Characteristics and outcome of children with carbon monoxide poisoning with and without smoke exposure referred for hyperbaric oxygen therapy

Does Exposure to Ambient Air Pollution Affect Gestational Age and Newborn Weight?-A Systematic Review

Current evidence suggests that airborne pollutants have a detrimental effect on fetal growth through the emergence of small for gestational age (SGA) or term low birth weight (TLBW). The study's objective was to critically evaluate the available literature on the association between environmental pollution and the incidence of SGA or TLBW occurrence. A comprehensive literature search was conducted across Pubmed/MEDLINE, Web of Science, Cochrane Library, EMBASE, and Google Scholar using predefined inclusion and exclusion criteria. The methodology adhered to the PRISMA guidelines. The systematic review protocol was registered in PROSPERO with ID number: CRD42022329624. As a result, 69 selected papers described the influence of environmental pollutants on SGA and TLBW occurrence with an Odds Ratios (ORs) of 1.138 for particulate matter ≤ 10 μm (PM10), 1.338 for particulate matter ≤ 2.5 μm (PM2.5), 1.173 for ozone (O3), 1.287 for sulfur dioxide (SO2), and 1.226 for carbon monoxide (CO). All eight studies analyzed validated that exposure to volatile organic compounds (VOCs) is a risk factor for SGA or TLBW. Pregnant women in the high-risk group of SGA occurrence, i.e., those living in urban areas or close to sources of pollution, are at an increased risk of complications. Understanding the exact exposure time of pregnant women could help improve prenatal care and timely intervention for fetuses with SGA. Nevertheless, the pervasive air pollution underscored in our findings suggests a pressing need for adaptive measures in everyday life to mitigate worldwide environmental pollution.

Can Hyperbaric Oxygen Therapy Be Used to Treat Children after COVID-19? A Bibliographic Review

The coronavirus disease (COVID-19) epidemic is a public health emergency of international concern. It was believed that SARS-CoV-2 virus was much less likely affect children. Statistics show that children account for 2-13% of all COVID-19 patients in individual countries. In the youngest population, acute respiratory failure is not as serious a problem as complications after COVID-19, mainly pediatric inflammatory multisystem syndrome (PIMS, MIS-C). This study used a bibliography review. The Medline database (using the PubMed platform) and the Cochrane Clinical Trials database were searched using the following keywords: hyperbaric oxygen therapy for children, treatment of children with COVID-19, and use of HBOT in the treatment of children following COVID-19. Thirteen publications that quantitatively and qualitatively described the efficacy of HBOT application in the treatment of pediatric diseases were eligible among the studies; those relating to the use of HBOT in the treatment of children with COVID-19 and its complications were not found. The bibliographic review showed that hyperbaric oxygen therapy can be used in the treatment of children after carbon monoxide poisoning, with soft tissue necrosis, bone necrosis, after burns, or after skin transplant. No evidence supported by research has been found in scientific journals on the effectiveness of the use of hyperbaric oxygen therapy in children with a history of COVID-19 infection. Research data are needed to develop evidence-driven strategies with regard to the use of HBOT therapy in the treatment of children and to reduce the number of pediatric patients suffering because of complications after COVID-19.

Delayed Neurological Sequelae in an Infant after Carbon Monoxide Intoxication

Delayed neurological sequelae are symptoms that appear over a period of time after an acute event of carbon monoxide poisoning. The incidence of delayed neurological sequelae is lower in children than in adults and is even more uncommon in infants. Here, we present a case of a 4-month-old infant who developed delayed neurological sequelae after carbon monoxide intoxication. She presented with neurologic symptoms, including opisthotonus, athetoid movements, anterior tongue thrust, and opsoclonus. Because these symptoms are starkly different from those of adults, they should be compared with age-appropriate developmental milestones. Because of their faster metabolic rate and presence of fetal hemoglobin, infants with developing brains may be especially vulnerable to carbon monoxide toxicity. Therefore, thorough neurologic examination and prompt treatment are critical for infants who experience carbon monoxide intoxication.

