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<< Diagnosis And Management Of Carbon Monoxide Poisoning In The Emergency Department


Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study, will be included in bold type following the reference, where available. In addition, the most informative references cited in this paper, as determined by the authors, are noted by an asterisk (*) next to the number of the reference.

  1. Ernst A, Zibrak JD. Carbon monoxide poisoning. N Engl J Med. 1998;339:1603-1608. (Review article)
  2. Weaver LK. Carbon monoxide poisoning. Crit Care Clin. 1999;15:297-317, viii. (Review article)
  3. Tibbles PM, Perrotta PL. Treatment of carbon monoxide poisoning: a critical review of human outcome studies comparing normobaric oxygen with hyperbaric oxygen. Ann Emerg Med. 1994;24:269-276. (Review article)
  4. Hampson NB, Weaver LK. Carbon monoxide poisoning: a new incidence for an old disease. Undersea Hyperb Med. 2007;34:163-168. (Retrospective incidence study)
  5. Hardy KR, Thom SR. Pathophysiology and treatment of carbon monoxide poisoning. J Toxicol Clin Toxicol. 1994;32:613- 629. (Review article)
  6. Centers for Disease Control and Prevention. Carbon monoxide poisoning fact sheet. http://www.cdc.gov/co/faqs.htm. Accessed 3/22/2010.
  7. * Wolf SJ, Lavonas EJ, Sloan EP, et al. Clinical policy: critical issues in the management of adult patients presenting to the emergency department with acute carbon monoxide poisoning. Ann Emerg Med. 2008;51(2);138-152. (Clinical policy)
  8. Centers for Disease Control and Prevention. Unintentional non-fire-related carbon monoxide exposures - United States, 2001-2003. MMWR. 2005;54(02);36-39.
  9. Centers for Disease Control and Prevention. Carbon monoxide poisonings resulting from open-air exposures to operating motorboats - Lake Havasu City, Arizona, 2003. MMWR. 2004;53(15);314-318.
  10. Tomaszewski C. Carbon monoxide. In: Goldfrank LR, Nelson LS, Howland MA, Lewin NA, Flomenbaum NE, Hoffman RS, eds. Goldfrank’s Toxicologic Emergencies. New York, NY: McGraw-Hill; 2006:1689-1704. (Textbook chapter)
  11. Satran D, Henry CR, Adkinson C, et al. Cardiovascular manifestations of moderate to severe carbon monoxide poisoning. J Am Coll Cardiol. 2005;45:1513-1516. (Retrospective study; 230 patients)
  12. Thom SR, Taber RL, Mendiguren II, et al. Delayed neuropsychologic sequelae after carbon monoxide poisoning: prevention by treatment with hyperbaric oxygen. Ann Emerg Med. 1995;25:474-480. (Prospective, randomized, controlled trial; 60 patients)
  13. * Choi IS. Delayed neurologic sequelae in carbon monoxide intoxication. Arch Neurol. 1983;40:433-435. (Prospective, descriptive study; 2360 patients)
  14. Kwon OY, Chung SP, Ha YR, et al. Delayed postanoxic encephalopathy after carbon monoxide poisoning. Emerg Med J. 2004;21:250-251. (Case report)
  15. Piantadosi CA, Zhang J, Levin ED, et al. Apoptosis and delayed neuronal damage after carbon monoxide poisoning in the rat. Exp Neurol. 1997;147:103-114. (Animal study)
  16. Lavonas EJ. Carbon monoxide poisoning. In: Shannon M, Borron S, Burns M, eds. Haddad and Winchester’s Clinical Management of Poisoning and Drug Overdose. Philadelphia, Pa: Elsevier; 2007:1297-1307. (Textbook chapter)
  17. Dolan MC, Haltom TL, Barrows GH, et al. Carboxyhemoglobin levels in patients with flu-like symptoms. Ann Emerg Med. 1987;16:782-786. (Prospective, descriptive study; 55 patients)
  18. Linden CH. Smoke inhalation. In: Shannon MW, Borron SW, Burns MJ, eds. Haddad and Winchester’s Clinical Management of Poisoning and Drug Overdose. Philadelphia, Pa: Elsevier; 2007:1284.
