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Sethuraman K, Thom SR. Hyperbaric oxygen should be used for carbon monoxide poisoning. Br J Clin Pharmacol 2023; 89:939-941. [PMID: 36457237 DOI: 10.1111/bcp.15605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 02/08/2022] [Accepted: 02/11/2022] [Indexed: 12/04/2022] Open
Abstract
This short review addresses the mechanisms of injury mediated by carbon monoxide (CO) and current information on efficacy of hyperbaric oxygen therapy (HBOT). Recent clinical series involving large, country-wide databases and prospective randomized trials are summarized. We conclude that there is an abundance of basic science and preclinical and clinical research supporting the use of HBOT for acute CO poisoning. With appropriate consideration for pathology and therapeutic mechanisms, HBOT at a dose of 2.5-3.0 atm absolute is a necessary treatment for this toxidrome.
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Affiliation(s)
- Kinjal Sethuraman
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Stephen R Thom
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
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Baharara H, Ghasemi H, Samadi S, Roohshad B, Jomehzadeh V, Ravankhah Moghaddam K, Mohammadpour AH, Arasteh O. The effect of preconditioning agents on cardiotoxicity and neurotoxicity of carbon monoxide poisoning in animal studies: a systematic review. Drug Chem Toxicol 2023; 46:256-270. [PMID: 35616381 DOI: 10.1080/01480545.2021.2021931] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Carbon monoxide (CO) poisoning is a common intoxication and many people die yearly due to CO poisoning and preconditioning agents attenuate brain and cardiac injury caused by intoxication. It is critical to fully understand the efficacy of new methods to directly target the toxic effect of CO, such as conditioning agents, which are currently under development. This study aims to systematically investigate current evidence from animal experiments and the effects of administration preconditions in acute and late phases after CO poisoning on cardiotoxicity and neurotoxicity. METHODS Four databases (PubMed, Embase, Scopus, and Web of Science) were systematically searched without language restrictions, and hand searching was conducted until November 2021. We included studies that compare preconditioning agents with the control group after CO poisoning in animals. The SYRCLE RoB tool was used for risk of bias assessments. RESULTS Thirty-seven studies were included in the study. Erythropoietin, granulocyte colony-stimulating factor (GCSF), hydrogen-rich saline, and N-butylphthalide (NBP) were found to have positive effects on reducing neurotoxicity and cardiotoxicity. As other preconditions have fewer studies, no valuable results can be deduced. Most of the studies were unclear for sources of bias. DISCUSSION Administration of the examined preconditioning agents including NBP, hydrogen-rich saline, and GCSF in acute and late phases could attenuate neurotoxicity and cardiotoxicity of CO poisoned animals. For a better understanding of mechanisms and activities, and finding new and effective preconditioning agents, further preclinical and clinical studies should be performed to analyze the effects of preconditioning agents.
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Affiliation(s)
- Hamed Baharara
- Department of Clinical Pharmacy, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Hanieh Ghasemi
- Department of Clinical Pharmacy, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Sara Samadi
- Department of Clinical Pharmacy, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran.,Student Research Committee, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Bahar Roohshad
- Student Research Committee, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Vahid Jomehzadeh
- Department of Surgery, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | | | - Amir Hooshang Mohammadpour
- Department of Clinical Pharmacy, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran.,Pharmaceutical Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Omid Arasteh
- Department of Clinical Pharmacy, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
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Omi T. Cerebrospinal Fluid Biomarkers for Monitoring Delayed Neurologic Sequelae after Carbon Monoxide Poisoning. Neurol India 2022; 70:1668-1669. [PMID: 36076681 DOI: 10.4103/0028-3886.355093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Delayed neuropsychiatric sequelae (DNS), which are related to neuropsychiatric symptoms and severe sequelae, occur within a few days of recovery from acute poisoning. They may involve a slowly progressing demyelinating white matter lesion caused by carbon monoxide cytotoxicity; moreover, the involvement of immune mechanisms has been reported. However, there remains no established treatment or therapeutic gain factors. A 29-year-old man with DNS who experienced carbon monoxide poisoning underwent corticosteroid therapy with concomitant measurements of cerebrospinal fluid levels of MBP, IL-6, and pNF-H. Treatment led to an improvement in symptoms and lesions on magnetic resonance imaging. Corticosteroid therapy and monitoring can be used to treat and monitor DNS.
