Occult carbon monoxide poisoning: A cause of winter headache

doi:10.1016/0735-6757(87)90320-2

The American Journal of Emergency Medicine

Volume 5, Issue 3, May 1987, Pages 201-204

https://doi.org/10.1016/0735-6757(87)90320-2 Get rights and content

Abstract

Headache is an early symptom of carbon monoxide (CO) poisoning, occurring at carboxyhemoglobin (COHb) levels of greater than 10%. We investigated 37 patients presenting to an emergency department during the winter-heating season with a complaint of headache for evidence of CO exposure. Seven of the 37 patients (18.9%) had COHb levels in excess of 10%, with a mean of 14.0%. Three of these seven patients (42.9%) used gas space heaters or kitchen stoves to heat their homes, and three (42.9%) had cohabitants at home with headache. Of the 30 patients with COHb levels of less than 10% (mean level, 3.2%), only four (13.3%) used gas space heaters and kitchen stoves for heat (P = NS), and none (0%) had cohabitants with headache (P = .0045). In six of the seven patients with elevated COHb levels (85.7%), gas company Investigation or historical information obtained retrospectively revealed a definite or probable toxic CO exposure. In none of these patients had the diagnosis of CO poisoning been suspected by the emergency department physician or the patient prior to obtaining the result of the COHb level. Occult CO poisoning may be an important cause of winter headache.

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Cited by (47)

