Carbon Monoxide Poisoning: Family of Six Treated in Chamber at University of Maryland Shock Trauma

An entire family succumbed to furnace exhaust in their home early Tuesday and is now recovering from carbon monoxide poisoning after being rushed to the University of Maryland's Shock Trauma Center. See the full story on WUSA9. UM is not yet listed in our Maryland treatment center directory. The center may operate the only 24/7 hyperbaric chamber in the Washington-Baltimore region, as this report claims. We also note nearby chambers at Northwest Hospital in Randallstown, a UHMS accredited facility with a Level Two trauma center. We're on a mission to gather the most complete and reliable information about emergency-ready hyperbaric chambers to treat carbon monoxide and cyanide poisoning, smoke inhalation, burns, and other traumatic injuries.

Carbon Monoxide Poisoning: West Virginia's Only Emergency-Ready Hyperbaric Chamber Saves Life

Last week St Francis Hospital's Center for Hyperbaric Medicine in Charleston, West Virginia, successfully treated a local hotel guest for severe carbon monoxide poisoning. Another was pronounced dead at the scene. An exhaust pipe from a gas-powered swimming pool heater was the source of the leak. Read the full account in the Charleston Daily Mail.

Some details in this story caught our attention. Dr Lester Labus told reporters his patient arrived at the hospital with 42% carbon monoxide (CO) in his blood. Some additional figures:

• Mild symptoms begin at 10%-20%
• More serious symptoms begin >20%
• Seizures or death occur at 50%-60%
• Half-life of CO with room air = 5 hours
• Half-life of CO breathing pure oxygen = 45 minutes
• Half-life of CO breathing hyperbaric oxygen = 23 minutes

We're checking these facts. We cannot be 100% sure, either, about the article's claim that St Francis operates the only 24/7 access hyperbaric chamber in the state. Our treatment center directory lists five other West Virginia centers, in Bridgeport, Fairmont, Huntington, Morgantown, and Wheeling. None has provided HyperbaricLink with full information about their equipment, facilities, and staff.

We urge all hyperbaric oxygen therapy providers in West Virginia and across the nation to keep us up-to-date about their centers. It's as easy as 3-2-1.

[Photo: Charleston Daily Mail]

Carbon Monoxide Poisoning: Eau Claire, Wisconsin, Center Treats Three and Teaches All

Yesterday a faulty propane tank sickened 13 at a livestock rendering facility in Alma Center, Wisconsin. After treating 3 for carbon monoxide (CO) poisoning, the hyperbaric safety and technical director at OakLeaf Surgical Hospital took to the local media (and YouTube) to help educate the public about this most common cause of death and injury by poisoning. Philip Schell pretty clearly explains how CO kills and how hyperbaric oxygen works. Read more in the Eau Claire Leader-Telegram.

Carbon Monoxide (CO) Poisoning: Fumes Overcome 42 in US Merchant Marine Academy Dorm

A carbon monoxide (CO) leak, apparently from heating equipment, last night filled a dormitory at the US Merchant Marine Academy in Kings Point, Long Island, New York. The New York Post reports 42 midshipmen were sickened and 39 treated at local hospitals. Three victims with the highest CO levels were airlifted to the nearest emergency-ready hyperbaric oxygen chamber at Jacobi Hospital in the Bronx. Every year CO poisoning accounts for some 50,000 emergency room visits and kills about 450 Americans by accidental exposure alone. Visit our Carbon Monoxide Poisoning page for more information about the use of hyperbaric oxygen and the mounting clinical evidence for this FDA-cleared and UHMS-approved indication.

Keepers: Our Top 10 Favorite Posts of 2011

In 2011 we posted 136 blog entries. Every day we scour the hyperbaric business and science news. Often we're inspired to share the news with you. Sometimes we hit on a topic, share a video, or link to a story that really reminds us why we do this. Here's a quick selection of favorites you may have missed or may wish to read again.