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Affiliation(s)
- Tsubasa Omi
- Health Service Center, Saitama University, Saitama-shi, Japan
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Ruhela D, Bhopale VM, Kalakonda S, Thom SR. Astrocyte-derived microparticles initiate a neuroinflammatory cycle due to carbon monoxide poisoning. Brain Behav Immun Health 2021; 18:100398. [PMID: 34917988 PMCID: PMC8645452 DOI: 10.1016/j.bbih.2021.100398] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 11/23/2021] [Accepted: 11/24/2021] [Indexed: 11/30/2022] Open
Abstract
We hypothesized that carbon monoxide (CO) establishes an inflammatory cycle mediated by microparticles (MPs). Mice exposed to a CO protocol (1000 ppm for 40 min and then 3000 ppm for 20 min) that causes neuroinflammation exhibit NF-κB activation in astrocytes leading to generation of MPs expressing thrombospondin-1(TSP-1) that collect in deep cervical lymph nodes draining the brain glymphatic system. TSP-1 bearing MPs gain access to the blood stream where they activate neutrophils to generate a new family of MPs, and also stimulate endothelial cells as documented by leakage of intravenous 2000 kDa dextran. At the brain microvasculature, neutrophil and MPs sequestration, and myeloperoxidase activity result in elevations of the p65 subunit of NF-κB, serine 536 phosphorylated p65, CD36, and loss of astrocyte aquaporin-4 that persist for at least 7 days. Knock-out mice lacking the CD36 membrane receptor are resistant to all CO inflammatory changes. Events triggered by CO are recapitulated in naïve wild type mice injected with cervical node MPs from CO-exposed mice, but not control mice. All MPs-mediated events are inhibited with a NF-κB inhibitor, a myeloperoxidase inhibitor, or anti-TSP-1 antibodies. We conclude that astrocyte-derived MPs expressing TSP-1 establish a feed-forward neuroinflammatory cycle involving endothelial CD36-to-astrocyte NF-κB crosstalk. As there is currently no treatment for CO-induced neurological sequelae, these findings pose several possible sites for therapeutic interventions. Carbon monoxide (CO) causes neurological injuries poorly correlated to hypoxic stress. Astrocyte NF-κB triggers thrombospondin-1(TSP-1) microparticle (MP) production. TSP-1 MPs enter the blood stream, stimulating neutrophils and endothelium. Circulating MPs linkage to endothelial cell CD36 causes vascular damage. Endothelial CD36-to-astrocyte NF-κB crosstalk establishes a neuroinflammatory cycle.
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Key Words
- 4-methyl-N1-(3-phenyl-propyl)-benzene-1,2-diamine, JSH-23
- Acetyl-lysyltyrosylcysteine
- Aquaporin-4
- Aquaporin-4, AQP4
- Astrocyte
- CD36
- Carbon monoxide, CO
- Carboxyhemoglobin, COHb
- Glial fibrillary acidic protein, GFAP
- Glymphatics
- Magnetic resonance imaging, MRI
- Microparticles, MPs
- Myelin basic protein, MBP
- Myeloperoxidase
- Myeloperoxidase, MPO
- Neuronal pentraxin receptor, NPR
- Neutrophil
- Nod-like receptor pyrin containing 3, NLRP3
- Nuclear factor- κB, NF-κB
- Phosphate buffered saline, PBS
- Phosphatidylserine, (PS)
- Thrombospondin-1
- Thrombospondin-1, TSP-1
- Transmembrane protein119, TMEM
- acetyl-lysyltyrosylcysteine, KYC
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Affiliation(s)
- Deepa Ruhela
- Department of Emergency Medicine, University of Maryland School of Medicine, USA
| | - Veena M Bhopale
- Department of Emergency Medicine, University of Maryland School of Medicine, USA
| | - Sudhakar Kalakonda
- Department of Emergency Medicine, University of Maryland School of Medicine, USA