  19. Piantadosi CA. Carbon monoxide poisoning. Undersea Hyperb Med. 2004;31:167-177. (Review article)
  20. Piatkowski A, Ulrich D, Greib G, et al. A new tool for the early diagnosis of carbon monoxide intoxication. Inhalation Toxicology. 2009;21(13):1144-1147. (Prospective, descriptive study; 25 patients)
  21. Coulange M, Barthelemy A, Hug F, et al. Reliability of new pulse CO oximeter in victims of carbon monoxide poisoning. Undersea Hyperb Med. 2008;35(2):107-111. (Prospective, descriptive study; 12 patients)
  22. O’Malley GF. Non-invasive carbon monoxide measurement is not accurate. Ann Emerg Med. 2006;48:477-478. (Letter)
  23. Harper A, Croft-Baker J. Carbon monoxide poisoning: undetected by both patients and their doctors. Age Ageing. 2004;33:105-109. (Review article)
  24. Touger M, Gallagher EJ, Tyrell J. Relationship between venous and arterial carboxyhemoglobin levels in patients with suspected carbon monoxide poisoning. Ann Emerg Med. 1995;25:481-483. (Comparative study; 61 patients)
  25. Ratney RS, Wegman DH, Elkins HB. In vivo conversion of methylene chloride to carbon monoxide. Arch Environ Health. 1974;28:223-236.
  26. Anderson EF, Allensworth DC, DeGroot WJ. Myocardial toxicity from carbon monoxide poisoning. Ann Internal Med. 1967;67:1172-1182.
  27. Cramlet SH, Erickson H, Gorman HA. Ventricular function following carbon monoxide exposure. J Appl Physiol. 1975;39:482-486. (Animal study)
  28. Hill EP, Hill JR, Power GG, et al. Carbon monoxide exchanges between the human fetus and mother: a mathematical model. Am J Physiol. 1977;232:H311-H323.
  29. Jones JS, Lagasse J, Zimmerman G. Computed tomographic findings after acute carbon monoxide poisoning. Am J Emerg Med. 1994;12:448-451. (Prospective, descriptive study; 19 patients)
  30. Kim KS, Weinberg PE, Suh JH, et al. Acute carbon monoxide poisoning: computer tomography of the brain. Am J Neuroradiol. 1980;1:399-402.
  31. Sokal JA, Kralkowska E. The relationship between exposure duration, carboxyhemoglobin, blood glucose, pyruvate, and lactate and the severity of intoxication in 39 cases of acute carbon monoxide poisoning in man. Arch Toxicol. 1985;57:196- 199. (Prospective, descriptive study; 39 patients)
  32. * Juurlink DN, Buckley NA, Stanbrook MB, et al. Hyperbaric oxygen for carbon monoxide poisoning. Cochrane Database Syst Rev. 2005;(1):CD002041. (Meta-analysis)
  33. Brown SD, Piantadosi CA. Recovery of energy metabolism in rat brain after carbon monoxide hypoxia. J Clin Invest. 1992;89(2):666-672. (Animal study)
  34. Chen KC, McGrath JJ. Response of the isolated heart to carbon monoxide and nitrogen anoxia. Toxicol Appl Pharmacol. 1985;81:363-370. (Animal study)
  35. Thom SR. Functional inhibition of leukocyte B2 integrins by hyperbaric oxygen in carbon monoxide-mediated brain injury in rats. Toxicol Appl Pharmacol. 1993;123:248-256. (Animal study)
  36. Thom SR. Carbon monoxide. In: Brent J, Phillips SD, Wallace KL, eds. Critical Care Toxicology. Philadelphia, Pa: Elsevier Mosby; 2005:975-985. (Textbook chapter)
  37. Ilano AL, Raffin TA. Management of carbon monoxide poisoning. Chest. 1990;7:165-169. (Review article)
  38. * Elkharrat D, Raphael JC, Korach JM, et al. Acute carbon monoxide intoxication and hyperbaric oxygen in pregnancy. Intensive Care Med. 1991;17:289-292. (Prospective study; 44 patients)