Diagnosis and management of occupational and environmental carbon monoxide neurotoxicity
2022, Advances in Neurotoxicology
Citation Excerpt :
A small portion of patients may present with signs and symptoms that are not readily attributable to CO poisoning especially during winter months. Symptoms seen in these patients are often nonspecific and flu-like emerged over days or weeks during chronic exposure to low concentrations of CO (Heckerling, 1987; Heckerling et al., 1990). The diagnosis of these patients is complicated further by their percent COHb which may not be remarkably elevated on admission (Heckerling, 1987; Heckerling et al., 1990).
Despite improvements in occupational and environmental safety CO poisoning continues to be a significant cause of morbidity and mortality. While some patients present in the emergency room, occupational and environmental medicine providers are frequently called upon to assist in the diagnosing and treating CO exposure. Many patients exposed to CO experience neurological symptoms which often emerge days to weeks after the exposure has ended. The delayed onset of these symptoms relative to the exposure creates a unique diagnostic challenge which, requires an understanding of the neurotoxic mechanisms of action that give rise to these neurological manifestations. The differential diagnosis of CO neurotoxicity is complicated further by the clinical presentation which often includes symptoms and signs of motor dysfunction and cognitive deficits which resemble the symptoms seen in demyelinating and neurodegenerative diseases. Serial neuropsychological testing and neuroimaging studies are necessary to diagnosis the residual neurological symptoms of CO poisoning. The authors draw upon their expertise in occupational and environmental medicine, neurology, behavioral neuroscience and toxicology to effectively summarizes the peer-reviewed literature on each of these important topics in an easy to use format for occupational and environmental medicine providers and other practitioners involved in the diagnosis and management of the neurological effects of CO poisoning.
Elevated Carboxyhemoglobin: Sources of Carbon Monoxide Exposure
2014, Archivos de Bronconeumologia
Inhalation of carbon monoxide (CO) can result in poisoning, with symptoms ranging from mild and nonspecific to severe, or even death. CO poisoning is often underdiagnosed because exposure to low concentrations goes unnoticed, and threshold values for normal carboxyhemoglobin vary according to different authors. The aim of our study was to analyze carboxyhemoglobin (COHb) levels in an unselected population and detect sources of CO exposure.
In a cross-sectional descriptive study, we analyzed consecutive arterial blood gas levels processed in our laboratory. We selected those with COHb≥2.5% in nonsmokers and ≥5% in smokers. In these cases a structured telephone interview was conducted.
Elevated levels of COHb were found in 64 (20%) of the 306 initial determinations. Of these, data from 51 subjects aged 65±12 years, 31 (60%) of which were men, were obtained. Mean COHb was 4.0%. Forty patients (78%) were non-smokers with mean COHb of 3.2%, and 11 were smokers with COHb of 6.7%. In 45 patients (88.2%) we detected exposure to at least one source of ambient CO other than cigarette smoke.
A significant proportion of individuals from an unselected sample had elevated levels of COHb. The main sources of CO exposure were probably in the home, so this possibility should be explored. The population should be warned about the risks and encouraged to take preventive measures.
La inhalación de monóxido de carbono (CO) puede producir intoxicación, ocasionando desde una sintomatología inespecífica hasta la muerte. Muchas veces hay infradiagnóstico ya que exponerse a concentraciones bajas pasa inadvertida, y los valores umbral de normalidad para la carboxihemoglobina varían según distintos autores. El objetivo de nuestro trabajo fue analizar los niveles de carboxihemoglobina (COHb) en una población no seleccionada y detectar las fuentes de exposición al monóxido de carbono.
Con un diseño transversal y descriptivo, se analizaron consecutivamente las gasometrías arteriales procesadas en nuestro laboratorio. Se seleccionaron aquellos que tenían una COHb ≥ 2,5% en no fumadores y ≥ 5% en fumadores. A los casos seleccionados se realizó entrevista telefónica estructurada.
De 306 valoraciones iniciales, 64 casos (20%) tenían valores elevados de COHb y se obtuvieron datos de 51, 31 (60%) varones, de 65 ± 12 años. La media de COHb fue de 4,0%. Cuarenta pacientes (78%) eran no fumadores con niveles de COHb de 3,2% y 11 fumadores con niveles de COHb de 6,7%. En 45 pacientes (88,2%) se detectó exposición a al menos una fuente de producción de CO ambiental distinta al humo del tabaco.
Un porcentaje relevante de individuos de una muestra no seleccionada tiene valores elevados de COHb. Posiblemente las principales fuentes de exposición estén en el domicilio particular, por lo que debe explorarse esta posibilidad, alertar sobre los riesgos y estimular la toma de medidas preventivas.
A rare cause of chronic headache that may be misdiagnosed as migraine: Chronic carbon monoxide poisoning
2014, Turkiye Acil Tip Dergisi
Citation Excerpt :
The association between unsuspected CO poisoning and headache has been investigated in several studies. Heckerling et al.[4] investigated the frequency of occult CO poisoning in patients presenting with headache and dizziness. Of 48 patients presenting with headache, they found increased levels of COHb (greater than 10%) in seven patients, giving a prevalence of 14.6% for CO intoxication.
