Carbon Monoxide Poisoning: From Occupational Health to Emergency Medicine

Carbon monoxide poisoning remains a leading cause of accidental poisoning worldwide (both at home and at work), and it is also a cause of suicidal poisoning. Such poisoning can arise following prolonged exposure to low levels of CO or following brief exposure to high concentrations of the gas. In fact, despite exposure limits, high safety standards, and the availability of CO alarms, nearly 50,000 people in the United States visit the emergency department each year due to poisoning. Additionally, CO poisoning in the United States causes up to 500 deaths each year. Despite the widespread nature of this form of poisoning, known about for centuries and whose damage mechanisms have been recognized (or rather hypothesized about) since the 1800s, early recognition, especially of late complications, and treatment remain a medical challenge. A well-designed therapeutic diagnostic process is necessary so that indication for hyperbaric or normobaric therapy is correctly made and so that patients are followed up even after acute exposure to diagnose late complications early. Furthermore, it is necessary to consider that in the setting of emergency medicine, CO poisoning can be part of a differential diagnosis along with other more frequent conditions, making its recognition difficult. The last thirty years have been marked by a significant increase in knowledge regarding the toxicity of CO, as well as its functioning and its importance at physiological concentrations in mammalian systems. This review, taking into account the significant progress made in recent years, aims to reconsider the pathogenicity of CO, which is not trivially just poisonous to tissues. A revision of the paradigm, especially as regards treatment and sequelae, appears necessary, and new studies should focus on this new point of view.

An innovative fluorescent probe for the detection of cyanide - enhanced sensitivity by controlling its electrostatic potential and suitable for applications such as cell imaging and food analysis

As cyanide is a huge hazard to the environment and human health, the study of the method of detecting low concentrations of cyanide is of great significance. In general, materials with strong positive electrostatic properties can use electrostatic attraction to enrich anions in the water near the materials, then realize rapid detection of low concentration anions by fluorescent probes. In this paper, fluorescent probes PI-S, PI-I and PI-N with cyanide-specific recognition and different charges were synthesized to study the relationship between the charge effect of probes and the sensing sensitivity. Through the zeta potential test and the calculation of the surface electrostatic potential, the positive electricity of PI-S, PI-I and PI-N gradually increased, the ΔG < 0 of the adsorption process gradually decreased, CN- could be aggregated to the vicinity of probes. As a result, the detection limit of the probe was gradually reduced from 1.07 × 10-6 to 5.03 × 10-8 M, the sensitivity was significantly enhanced. Therefore, this is expected to be a new strategy to improve the sensitivity of anion probes by increasing the positive electricity of molecules. In addition, PI-N has good anti-interference ability, short response time and certain application value in cell imaging and identification of endogenous cyanide in food.

Observation and comparison of gas formation during holmium:YAG laser lithotripsy of cystine, uric acid, and calcium oxalate stones: a chromatographic and electron microscopic analysis

The primary aim of the present in vitro study is to analyze the chemical content of the bubbles occurring during the fragmentation of cystine stones with both the high-power and low-power holmium:YAG (Ho:YAG) lasers. The secondary aim is to discuss their clinical importance. Three types of human renal calculi calcium oxalate monohydrate (COM), cystine, and uric acid were fragmented with both low-power and high-power Ho:YAG lasers in separate experimental setups at room temperature, during which time it was observed whether gas was produced. After laser lithotripsy, a cloudy white gas was obtained, after the fragmentation of cystine stones only. A qualitative gas content analysis was performed with a gas chromatography-mass spectrometry (GC-MS) device. The fragments in the aqueous cystine calculi setup were dried and taken to the laboratory to be examined by scanning electron microscopy with energy dispersive X-ray spectroscopy (SEM-EDX) and X-ray diffraction analysis. No gas production was observed after fragmentation in the COM and uric acid stones. Free cystine, sulfur, thiophene, and hydrogen sulfide gas were produced by both low-power and high-power Ho:YAG laser lithotripsy of the cystine stones. In the SEM-EDX mapping analysis, a free cystine molecule containing 42.8% sulfur (S), 21% oxygen (O), 14.9% carbon (C), and 21% nitrogen (N) atoms was detected in the cystine stone experimental setup. The evidence obtained, which shows that hydrogen sulfide emerges in the gaseous environment during Ho:YAG laser fragmentation of cystine stones, indicates that caution is required to prevent the risk of in vivo production and toxicity.