  39. Cho SH, Yun DR. The experimental study on the effect of hyperbaric oxygen on the pregnancy wastage of rats with acute carbon monoxide poisoning. Seoul Journal of Medicine. 1982;23:67-75. (Animal study)
  40. * Weaver LK, Hopkins RO, Chan KJ, et al. Hyperbaric oxygen for acute carbon monoxide poisoning. N Engl J Med. 2002;347:1057-1067. (Prospective, randomized, controlled trial; 152 patients)
  41. * Ducasse JL, Celsis P, Marc-Vergnes JP. Non-comatose patients with acute carbon monoxide poisoning: hyperbaric or normobaric oxygenation? Undersea Hyperb Med. 1995;22:9-15. (Prospective, randomized, controlled trial; 26 patients)
  42. * Raphael JC, Elkharrat D, Jars-Guincestre MC, et al. Trial of normobaric and hyperbaric oxygen for acute carbon monoxide intoxication. Lancet. 1989;2:414-419. (Prospective, randomized, controlled trial; 629 patients)
  43. * Scheinkestel CD, Bailey M, Myles PS, et al. Hyperbaric or normobaric oxygen for acute carbon monoxide poisoning: a randomised controlled clinical trial. Med J Aust. 1999;170:203- 210. (Prospective, randomized, controlled trial; 191 patients)
  44. Hyperbaric Oxygen Therapy Committee. Indications for hyperbaric oxygen therapy, 12th edition. Undersea & Hyperbaric Medical Society. http://www.uhms.org/Default. aspx?tabid=270 Accessed 5/5/2010.
  45. BlueCross BlueShield of Tennessee Medical Policy Manual. http://www.bcbst.com/mpmanual/WHStart. htm. Accessed 8/14/2010. (Insurance policy manual)
  46. BlueCross BlueShield of Massachusetts Medical Policy #435, revised 9/23/09. http://www.priorityhealth.com/provider/ manual/policies/91151.pdf. Accessed 6/30/2010. (Insurance policy manual)
  47. Hamilton MG, Tranmer BI, Auer RN. Insulin reduction of cerebral infarction due to transient focal ischemia. J Neurosurg. 1995;82:262-268. (Animal study)
  48. White SR, Penney DG. Initial study: effects of insulin and glucose treatment on neurologic outcome after CO poisoning. Ann Emerg Med. 1994;23:606.
  49. Penney DG, Chen K. NMDA receptor-blocker ketamine protects during acute carbon monoxide poisoning, while calcium channel-blocker verapamil does not. J Appl Toxicol. 1996;16(4):297-304. (Animal study)
  50. Kim SJ, Jung YS, Yoon MY, et al. Comparative effects of dimethylsulfoxide on metabolism and toxicity of carbon tetrachloride and dichloromethane. J Appl Toxicol. 2007;27(1):25- 31. (Animal study)
  51. Howard RJ, Blake DR, Pall H, et al. Allopurinol/Nacetylcysteine for carbon monoxide poisoning. Lancet. 1987;2(8559):628-629. (Case report)
  52. Koren G, Sharav T, Pastuszak A, et al. A multicenter, prospective study of fetal outcome following accidental carbon monoxide poisoning in pregnancy. Reprod Toxicol. 1991;5:397- 403. (Prospective, descriptive study; 32 patients)
  53. Norman CA, Halton DM. Is carbon monoxide a workplace teratogen? A review and evaluation of the literature. Ann Occup Hyg. 1990;34:335-347. (Review article)
  54. Van Hoesen KB, Camporesi EM, Moon RE, et al. Should hyperbaric oxygen be used to treat the pregnant patient for acute carbon monoxide poisoning? A case report and literature review. JAMA. 1989;261:1039-1043. (Case report)

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