| | - Stephen R Thom
- Department of Emergency Medicine, University of Maryland School of Medicine, USA
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5
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Association between Neuron-Specific Enolase Gene Polymorphism and Delayed Encephalopathy after Acute Carbon Monoxide Poisoning. Behav Neurol 2020; 2020:8819210. [PMID: 33123300 PMCID: PMC7584970 DOI: 10.1155/2020/8819210] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 09/11/2020] [Accepted: 09/30/2020] [Indexed: 11/18/2022] Open
Abstract
Objective The aim of this study is to explore the relationship between neuron-specific enolase (NSE) gene polymorphism and delayed encephalopathy after acute carbon monoxide poisoning (DEACMP) and provide a theoretical basis for DEACMP pathogenesis, diagnosis, and prognosis. Methods To investigate this relationship, we screened 6 NSE single nucleotide polymorphisms (SNPs), based on the results of the previous genome-wide association studies (GWAS). A total of 1,201 patients, including 416 in the DEACMP group and 785 in the acute carbon monoxide poisoning (ACMP) group, were detected by the Sequenom MassARRAY® method. The genotype frequencies and alleles of the 6 NSE SNPs (rs2071074, rs2071417, rs2071419, rs11064464, rs11064465, and rs3213434) were compared using different genetic models. Results In the SNPs rs2071419 and rs3213434, we found that the genotypes and allele frequencies in the two groups significantly correlated with the grouping of patients (χ 2 = 6.596, p = 0.037; χ 2 = 8.769, p = 0.012). The haplotypes GGTTTC and CCTTTC of ACMP and DEACMP were different (χ 2 = 6.563, p = 0.010; χ 2 = 4.151, p = 0.042). We also observed that rs2071419 and rs3213434 significantly correlated with DEACMP-increased risk in the dominant, codominant, and overdominant genetic models. In addition, we speculated that the C allele of the rs2071419 polymorphism and the T allele of the rs3213434 polymorphism in NSE may increase the DEACMP risk (p = 0.011, p = 0.006). Conclusions The results show that rs2071419 and rs3213434 are susceptible sites of DEACMP. The NSE C allele of rs2071419 and T allele of rs3213434 and the haplotypes GGTTTC and CCTTTC may be risk factors for DEACMP.
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Reisinger A, Rabensteiner J, Hackl G. Diagnosis of acute intoxications in critically ill patients: focus on biomarkers - part 2: markers for specific intoxications. Biomarkers 2020; 25:112-125. [PMID: 32011177 DOI: 10.1080/1354750x.2020.1725787] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
In medical intensive care units, acute intoxications contribute to a large proportion of all patients. Epidemiology and a basic overview on this topic were presented in part one. The purpose of this second part regarding toxicological biomarkers in the ICU setting focuses on specific poisons and toxins. Following the introduction of anion and osmol gap in part one, it's relevance in toxic alcohols and other biomarkers for these poisonings are presented within this publication. Furthermore, the role of markers in the blood, urine and cerebrospinal fluid for several intoxications is evaluated. Specific details are presented, amongst others, for cardiovascular drug poisoning, paracetamol (acetaminophen), ethanol, pesticides, ricin and yew tree intoxications. Detailed biomarkers and therapeutic decision tools are shown for carbon monoxide (CO) and cyanide (CN-) poisoning. Also, biomarkers in environmental toxicological situations such as mushroom poisoning and scorpion stings are presented.