Pediatric Carbon Monoxide Poisoning in Southern Israel: A Cross-Sectional Study

OBJECTIVES

This study aimed to describe the epidemiology and clinical burden of unintended carbon monoxide (CO) poisoning among children in the Negev region of southern Israel.

METHODS

This was a cross-sectional retrospective study of CO poisoning patients admitted to Soroka University Medical Center in 2011 through 2015.

RESULTS

Overall, 43 cases of CO poisoning were recorded among children younger than 18 years. Five patients died, all upon admission. Poisoning due to smoke "per se" and due to CO emitted from heating devices were responsible for 28 (65.1%) and 14 (32.6%) cases, respectively. Eight (18.6%) patients suffered from convulsions, and 13 (43.3%) of 30 evaluable patients complained of headaches. Twenty-two (51.2%) were found unconscious in the field, and 7 (16.3%) were unconscious at examination at the emergency department. The average carboxyhemoglobin level on admission was 10.5% ± 10.4% (level ranging from 0.1% to 46.2%). Treatment included oxygen in 34 patients (79%) and hyperbaric oxygen therapy in 8 patients (19%). No differences were found between Bedouin and Jewish children in sex, age, residence area, source of CO poisoning, symptoms severity, and need for hyperbaric oxygen therapy. More patients with exposure to water heating devices were older than 4 years, lived in villages, and were diagnosed as having loss of consciousness in the field compared with those exposed to smoke inhalation.

CONCLUSIONS

Carbon monoxide poisoning in children is frequent in southern Israel. Education about prevention, implementation of safer standards for home heating systems, and government supervision are required management strategies to decrease the CO poisoning incidence in southern Israel.

Clinical Characteristics of Pediatric Patients With Carbon Monoxide Poisoning

OBJECTIVES

Carbon monoxide (CO) poisoning is a common and deadly form of poisoning that is often treated with hyperbaric oxygen. The characteristics of children exposed to CO and then treated with hyperbaric oxygen have not been delineated. The purpose of this study was to describe the clinical characteristics of children treated with hyperbaric oxygen therapy for CO poisoning at a regional hyperbaric referral center.

METHODS

The study is based on a retrospective review of data extracted from the medical records of children (age <19 years) who were referred to our center for hyperbaric oxygen therapy for CO poisoning between 2008 and 2013. Inferential analyses were used to compare demographic characteristics, serum carboxyhemoglobin (COHb) levels, and presenting symptoms.

RESULTS

Forty-seven children met our study criteria. Their mean age was 8.9 years, and their mean COHb level was 14.3% (range, 3.4%-30.1%). Severity of symptoms did not correlate with serum COHb levels; however, neurologic symptoms at presentation were more common in patients with a COHb level greater than 25%. There was a correlation between increasing age and higher COHb levels and between COHb and lactate levels.

CONCLUSIONS

Our retrospective review of patients' records showed no correlation of serum COHb levels with symptoms on presentation; however, a correlation was found between increasing age and COHb level as well as lactate level and COHb level.

The Diagnosis and Treatment of Carbon Monoxide Poisoning

BACKGROUND

The symptoms of carbon monoxide (CO) poisoning are nonspecific, ranging from dizziness and headache to unconsciousness and death. A German national guideline on the diagnosis and treatment of this condition is lacking at present.

METHODS

This review is based on a selective literature search in the PubMed and Cochrane databases, as well as on existing guidelines from abroad and expert recommendations on diagnosis and treatment.