Differential diagnosis of primary headache disorders can be challenging for physicians. Although the association of headache with acute carbon monoxide intoxication is very well-defined, in refractory nonspecific headaches associated with chronic low dose exposure to carbon monoxide, CO intoxication is usually overlooked, mostly due to vague symptoms. Herein we present a 15-year-old female patient with chronic carbon monoxide poisoning who was undergoing two years of follow-up care for migraines. Chronic carbon monoxide intoxication may mimic the episodic nature and familial predisposition of migraine attacks. Normal carboxyhemoglobin levels do not exclude the diagnosis, and smoking is a confounding factor. In emergency rooms, patients presenting with headaches had higher levels of carboxyhemoglobin, but, as far as we know, there have been no studies investigating carboxyhemoglobin levels in migraine patients. Chronic carbon monoxide poisoning should be suspected in migraine patients, especially if the attacks occur during winter months.
Primer baş ağrısında ayırıcı tanının yapılması bazen doktorlar açısından zor olabilmektedir. Literatürde karbon monoksit ile baş ağrısı arasındaki ilişki çok iyi ortaya konulmuş olmasına karşın, dirençli ve nonspesifik başağrısı nedenlerinden biri olan kronik düşük doz karbon monoksit maruziyeti kendine özgü bulgusu olmadığından sıklıkla atlanmaktadır. Bu yazıda, iki yıl migren tanısı ile takip ve tedavi edilen kronik karbon monoksit zehirlenmesi olan bir olgu sunuldu. Kronik karbon monoksit zehirlenmesi epizodik paterni ve aile fertlerinde benzer şikayetlerin olması nedeniyle migren ataklarını andırabilmektedir. Karboksihemoglobin konsantrasyonlarının normal saptanması tanıyı ekarte ettirmemekte, ayrıca sigara kullanımı da karıştırıcı bir faktör olabilmektedir. Acil servislerine baş ağrısı ile başvuran hastaların karboksihemoglobin seviyeleri başağrısı olmadan acile başvuran hastalardan daha yüksek saptanmaktadır; fakat bildiğimiz kadarı ile karboksihemoglobin seviyesi ile migren arasındaki ilişkinin araştırıldığı bir çalışma literatürde bulunmamaktadır. Migren atakları özellikle kış aylarında tekrarlayan hastalarda kronik karbon monoksit zehirlenmesi akılda tutulmalıdır.
Severity score for predicting pneumonia in inhalation injury patients
2012, Burns
Citation Excerpt :
FiO2/PiO2 less than 300 means acute lung injury; therefore we chose it for the cut off in our study. Significant deterioration in the PaO2:FiO2 ratios were found in both ARDS and inhalation cases in a study by Steinvall et al. [18] Because heavy smokers can have as much as about 9% COHb as well as headache is an early symptom of carbon monoxide (CO) intoxication occurring at COHb >10%, we chose COHb >10% for the cut off in this model [19]. Because the patients of bronscopy grade 1 and 4 were not enough in the study; we were forced to dichotomized “grade 1 or grade 2” and “grade 3 or grade 4” for the logistic regression.
Inhalation injuries contribute significantly to morbidity and mortality in both children and adults with burns. Pneumonia is a major compromising factor in these patients. The purpose of this article was to evaluate the characteristics, impact factors, incidence, morbidity, and mortality of pneumonia in inhalation injuries. Furthermore, a severity score has been formulated to help predict the probability of developing pneumonia following inhalation injuries.
A retrospective study was performed of 214 patients, treated for inhalation injuries from 1999 to 2009 at the Burn Center in Chang Gung Memorial Hospital, Linkou, Taiwan. Patients’ characteristics, length of hospitalization, total burn surface area, initial PaO₂:FiO₂ ratio, number of intubated days, bronchoscope grade, initial carboxyhemoglobin level (COHb) and mortality rate were recorded. A Student's t-test was used for comparison of inhalation injury patients with and without pneumonia and was also used for comparing a TBSA of >20% to those with a TBSA of ≤20% in patients with inhalation injury and pneumonia. Logistic regression analyses were utilized to create a severity score related to pneumonia. 129 patients with inhalation injury were included in the analysis. Overall, 38% (49/129) patients developed pneumonia. Pneumonia associated with inhalation injury occurred more often in patients with a TBSA>20% (P < 0.05). The intubation days, bronchoscope grade and COHb level of pneumonia patients were significantly longer (P < 0.05). Initial PaO₂:FiO₂ ratio (PaO₂/FiO₂) was significantly lower in patients with pneumonia (P < 0.05). Mortality following pneumonia was increased sevenfold (P < 0.05). Hospitalization days and intubation days were significantly longer in TBSA > 20%. Logistic regression analysis was performed to find out the impact factors of pneumonia in inhalation injury patients and to set a severity score. Patients age >60 years, TBSA >20%, bronchoscope grade is 3 or 4, initial PaO₂/FiO₂ ≦ 300 and initial COHb level>10% showed a significant difference (P < 0.05). The total severity scale was set at 5 points. Each impact factor was given one point and when the score ≥2 it means patients have high risk of development of pneumonia.
This study had identified the significant risk factors for potential development of pneumonia in a group of inhalation injury patients. The impact of these risk factors should be validated in further prospective trials to improve outcome or at least reduce the incidence of the surrogate diagnosis of pneumonia.
Carbon Monoxide Poisoning
2007, Haddad and Winchester's Clinical Management of Poisoning and Drug Overdose, Fourth Edition
Toxicity associated with carbon monoxide
2006, Clinics in Laboratory Medicine

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^☆: Abstract presented in part at the Society for Research and Education in Primary Care Internal Medicine, Washington, D.C., May 1, 1986.

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Occult carbon monoxide poisoning: A cause of winter headache☆

Abstract

JACEP

Ann Emerg Med

Lancet

Occult carbon monoxide poisoning

Arch Intern Med

Subacute carbon monoxide poisoning: Another great imitator

JAMA