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Affiliation(s)
- Alexander Reisinger
- Intensive Care Unit, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Jasmin Rabensteiner
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, Graz, Austria
| | - Gerald Hackl
- Intensive Care Unit, Department of Internal Medicine, Medical University of Graz, Graz, Austria
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Gu J, Zeng J, Wang X, Gu X, Zhang X, Zhang P, Zhang F, Han Y, Han Y, Zhang H, Li W, Gu R. LRCH1 polymorphisms linked to delayed encephalopathy after acute carbon monoxide poisoning identified by GWAS analysis followed by Sequenom MassARRAY® validation. BMC MEDICAL GENETICS 2019; 20:197. [PMID: 31842790 PMCID: PMC6916040 DOI: 10.1186/s12881-019-0931-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Accepted: 11/28/2019] [Indexed: 11/10/2022]
Abstract
BACKGROUND We explored the association of leucine-rich repeats and calponin homology domain containing 1 (LRCH1) gene polymorphisms with genetic susceptibility to delayed encephalopathy after acute carbon monoxide poisoning (DEACMP), which might provide a theoretical basis for the pathogenesis, diagnosis, and prognosis research of DEACMP. METHODS Four single nucleotide polymorphisms, rs1539177 (G/A), rs17068697 (G/A), rs9534475 (A/C), and rs2236592 (T/C), of LRCH1, selected as candidate genes through genome-wide association analysis, were genotyped in 661 patients (DEACMP group: 235 cases; ACMP group: 426 cases) using Sequenom Massarray®. The association analysis of four SNPs and LRCH1 was performed under different genetic models. RESULTS LRCH1 polymorphisms (rs1539177, rs17068697, rs9534475) under additive and dominant genetic models were significantly associated with an increased risk of DEACMP, but no significant association under allele and recessive models was found. The LRCH1 rs2236592 polymorphism was susceptible to DEACMP only under the dominant model (TT/TC + CC, OR = 1.616, 95% CI: 1.092-2.390, P = 0.015784). In addition, the A allele gene of rs9534475 polymorphism in LRCH1 might increase the risk for DEACMP (OR = 1.273, 95% CI: 1.013-1.601, P = 0.038445). CONCLUSIONS We found a significant association between the four LRCH1 polymorphisms and DEACMP. The allelic A of rs9534475 polymorphism in LRCH1 might be a risk factor for DEACMP.
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Affiliation(s)
- Jiapeng Gu
- Henan Mental Hospital, The Second Affiliated Hospital of Xinxiang Medical University, No. 388 Jianshe Middle Road, Muye District, Xinxiang City, 453002, Henan Province, China
| | - Jiao Zeng
- Henan Mental Hospital, The Second Affiliated Hospital of Xinxiang Medical University, No. 388 Jianshe Middle Road, Muye District, Xinxiang City, 453002, Henan Province, China
| | - Xi Wang
- Henan Mental Hospital, The Second Affiliated Hospital of Xinxiang Medical University, No. 388 Jianshe Middle Road, Muye District, Xinxiang City, 453002, Henan Province, China
| | - Xin Gu
- Henan Mental Hospital, The Second Affiliated Hospital of Xinxiang Medical University, No. 388 Jianshe Middle Road, Muye District, Xinxiang City, 453002, Henan Province, China
| | - Xiaoli Zhang
- Henan Mental Hospital, The Second Affiliated Hospital of Xinxiang Medical University, No. 388 Jianshe Middle Road, Muye District, Xinxiang City, 453002, Henan Province, China
| | - Ping Zhang
- Henan Mental Hospital, The Second Affiliated Hospital of Xinxiang Medical University, No. 388 Jianshe Middle Road, Muye District, Xinxiang City, 453002, Henan Province, China
| | - Fan Zhang
- Henan Mental Hospital, The Second Affiliated Hospital of Xinxiang Medical University, No. 388 Jianshe Middle Road, Muye District, Xinxiang City, 453002, Henan Province, China
| | - Yongkai Han
- Henan Mental Hospital, The Second Affiliated Hospital of Xinxiang Medical University, No. 388 Jianshe Middle Road, Muye District, Xinxiang City, 453002, Henan Province, China
| | - Yazhou Han
- Qinyang People's Hospital, Jiaozuo City, 454550, Henan Province, China
| | - Hongxing Zhang
- The Psychology College of Xinxiang Medical University, Xinxiang City, 453002, Henan Province, China
| | - Wenqiang Li
- International Joint Research Laboratory for Psychiatry and Neuroscience of Henan, Henan Key Lab of Biological Psychiatry of Xinxiang Medical University, Xinxiang City, 453002, Henan Province, China.
| | - Renjun Gu
- Henan Mental Hospital, The Second Affiliated Hospital of Xinxiang Medical University, No. 388 Jianshe Middle Road, Muye District, Xinxiang City, 453002, Henan Province, China.