RESULTS

The initiation of 100% oxygen breathing as early as possible is the most important treatment for carbon monoxide poisoning. In case of CO poisoning, the reduced oxygen-carrying capacity of the blood, impairment of the cellular respiratory chain, and immune-modulating processes can lead to tissue injury in the myocardium and brain even after lowering of the carboxyhemoglobin (COHb) concentration. In patients with severe carbon monoxide poisoning, an ECG should be obtained and biomarkers for cardiac ischemia should be measured. Hyperbaric oxygen therapy (HBOT) should be critically considered and initiated within six hours in patients with neurologic deficits, unconsciousness, cardiac ischemia, pregnancy, and/or a very high COHb concentration. At present, there is no general recommendation for HBOT, in view of the heterogeneous state of the evidence from multiple trials. Therapeutic decision-making is directed toward the avoidance of sequelae such as cognitive dysfunction and cardiac complications, and the reduction of mortality. Smoke intoxication must be considered in the differential diagnosis. The state of the evidence on the diagnosis and treatment of this condition is not entirely clear. Alternative or supplementary pharmacological treatments now exist only on an experimental basis.

CONCLUSION

High-quality, prospective, randomized trials that would enable a definitive judgment of the efficacy of HBOT are currently lacking.

Pediatric inhalation injury

Smoke inhalation injury can cause severe physiologic perturbations. In pediatric patients, these perturbations cause profound changes in cardiac and pulmonary physiology. In this review, we examine the pathology, early management options, ventilator strategy, and long-term outcomes in pediatric patients who have suffered a smoke inhalation injury.

Epidemiology, pathophysiology, clinical evaluation, and treatment of carbon monoxide poisoning in child, infant, and fetus

Carbon monoxide (CO) poisoning is one of the most common types of poisoning causing death worldwide. In our country, it occurs particularly during winter as a result of leak from stove or water heater, or as result of inhalation during a fire. Although most poisonings occur accidentally, some cases are suicide attempt. As CO is a substance that is not visible and has no taste or smell and is therefore difficult to detect, the gas can be a “silent killer” that is not noticed until effects develop. CO reacts with oxygen, creating carboxy hemoglobin (COHb), which leads to tissue hypoxia. In addition, it has direct effect of causing cellular damage. Although symptoms of acute poisoning are most commonly observed in patients admitted to emergency rooms, effects of chronic exposure to CO can also seen. Clinically, although it affects all organ systems, involvement of central nervous system (CNS) and cardiovascular system is predominant. Most common poisoning symptoms are weakness, dizziness, headache, nausea, and nonspecific flu-like symptoms, like vomiting. Depending on severity of exposure, seizures, syncope, and arrhythmia may also be observed. In pregnant women, fetus can be harmed with relatively low level of COHb. Poisoning in infants has a more severe course than seen in other age groups. Symptoms must be associated with cause of poisoning, and careful anamnesis and treatment must be conducted quickly. Oxygen is the antidote for CO. It is administered through a mask in the form of normobaric oxygen therapy or through specific devices in the form of hyperbaric oxygen therapy. In this review, clinical data and current diagnostic and therapeutic approaches concerning CO poisoning are discussed.

Characteristics of Children with Acute Carbon Monoxide Poisoning in Ankara: A Single Centre Experience

The purpose of the study was to define characteristics of children with acute carbon monoxide poisoning. Eighty children hospitalized with acute carbon monoxide poisoning were recruited prospectively over a period of 12 months. Sociodemographic features, complaints and laboratory data were recorded. When the patient was discharged, necessary preventive measures to be taken were explained to parents. One month later, the parents were questioned during a control examination regarding the precautions that they took. The ages of the cases were between one month and 16 yr. Education levels were low in 86.2% of mothers and 52.6% of fathers. All families had low income and 48.8% did not have formal housing. The source of the acute carbon monoxide poisoning was stoves in 71.2% of cases and hot-water heaters in 28.8% of cases. Three or more people were poisoned at home in 85.1% of the cases. The most frequent symptoms of poisoning were headache and vertigo (58.8%). Median carboxyhemoglobin levels at admission to the hospital and discharge were measured as 19.5% and 1.1% (P < 0.001). When families were called for re-evaluation, it was determined that most of them had taken the necessary precautions after the poisoning incident (86.3%). This study determined that children with acute childhood carbon monoxide poisoning are usually from families with low socioeconomic and education levels. Education about prevention should be provided to all people who are at risk of carbon monoxide poisoning before a poisoning incident occurs.