Quad Cities Homeless Man Gets HBOT for Frostbite

FDA Urges Caution in Negative Pressure Wound Therapy

Evidence-based HBOT: Trust It or Trash It?

Evidence-based HBOT Is Not CAM

Mixing Hyperbaric Oxygen with Other Prescription Drugs

HyperbaricLink: The Only HONcode Certified Website Focused Exclusively on Hyperbaric Oxygen Therapy

HBOT Program Oversight: Exposé Makes Good Points

VIDEO: Fire Suppression Test of USC Catalina Chamber, Avalon, California

CRAO: Fast Intervention with Hyperbaric Oxygen Helps Save Student's Eyesight

Serious Carbon Monoxide Poisoning Risk from Ice Resurfacing Equipment at Indoor Rinks

We thank you for your readership and participation in the year past, and we look forward to bringing you even more evidence-based hyperbaric oxygen therapy news in the year ahead.

Serious Carbon Monoxide Poisoning Risk from Ice Resurfacing Equipment at Indoor Rinks

Hockey is a violent sport. Figure skaters fall hard. But perhaps the greatest danger at the community ice rink is the Zamboni. This morning the NBC Today Show aired some new twists on a story you often see this time of year, about the threat of carbon monoxide (CO) poisoning at indoor rinks. One full hour after the ice was resurfaced, instruments recorded high levels of CO and investigators evacuated the building. Click play to watch the video below.

The Centers for Disease Control and Prevention (CDC) has plainly said, "Do not operate gasoline-powered engines in confined spaces." Electric ice resurfacers have replaced gasoline-powered machines in some communities. Still, there's no substitute for working carbon monoxide detectors and proper ventilation. More data and recommendations in this excellent paper [Occup Environ Med 2002;59:224-233 doi:10.1136/oem.59.4.224] from 2002.

Only three states—Massachusetts, Minnesota, and Rhode Island—regulate air quality at indoor rinks.

Visit msnbc.com for breaking news, world news, and news about the economy

New on HyperbaricLink: Hyperbaric Oxygen for Smoke Inhalation

Today we have added smoke inhalation to our Diseases and Conditions section. Smoke inhalation is the leading cause of death related to fire. During structure fires, especially, the combustion of plastics, textiles, and other synthetic materials produces a highly toxic mix of cyanide and carbon monoxide. Hyperbaric oxygen therapy (HBOT) is indicated for the emergency treatment of carbon monoxide poisoning complicated by cyanide poisoning after smoke inhalation.

HBOT gives the emergency physician a powerful option for treating smoke inhalation. But ready access to properly equipped and competently staffed hyperbaric treatment centers is spotty, at best. From our commentary:

The emergency treatment of smoke inhalation offers perhaps the single best reason for the healthcare community to demand 24/7 access to hyperbaric chambers across the US. Cyanide, carbon monoxide, inhaled particulates, and thermal injuries together require speedy action to save the lives of firefighters and other fire victims. Ongoing surveillance projects and prospective trials may bolster the clinical case for HBOT in the routine treatment of smoke inhalation.

We urge swift and concerted political action, as well, and will ramp up our support of the hyperbaric and emergency medical communities in the months and years ahead.

Our new page includes more carefully selected links to trustworthy patient and clinical resources. We also recommend the excellent Young Men and Fire by Norman Maclean.

[Photo: A Firefighters Own Worst Enemy blog]

Update: Hyperbaric Oxygen Therapy for Carbon Monoxide (CO) Poisoning

Today we have upgraded and expanded our carbon monoxide (CO) poisoning page. Carbon monoxide is the most common cause of injury and death by poisoning, both accidental and intentional (suicide). Inhaling even small amounts of CO can be fatal. Serious neurological effects may be delayed days or weeks after acute poisoning.