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8
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Kim H, Choi S, Park E, Yoon E, Min Y, Lampotang S. Serum markers and development of delayed neuropsychological sequelae after acute carbon monoxide poisoning: anion gap, lactate, osmolarity, S100B protein, and interleukin-6. Clin Exp Emerg Med 2018; 5:185-191. [PMID: 30269454 PMCID: PMC6166038 DOI: 10.15441/ceem.17.217] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 08/29/2017] [Indexed: 12/15/2022] Open
Abstract
Objective Reliable biomarkers of delayed neuropsychological sequelae (DNS) after acute carbon monoxide (CO) poisoning are lacking. This study investigated the associations between potential serum markers and the development of DNS after acute CO poisoning. Methods Retrospective chart reviews were conducted for patients diagnosed with acute CO poisoning during a 28-month period. The patients were divided into two groups according to the presence or absence of having developed DNS. Multivariate analysis was performed to identify predictors of DNS after CO poisoning. Results Of a total of 102 patients, 10 (9.8%) developed DNS. The levels of serum osmolarity, S100B protein, and serum lactate, as well as serum anion gap, were statistically significant in univariate analysis. Multiple logistic regression analysis showed that anion gap (adjusted odds ratio [AOR], 1.36; 95% confidence interval [CI], 1.11 to 1.88), serum lactate level (AOR, 1.74; 95% CI, 1.26 to 2.75), and serum S100B protein level ([AOR, 7.02×105; 95% CI, 4.56×102 to 9.00×1010] in model 1, [AOR, 3.69×105; 95% CI, 2.49×102 to 2.71×1011] in model 2) were independently associated with DNS development. Conclusion Based on our preliminary results, serum lactate level, serum anion gap, and serum S100B protein level in the emergency department could be informative predictors of DNS development in patients with acute CO poisoning. These markers might have the potential to improve early recognition of DNS in patients with acute CO poisoning.
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Affiliation(s)
- Hyukhoon Kim
- Department of Emergency Medicine, Ajou University School of Medicine, Suwon, Korea
| | - Sangchun Choi
- Department of Emergency Medicine, Ajou University School of Medicine, Suwon, Korea.,Center for Safety, Simulation & Advanced Learning Technologies, University of Florida, Gainesville, FL, USA
| | - Eunjung Park
- Department of Emergency Medicine, Ajou University School of Medicine, Suwon, Korea
| | - Eunhui Yoon
- Center for Safety, Simulation & Advanced Learning Technologies, University of Florida, Gainesville, FL, USA
| | - Younggi Min
- Department of Emergency Medicine, Ajou University School of Medicine, Suwon, Korea
| | - Samsun Lampotang
- Center for Safety, Simulation & Advanced Learning Technologies, University of Florida, Gainesville, FL, USA
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Lotti M, Aminoff MJ. Evaluating suspected work-related neurologic disorders (clinical diagnosis). HANDBOOK OF CLINICAL NEUROLOGY 2015; 131:9-21. [PMID: 26563780 DOI: 10.1016/b978-0-444-62627-1.00002-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/05/2023]
Abstract
The clinical diagnosis of work-related neurologic disorders is essentially one of exclusion because symptoms and signs are often nonspecific. The clinical reasoning requires a three-step approach: (1) establish the characteristics of the presenting disease; (2) ascertain that observed clinical features are consistent with those caused by the suspected agent(s); and (3) assess occupational exposures. A detailed history is of paramount importance in evaluating patients with suspected work-related neurologic disorders as it is in other clinical contexts, especially because in some circumstances it may represent the only criterion to establish causality. Thus, besides characterization of neurologic symptoms, including their location, quality, timecourse, and possible other associated symptoms, the work environment of the patient should be understood in full detail. In this respect, when a neurotoxin is suspected, then the history collection can be guided by the knowledge of the likely syndromes it produces. Similarly, physical examination should be directed to the target of toxicity/entrapment based on information from the work history. Although specific sites and elements of the nervous system may be affected depending on the offending agent, most neurotoxic disorders are characterized by generalized rather than focal neurologic abnormalities. Laboratory toxicologic tests have limited application for the etiologic diagnosis of neurotoxic disorders, except in cases of acute poisoning and in patients exposed to neurotoxic chemicals with prolonged half-life. In most cases examination takes place after the end of exposure, when the offending chemical is no longer detectable in body fluids. Electrophysiologic studies, in particular evoked potentials, electromyography, and conduction velocities, are important to confirm the organic basis of symptoms, particularly to detect subclinical or early neurologic involvement and to reduce the number of disorders to be considered in the differential diagnoses. In general, imaging studies with computed tomography and magnetic resonance are of limited utility in the evaluation of suspected neurotoxic disorders, except for helping to exclude other causes of the patient's clinical state. Improved conditions and safer practices in the workplace have led to a gradual shift in application of neuropsychologic evaluation from the assessment of severe neurotoxic damage to the evaluation of mild subclinical disturbances, and these tests are nowadays extensively used in screening workers exposed to neurotoxicants. Tools used in the screening of large groups of workers exposed to neurotoxicants may differ from those used in the clinic. Whereas some are obviously impractical, such as physical examination, others, such as, for instance, toxicologic tests, are used for biologic monitoring of exposure to ascertain compliance with occupational exposure limits.
