9.10. POISONING BY SMOKE/NOx GAS

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Carbon monoxide (carbon monoxide).

Purpose of assistance

1. Remove the patient from the toxic environment.
2. Ensuring adequate ventilation, oxygenation and treatment of hypoperfusion.
3. Consider the use of ambient carbon monoxide (CO) measuring devices on first-in-effect bags to detect latent carbon monoxide poisoning.

Description of the patient

Carbon dioxide is odorless and colorless, has a strong ability to combine with hemoglobin and thus disrupts the combination of hemoglobin with oxygen, which, in turn, leads to hypoxia (pulse oximetry below 94%). There is a significant deterioration of the ability to transport oxygen to tissues and organs as a result of poisoning. Carbon monoxide is also a cellular toxin, poisoning with which can lead to delayed or permanent neurological disorders in large volumes. Carbon monoxide is produced by all types and forms of combustion sources (in the form of fire/smoke, eg: gas, kerosene, coal stoves or heaters), internal combustion engines (eg: generators, lawnmowers, cars, home heating systems). People in the fire zone can also be poisoned by cyanide as a result of the combustion of some synthetic materials. Cyanide poisoning should be suspected in patients with unstable hemodynamics after evacuation from the fire scene.

Inclusion criteria

1. Patients with carbon monoxide poisoning may exhibit the following spectrum of symptoms:

a) light intoxication:

• • • • nausea;
      • exhaustion;
      • headache;
      • dizziness;

b) intoxication from moderate to severe severity:

• • • • disturbance of consciousness;
      • tachypnea;
      • tachycardia;
      • convulsions;
      • cardiac arrest.

Exclusion criteria

No recommendations.

Management of the patient

Status assessment

1. Remove the patient from the toxic environment.
2. Perform a complete initial examination (ABCDE), if indicated, undress the patient and then cover him to keep warm.
3. Assess vital signs, including body temperature.
4. Apply a cardiac monitor, assess for arrhythmias, then record a 12-lead ECG.
5. Check your glucose level.
6. Monitor pulse oximetry and ETSO2 for respiratory decompensation.
7. Collect medical history relevant to this case.
8. Do a physical examination.

Treatment and intervention

1. Oxygen therapy with 100% oxygen via oxygen mask or AMBU bag or supralaryngeal airway.
2. In case of convulsions, act in accordance with the instruction “Convulsions”.
3. Transport a patient with severe carbon monoxide poisoning immediately to a specialized department with available pressure chambers and if there is no need for other types of care (burns, trauma, etc.).

Patient safety

1. Attach a carbon monoxide detector to your bag that you take to the scene to detect the possible presence of carbon monoxide (if a signal occurs, wear protective equipment and leave the scene).
2. Remove the patient and the EMD team from the potentially dangerous environment as soon as possible.
3. Instruct the patient, family members, and others at the scene not to enter the environment (eg, buildings, cars) where carbon monoxide is present until the source of the gas is located.
4. Do not try to detect reddening of the skin (characteristic cherry color), as this is a rare symptom of carbon monoxide poisoning.
5. The CO sensor may give inaccurate low/normal readings in a patient with carbon monoxide poisoning. All patients with actual or potential poisoning should be transported to the nearest appropriate emergency department based on their signs and symptoms.

Useful information for training

Key points

1. Pulse oximetry readings are inaccurate due to the binding of carbon monoxide to hemoglobin.
2. Since the level of carboxyhemoglobin of the mother does not always coincide with the level of the fetus, all pregnant patients will most likely undergo hyperbaric oxygen therapy.
3. Suspect poisonpoisoning with cyanide if the source of carbon monoxide is fire.
4. The use of CO sensors helps in detecting signs of carbon monoxide poisoning in conscious patients, do not expect immediate changes in indicators after starting oxygen therapy.

Corresponding evaluation results

1. Early and repeated assessment of the state of consciousness and motor function is extremely important in determining the response to therapeutic measures and the need for hyperbaric therapy.
2. Identification of the possible etiology of poisoning.
3. Time of manifestation of symptoms and time of initiation of treatment (specific to the causative agent of poisoning).
4. Response to treatment.

Key elements of documentation

1. When using a sensor for the presence of CO in the environment, document the indicators.

2. Signs of soot or burns of the face, nostrils and throat.

3. Early and periodic assessment of the state of consciousness and motor function is extremely important in determining the response to therapeutic measures and the need for hyperbaric therapy.

4. Accurate exposure history:

a) time of entry into the body/effect;
b) way of contact with the substance;
c) amount of the drug or substance (carefully collect all residues);
d) intake of alcohol or other intoxicating substances.

5. Signs and symptoms of other patients at the scene (if available).

Criteria for the effectiveness of aid provision

1. Early control of the respiratory tract in case of rapid deterioration of the patient’s condition.

2. Accurate exposure history:

a) time of entry into the body/impact;
b) route of exposure;
c) amount of drug or substance (carefully collect all residues);
d) intake of alcohol or other intoxicating substances.

3. Choosing the right protocol and further management of the patient.

4. Documentation of parts after each re-inspection.