid restoration of perfusion, and maintenance of good fluid and electrolyte balance. Hyperbaric treatment for CO poisoning remains controversial, especially if it affects the incidence of delayed neurologic complications in patients whose CO level is <30 on arrival to the ED.