Supplemental oxygen, at normal or hyperbaric pressures, is the primary treatment for carbon monoxide poisoning. Hyperbaric oxygen therapy (HBOT) dissolves additional oxygen in the blood plasma and has been shown to block all known cellular mechanisms of CO toxicity. HBOT is also FDA cleared and UHMS approved to treat smoke inhalation in firefighters and other fire victims who suffer carbon monoxide poisoning complicated by cyanide poisoning. 

CO poisoning remains an active area of HBOT clinical research. From our new commentary:

Every year CO poisoning accounts for some 50,000 emergency room visits and kills about 450 Americans by accidental exposure alone. US fire departments respond to seven nonfire CO incidents every hour [NFPA, 2005]. For more than 50 years emergency physicians have been increasing their use of hyperbaric oxygen to treat acute carbon monoxide poisoning, yet access to emergency-ready hyperbaric chambers remains a public health crisis in the US today. Since 2008 the UHMS has participated in the CDC national surveillance system for carbon monoxide poisoning. Findings from nearly 2,000 cases at 87 hyperbaric facilities in 39 states are just now emerging for careful analysis and publication. These data will make a welcome addition to the medical literature, which currently lacks the strongest evidence, from randomized controlled trials (RCTs), to support the routine use of hyperbaric oxygen for acute CO poisoning [Cochrane Collaboration, 2011]. 

Regular readers of this blog know this topic is dear to our hearts. Once again, we do not consider it unreasonable for the US healthcare community to demand access to an emergency-ready and professionally staffed hyperbaric chamber in every hospital. Yet we're eager to see new evidence in the months and years ahead to support or challenge our views of HBOT for carbon monoxide poisoning and other trauma indications.

Hyperbaric Centers on High Alert for Carbon Monoxide (CO) Poisoning

Warnings about the risk of carbon monoxide poisoning have begun to spread in the news media as the mercury drops and the snow flies in the West, the Midwest, and the Northeast. Hyperbaric oxygen treatment centers have featured prominently this week and last. Read "The Nebraska Medical Center Urges Caution with Carbon Monoxide" in the Journal-Democrat (Syracuse, Nebraska) and click the play button, below, to watch "Hospital sees spike in CO poisonings" from New8 (Hartford, Connecticut). You'll find both Hartford Hospital and Nebraska Medical Center in our treatment center directory.

Hospital sees spike in CO poisonings: wtnh.com

So Begins Another Heating and Carbon Monoxide Poisoning Season

In our local broadcast market the first story broke this week: Fumes send 4 to hospital. One man, in critical condition, "was rushed to the nearest hyperbaric chamber," very likely Advocate Lutheran General Hospital, "where the deadly gas will be forced out of his bloodstream under pressure."

All across America temperatures are dropping and buildings are firing up their furnaces. Every year at this time we send out our warning about carbon monoxide poisoning prevention and emergency preparedness. In three years on this beat we have not recorded any noticeable increase in the number of hyperbaric chambers with 24/7 emergency access, like the one at Lutheran General and at the University of Pittsburgh Medical Center, which so proudly promotes its on-call availability and location inside the emergency department. Now that's what we're talking about.

Someday there will be a round-the-clock chamber inside every ER from coast to coast. Until then, let's be careful in there. Install or check your CO detector today.

[Image: WGN-TV video capture]

CO Poisoning: A Little Help Reading A Big Study

Thanks to the learned evaluation by Dr Leon Gussow in The Poison Review, we have a much firmer grasp of the large study (385 patients) published 2 December 2010 in Intensive Care Medicine, which casts doubt on the efficacy of hyperbaric oxygen for acute carbon monoxide (CO) poisoning. Gussow rates the paper well worth reading: 3.5 skulls-and-crossbones on a scale of 5. But he finds some potentially serious flaws in the study design. Most important, he concludes that the paper "...doesn’t really answer (or address) the key question: Does treating a CO-exposed patient who at any time lost consciousness with HBO improve long-term neurological outcome?" The rest of the TPR analysis explains why.