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Affiliation(s)
- Marcello Lotti
- Department of Cardiology, Thoracic and Vascular Sciences, School of Medicine, University of Padua, Padua, Italy.
| | - Michael J Aminoff
- Department of Neurology, School of Medicine, University of California San Francisco, San Francisco, CA, USA
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10
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Abstract
Carbon monoxide (CO) is a colorless, odorless, nonirritant gas that accounts for numerous cases of CO poisoning every year from a variety of sources of incomplete combustion of hydrocarbons. These include poorly functioning heating systems, indoor propane-powered forklifts, indoor burning of charcoal burning briquettes, riding in the back of pick-up trucks, ice skating rinks using propane-powered resurfacing machines, and gasoline-powered generators that are not in correct locations. Once CO is inhaled it binds with hemoglobin to form carboxyhemoglobin (COHb) with an affinity 200 times greater than oxygen that leads to decreased oxygen-carrying capacity and decreased release of oxygen to tissues leading to tissue hypoxia. Ischemia occurs with CO poisoning when there is loss of consciousness that is accompanied by hypotension and ischemia in the arterial border zones of the brain. Besides binding to many heme-containing proteins, CO disrupts oxidative metabolism leading to the formation of free radicals. Once hypotension and unconsciousness occur with CO poisoning, lipid peroxidation and apoptosis follow. Because COHb has a short half-life, examination of other biomarkers of CO neurotoxicity that reflect inflammation or neuronal damage has not demonstrated consistent results. The initial symptoms with CO exposure when COHb is 15-30% are nonspecific, namely, headache, dizziness, nausea, fatigue, and impaired manual dexterity. However individuals with ischemic heart disease may experience chest pain and decreased exercise duration at COHb levels between 1% and 9%. COHb levels between 30% and 70% lead to loss of consciousness and eventually death. Following resolution of acute symptoms there may be a lucid interval of 2-40 days before the development of delayed neurologic sequelae (DNS), with diffuse demyelination in the brain accompanied by lethargy, behavior changes, forgetfulness, memory loss, and parkinsonian features. Seventy-five percent of patients with DNS recover within 1 year. Neuropsychologic abnormalities with chronic CO exposure are found even when magnetic resonance imaging (MRI) and magnetic resonance spectroscopy are normal. White-matter damage in the centrum semiovale and periventricular area and abnormalities in the globus pallidus are most commonly seen on MRI following CO exposure. Though not as common, toxic or ischemic peripheral neuropathies are associated with CO exposure in humans and animals. The cornerstone for treatment for CO poisoning is 100% oxygen using a tight-fitting mask for greater than 6 hours. The indications for treatment with hyperbaric oxygen to decrease the half-life of COHb remain controversial.
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Affiliation(s)
- Margit L Bleecker
- Center for Occupational and Environmental Neurology, Baltimore, MD, USA.