Practice recommendations in the diagnosis, management, and prevention of carbon monoxide poisoning

Carbon monoxide (CO) poisoning is common in modern society, resulting in significant morbidity and mortality in the United States annually. Over the past two decades, sufficient information has been published about carbon monoxide poisoning in the medical literature to draw firm conclusions about many aspects of the pathophysiology, diagnosis, and clinical management of the syndrome, along with evidence-based recommendations for optimal clinical practice. This article provides clinical practice guidance to the pulmonary and critical care community regarding the diagnosis, management, and prevention of acute CO poisoning. The article represents the consensus opinion of four recognized content experts in the field. Supporting data were drawn from the published, peer-reviewed literature on CO poisoning, placing emphasis on selecting studies that most closely mirror clinical practice.

Predictive role of arterial carboxyhemoglobin concentrations in ovine burn and smoke inhalation-induced lung injury

Inhalation injury frequently occurs in burn patients and contributes to the morbidity and mortality of these injuries. Arterial carboxyhemoglobin has been proposed as an indicator of the severity of inhalation injury; however, the interrelation between arterial carboxyhemoglobin and histological alterations has not yet been investigated. Chronically instrumented sheep were subjected to a third degree burn of 40% of the total body surface area and inhalation of 48 breaths of cotton smoke. Carboxyhemoglobin was measured immediately after injury and correlated to clinical parameters of pulmonary function as well as histopathology scores from lung tissue harvested 24 hours after the injury. The injury was associated with a significant decline in pulmonary oxygenation and increases in pulmonary shunting, lung lymph flow, wet/dry weight ratio, congestion score, edema score, inflammation score, and airway obstruction scores. Carboxyhemoglobin was negatively correlated to pulmonary oxygenation and positively correlated to pulmonary shunting, lung lymph flow, and lung wet/dry weight ratio. No significant correlations could be detected between carboxyhemoglobin and histopathology scores and airway obstruction scores. Arterial carboxyhemoglobin in sheep with combined burn and inhalation injury are correlated with the degree of pulmonary failure and edema formation, but not with certain histological alterations including airway obstruction scores.

Carbon monoxide poisoning in children

BACKGROUND

Carbon monoxide (CO) is an important source of poisoning in children. We performed this study in order to clarify the clinical characteristics of pediatric patients with CO poisoning.

METHODS

We identified and reviewed the medical records of pediatric patients diagnosed with CO intoxication and hospitalized in our department during a 10-year period. Epidemiologic and clinical data were collected and analyzed.

RESULTS

A total of 30 children with CO poisoning were identified. Their ages ranged from 2 to 17 years, with a mean of 9.5 +/- 4.5 years. Improperly vented exhaust produced by gas hot water heaters was the most common cause of intoxication (53.3%), followed by house fires (26.7%). Intentional poisoning by charcoal burning by parents occurred in six patients (20.0%). The majority of events occurred during cool seasons (76.7%). The most common presenting symptom was consciousness disturbance (86.7%). Only one child died and the mortality was 0.03%. Five (16.7%) children developed delayed neurologic sequelae (DNS), but they all recovered completely within 2 months. Seizures during the acute stage, severe metabolic acidosis, significant hypotension, longer times for recovery to full consciousness, and longer hospital stays were observed in children with DNS.

CONCLUSION

Children with CO poisoning had good outcomes in this series. Although improperly vented exhaust from water heaters and house fires were the most common causes, intentional poisoning by parents through charcoal burning was also an important factor. Early identification of DNS risk factors might help to provide better care.