Meanwhile, in the news just this last week, HBOT proved instrumental in treating people overcome by carbon monoxide fumes in Hyattsville MD, Baltimore, suburban Dayton, Gunnison CO, and Sebring FL. The Florida incident occurred at a hyperbaric oxygen treatment center.

O2.0 is the news blog of HyperbaricLink, the independent web guide to hyperbaric oxygen therapy.

Black Friday

Is the shift from a day dedicated to thanksgiving to a day devoted to voracious acquisitiveness giving you philosophic whiplash? Does the prospect of working off turkey fat by elbowing your way to the best deals on this season's consumer electronics seem rather distonic?

Join us, then, as winter heating season begins, for a brisk walk through the terrain of uncertainty surrounding patients suffering from carbon monoxide poisoning and its long-term effects. Although CO poisoning is an approved indication for hyperbaric oxygen therapy, it is a vastly underutilized treatment for that condition and one for which clinical research is sparse and contradictory.

In studies cited by the Undersea and Hyperbaric Medical Society's Hyperbaric Oxygen Therapy Indications, the 1,500+ patents treated with hyperbaric oxygen during a ten year period from 1992 to 2002 represent only a tiny portion of the 400,000 people estimated to have been seen in emergency rooms for CO poisoning during the same period. Not all incidents of carbon monoxide poisoning are acute, and not all victims seek immediate medical care, so the number of people effected could well be higher.

What accounts for the shortfall? As we previously reported, accurate diagnosis of CO poisoning is an issue. But the state of existing research and a lack of widely accepted protocols undoubtedly has a role in physician acceptance. Uncertainty over efficacy and treatment protocols weighed against potential side effects likely makes physicians reluctant to prescribe the treatment.

Even when detected by a doctor who regards HBOT as an effective treatment and appropriate for the case at hand, access to resources is an issue. Although there are well over 1,000 hyperbaric treatment centers in the United States, many are outpatient wound care facilities, independent hyperbaric clinics, or otherwise not integrated with a hospital's emergency services. For acute cases, access to hyperbaric facilities is likely to require patient transportation in many parts of the country. Traveling a considerable distance for multiple treatments adds to the challenges faced by patients suffering neurologic effects.

Much of the attention focused on carbon monoxide intoxication focuses on acute cases and short-term treatment. Standard protocols and current clinical trials involve 1 to 3 treatments and neuropsychiatric outcomes after 6 weeks. There is, however, research to support more lasting effects of COI. A 2009 review of clinical literature from 1974 through 2006 by the Department of Psychiatry at the University Hospital of Geneva found patients reporting symptoms for more than 30 years after CO poisoning and "affective disorders are observed in almost three-fourths of patients and personality disorders in more than half." The authors speculate that carbon monoxide intoxication may "constitute a risk factor in the waking of long-term neuropsychiatric disorders."

While not all victims of carbon monoxide poisoning have pre-existing risks for psychiatric disorders or suffer severe long-term effects of COI, there are still an array of potential cognitive and affective impairments. What can be done to detect these and measure the efficacy of hyperbaric oxygen therapy in improving patient outcomes? According to a 1995 study by the Center for Prehospital Care at UCLA Hospitals and Clinics, the standard CO Neuropsychological Screening Battery (CONSB) was "ineffective in detecting subtle neurological disturbances in victims of low-level CO poisoning", although the 1991 study by the Maryland Institute for Emergency Medical Services found the test battery to be "effective in evaluating cerebrally impaired CO-poisoned patients" and recommended its use for adequately assessing patients requiring aggressive hyperbaric oxygen therapy. The choice of diagnostic tools may need to be more closely calibrated to the severity and duration of carbon monoxide exposure.

