Specific Issues

CO intoxication is especially harsh on the very old and very young. It does not differentiate as to gender. Pregnant patients with CO intoxication have no greater risk, but the fetus is at greater risk than the mother for ischemic injury due the greater affinity of fetal hemoglobin than adult hemoglobin for CO. 18

CO intoxication is more severe in patients with the comorbidity of multiple trauma, thermal or chemical burns, smoke inhalation, cerebral ischemia, or myocardial ischemia. CO intoxication coupled with drug intoxicants increases the risk of failure at self-evacuation from a toxic atmosphere. Further, concurrent inhalation of inert gas (natural gas), carbon dioxide, or chemical asphyxiants (NO, H2S, HCN) can augment ischemic insult in a CO patient.

Missed diagnosis of CO intoxication is a potential malpractice liability for the emergency physician. The return of a patient to a yet unidentified toxic environment must be prevented. In particular, the failure to understand that serious CO intoxication with residual ischemic injury may exist in a patient even with low HbCO levels has led to malpractice judgments against the emergency physician. In addition, the failure to identify, in a CO-injured patient, nonresponse to normobaric oxygen treatment and hence the failure to access hyperbaric oxygen treatment has resulted in large awards to the patient.

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