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Park EJ, Min YG, Kim GW, Cho JP, Maeng WJ, Choi SC. Pathophysiology of brain injuries in acute carbon monoxide poisoning: A novel hypothesis. Med Hypotheses 2014; 83:186-9. [DOI: 10.1016/j.mehy.2014.04.032] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Revised: 04/19/2014] [Accepted: 04/29/2014] [Indexed: 11/28/2022]
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Park E, Ahn J, Min YG, Jung YS, Kim K, Lee J, Choi SC. The usefulness of the serum s100b protein for predicting delayed neurological sequelae in acute carbon monoxide poisoning. Clin Toxicol (Phila) 2012; 50:183-8. [PMID: 22372785 DOI: 10.3109/15563650.2012.658918] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
CONTEXT Some patients with acute carbon monoxide poisoning will experience delayed neurological sequelae. Several factors associated with delayed neurological sequelae have been reported, but these factors are unsatisfactory for the assessment of unconscious patients. OBJECTIVE The aim of this study was to assess the usefulness of the serum S100B protein as a biochemical marker for predicting delayed neurological sequelae. MATERIALS AND METHODS In this retrospective study, we evaluated the data for patients who visited an emergency medical center once during a period of 7 months. The enrollment criteria were the diagnosis of acute carbon monoxide poisoning and the measurement of the serum S100B level. A standardized extraction using medical records was performed. RESULT A total of 71 patients were enrolled, and 10 patients (14.1%) presented delayed neurological sequelae. The delayed neurological sequelae group had a longer duration of carbon monoxide exposure, a longer duration of loss of consciousness, and a worse mental status (p-value < 0.001). In addition, the S100B protein levels were higher in the delayed neurological sequelae group (0.891 vs. 0.063, p-value < 0.001). Multiple logistic regression analysis showed that only the serum S100B protein level was independently associated with the development of delayed neurological sequelae (OR, 120.594; 95% CI, 4.194-3467.220), and a serum S100B protein level of more than 0.165 μg/L predicted the development of delayed neurological sequelae (sensitivity 90%, specificity 87%). DISCUSSION AND CONCLUSION In the present study, the level of serum S100B protein was found to be useful for evaluating acute CO poisoning patients and was found to be an independent predictor of the development of DNS after acute CO poisoning.
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Affiliation(s)
- Eunjung Park
- Department of Emergency Medicine, Ajou University School of Medicine, Suwon, Republic of Korea
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13
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Abstract
This article describes carbon monoxide poisoning. Using a case study approach, the article covers pathophysiology, epidemiology, clinical presentation, and complications. A nursing care plan is presented to guide the critical care nurse in the care of patients in this type of condition.
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14
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Elevated S100B level in cerebrospinal fluid could predict poor outcome of carbon monoxide poisoning. Am J Emerg Med 2012; 30:222-5. [DOI: 10.1016/j.ajem.2010.11.025] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2010] [Accepted: 11/14/2010] [Indexed: 11/20/2022] Open
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15
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Intoxication au monoxyde de carbone et place de l’oxygénothérapie hyperbare. MEDECINE INTENSIVE REANIMATION 2011. [DOI: 10.1007/s13546-011-0327-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
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Kamijo Y, Ide T, Ide A, Soma K. Severe carbon monoxide poisoning complicated by hypothermia: a case report. Am J Emerg Med 2010; 29:357.e5-7. [PMID: 20674229 DOI: 10.1016/j.ajem.2010.04.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2010] [Revised: 04/13/2010] [Accepted: 04/15/2010] [Indexed: 11/16/2022] Open
Abstract
It is proposed that the significant elevation of interleukin-6 (>400 pg/mL) in cerebrospinal fluid during the early phase of carbon monoxide poisoning may be a predictive biomarker for the development of delayed encephalopathy. A 52-year-old man presented to the emergency department with severe carbon monoxide poisoning. On arrival, the patient was comatose with decorticate rigidity (Glasgow Coma Scale, E1V1M3). His core body temperature, measured in the urinary bladder, was 32.4°C. Laboratory blood analysis revealed elevated CO-Hb (36.0%) and metabolic acidosis with elevated lactate (pH 7.081; base excess [BE], -19.2 mmol/L; HCO3, -9.8 mmol/L; lactate, 168.8 mg/dL). After treatment with hyperbaric oxygen and several different rewarming techniques, he became alert and his core body temperature increased to normal. Interleukin-6 in cerebrospinal fluid at 5.5 hours after his last exposure to carbon monoxide was significantly elevated (752 pg/mL). However, he did not develop delayed encephalopathy. In this case, hypothermia in the range of therapeutic hypothermia (32°C to 34°C) may have suppressed formation of reactive oxygen species and subsequent lipid peroxydation, preventing the development of delayed encephalopathy. Therapeutic hypothermia initiated soon after the last exposure to carbon monoxide may be an effective prophylactic method for preventing the development of delayed encephalopathy.
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Affiliation(s)
- Yoshito Kamijo
- Department of Emergency and Critical Care Medicine, School of Medicine, Kitasato University, Kanagawa 252-0374, Japan.
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