None of the previous studies or current clinical trials evaluate long-term treatment of CO poisoning with HBOT, or speculate as to how neuropsychiatric improvements resulting from HBOT treatment could be measured effectively over time spans exceeding those considered in current studies. While it's possible recent advances in imaging can contribute to the body of evidence, it's likely cognitive testing will continue to be an important resource.

We'd like to suggest exploring a role for the subject-object interview as a diagnostic tool. Based on the understanding that people do not normally regress in their order of consciousness, the test could be used to detect the effects of CO poisoning if it can be shown that regression occurs in individuals effected by forms of brain injury. While the most useful context for comparison would be a relatively recent test prior to injury, severe impairment might be distinguishable relative to normative values for a relevant population group. Speculative, to be sure, but we're generally in favor of the subject-object interview being more widely conducted and understood. If it helps gain greater insight into brain injuries, so much the better.

Good luck with the shopping.

A Model For Hyperbaric Referral Instructions

How delighted we'd be if every ProfilePlus page in the HyperbaricLink treatment center directory were linked to such clear and complete information for referring physicians as Virginia Mason Medical Center (Seattle WA) provides on its website. The center's updated Emergency Hyperbaric Referral Instructions page, strictly covering carbon monoxide poisoning, decompression sickness, and arterial gas embolism, neatly summarizes:

• Definitions/Causes
• Diagnosis/Symptoms
• Indications for hyperbaric treatment
• EMS management guidelines
• Patient information to capture

We think this simple format is a model of its kind. But why limit such helpful information to emergency indications? Referring physicians might benefit even more from expert guidance on chronic diseases and conditions.

O2.o is the news blog of HyperbaricLink, the independent web guide to hyperbaric oxygen therapy, at www.hyperbariclink.com

Hyperbaric Oxygen: What Is The Correct Dose?

Ask four experts and you'll get five opinions, as the old joke goes. We were so looking forward to Thursday afternoon's UHMS plenary session but came away even more completely baffled about how your average hyperbaric physician decides what pressure, duration, and number of treatments to prescribe. To say there is wide variation in practice would be a gross understatement.

Only the Navy, the Air Force, and the Divers Alert Network, it seems, stick to some sort of standard dosing tables. Even these standards share a dubious pedigree, which speaker Paul Sheffield traced back to (1) the arbitrary selection of the 90-minute sessions used to treat gas gangrene in 1961 and (2) the strange translation from 45 feet of seawater or FSW to 2.36 atmospheres absolute or ATA. Well, that explains that, anyway.

Practice is one thing. A lack of guidance on dosing also hamstrings the responsible clinical investigator. Dr Neil Hampson, of Virginia Mason Medical Center in Seattle, recounted his quest for "the Holy Grail of HBO2 dosing" when powering his ongoing randomized, controlled trial for carbon monoxide poisoning. He ended the session by suggesting that some measure of cumulative dose, such as ATA-hours, might prove more meaningful than individual doses or numbers of treatments. We seriously doubt it. And we're little comforted by Dr Hampson's claim that "HBOT works, but we still don't know the right dose." Only the right dose works, or are we wrong?

Oxygen is a drug. Pressure is strong medicine. Yet dose ranging studies and so much other basic science has been left undone, for so many decades, we sometimes wonder how hyperbaric physicians expect to gain the respect of the broader medical community.

By holding plenary sessions like this one, is the answer, and sharing a healthy, truthful accounting of the state of affairs. Now to act on the lack of information. Then the applause, applause.

CO Detection: There's An App For That

Soon your cell phone may grow a nose that constantly sniffs the air for carbon monoxide and other dangerous airborne chemicals. Not only would this electronic innovation make your phone a personal CO detector, it could also alert civil defense authorities and emergency first responders to chemical events in real time.

Scientists at UC San Diego and Rhevision developed the tiny detectors, which use supermacro lenses to watch silicon chips that change color when exposed to airborne chemicals. Patterns of color on a single chip can signal a wide variety of toxic hazards.

UCSD's Michael Sailor and team are busy working on prototypes for cell phones and firefighter helmets. The project is funded by the Department of Homeland Security.

Thank you, Medgadget, for alerting us to another amazing new technology.

(Photo: Sailor Lab/UCSD)

CO Poisoning: Is HBOT Still The Gold Standard?

One of our chief missions is to raise awareness and help increase 24/7 access to HBOT chambers at emergency rooms for victims of thermal burns, smoke inhalation, and carbon monoxide poisoning. (Review our past coverage here.) So we were especially pleased to discover a new posting of a 2007 talk by Dr Fred Fiesseler of Morristown (NJ) Memorial Hospital. Drawn from case studies and a review of the medical literature, Fiesseler's presentation reaffirms our commitment to this mission. To listen to the audio file follow this link:

Is Hyperbaric Oxygen Still the Standard for Carbon Monoxide Poisoning?

Going forward we will be identifying ER-accessible chambers in our treatment center directory and partnering with emergency medical associations and innovative companies like Healthagen to spread this lifesaving information far and wide.

Of course some political activism may be in order, too, and count on HyperbaricLink to be there.

HCMC Chamber Reprieved By Senate Earmark

Confirmation arrives late that the US Senate's year-end spending bill, a whopping $1 trillion that barely escaped a filibuster Sunday, includes a $400,000 earmark for replacement of Hennepin County Medical Center's aging hyperbaric chamber. We'd like to think our fall coverage played a small part (but know better). Here's wishing HCMC speedy project funding and completion.

HBOT: Homeland Security Against Cyanide Terrorism

One shudders to think of it, but cyanide poison has become an all-too-imaginable weapon of terror in these troubled times. Maybe we're especially troubled, writing to you from Chicago, home of the 1982 Tylenol murders and the subway scare of 2002.

Hyperbaric oxygen may play a small but critical role in our preparedness for cyanide attacks. According to the chemical terrorism update by Coleman O. Martin, MD, in the July 2002 issue of Emergency Medicine:

Hyperbaric oxygen administration is an adjunctive therapy in patients who do not respond to cyanide antidotes. This may be particularly helpful in cases where methemoglobinemia is excessive and the patient cyanotic. Hyperbaric oxygen should also be considered in patients with cyanide toxicity from smoke inhalation because their high levels of carboxyhemoglobin can hinder safe induction of methemoglobinemia.

Of course O2.0 readers will know that HBOT is approved for treating carbon monoxide (CO) poisoning complicated by cyanide poisoning after smoke inhalation. Better homeland security provides all the more reason every fire rescue squad and trauma center in the US should have 24/7 access to emergency-ready hyperbaric oxygen chambers—plenty enough to handle large-scale disasters, whether tragic accidents or unspeakable acts.

Minnesota: HCMC Fights Back

As the mercury falls in Minnesota, so rises the battle cry to save Hennepin County Medical Center from deep budget cuts. Without swift legislative action, before March 2010, the state's only 24/7 emergency-ready hyperbaric chamber is sure to shut down. (See our October 4 story, "Embattled MN Chamber Faces Ax.")

HCMC is fighting back. Making savvy use of online social media and good old-fashioned grassroots politics, the new Will You Lose? campaign underscores the medical center's proud history and modern role in disaster preparedness and statewide emergency healthcare access, especially for the uninsured. It also offers a great way for the hyperbaric medicine community to get involved. Please join O2.0 in signing up and spreading the word.

(Pictured: Jim Harris, CHT, at the HCMC chamber controls. Photo: Jim Gehrz, Star Tribune)

Carbon Monoxide Poisoning: A Public Health Crisis

We bring you yet more deadly stats for the cold and "flue" season. Carbon monoxide poisoning accounts for some 50,000 emergency room visits annually in the US. Every year about 450 Americans die from accidental exposure alone. Death rates peak in December and January. Almost all survivors experience serious immediate and lasting neuropsychological effects.