Acute carbon monoxide poisoning as a cause of rhabdomyolysis in a case of flame burn

Carbon monoxide (CO) poisoning typically occurs from inhalation of CO at excessive levels. Rhabdomyolsis is not an uncommon complication following acute CO poisoning, yet there are very few reported cases in the literature. It is characterised by rapid breakdown of skeletal muscles and release of its contents into the circulation, leading to acute kidney injury (AKI). Early diagnosis and treatment are crucial to avoid anticipated morbidity and mortality. We are presenting a case of a woman in her 40s with 28% flame burn in a closed space. The patient developed CO poisoning, which led to rhabdomyolysis as evidenced by clinical manifestations and laboratory findings (creatine kinase had reached an unmeasurable level). The patient developed AKI and was successfully managed in our ICU. Here, we are highlighting the importance of considering CO poisoning as one of the potential causes of rhabdomyolysis in burn victim.

Comprehensive understanding of electrochemical treatment systems combined with biological processes for wastewater remediation

The presence of toxic pollutants in wastewater discharge can affect the environment negatively due to presence of the organic and inorganic contaminants. The application of the electrochemical process in wastewater treatment is promising, specifically in treating these harmful pollutants from the aquatic environment. This review focused on recent applications of the electrochemical process for the remediation of such harmful pollutants from aquatic environments. Furthermore, the process conditions that affect the electrochemical process performance are evaluated, and the appropriate treatment processes are suggested according to the presence of organic and inorganic contaminants. Electrocoagulation, electrooxidation, and electro-Fenton applications in wastewater have shown effective performance with high removal rates. The disadvantages of these processes are the formation of toxic intermediate metabolites, high energy consumption, and sludge generation. To overcome such disadvantages combined ecotechnologies can be applied in large-scale wastewater pollutants removal. The combination of electrochemical and biological treatment has gained importance, increased removal performance remarkably, and decreased operational costs. The critical discussion with depth information in this review could be beneficial for wastewater treatment plant operators throughout the world.

A novel coumarin derivative-modified cellulose fluorescent probe for selective and sensitive detection of CN- in food samples

In this work, a novel coumarin derivative-modified cellulose acetate (DCB-CA) was synthesized as a fluorescent probe for highly selective and sensitive determination of CN^- in food samples. The DCB-CA was synthesized by using CA as a skeleton, and the coumarin derivative as the fluorophore. The DCB-CA obtained was characterized by different methods including FTIR, SEM, ¹H-NMR, TGA and UV-vis spectroscopy. The DCB-CA exhibited a significant "turn-off" fluorescence response to CN^-, accompanied by a distinct fluorescence color change from bright yellow to colorless. The detection limit of CN^- using DCB-CA was calculated to be 5.8 × 10^-7 M, which was much lower than the threshold limit of CN^- recommended by the World Health Organization (1.9 × 10^-6 M). Because of the favorable solubility and processability of the CA, the DCB-CA was easily processed into different fluorescent materials including fluorescent films and coatings. The fluorescent film obtained was also applied to the selective detection of CN^-. Furthermore, the DCB-CA was successfully applied to determine CN^- in food samples.

Dual-Responsive Benzo-Hemicyanine-Based Fluorescent Probe for Detection of Cyanide and Hydrogen Sulfide: Real-Time Application in Identification of Food Spoilage

Colorimetric and fluorescent probes have received a lot of attention for detecting lethal analytes in realistic systems and in living things. Herein, a dual-approachable Benzo-hemicyaninebased red-emitting fluorescent probe PBiSMe, for distinct and instantaneous detection of CN^- and HS^- was synthesized. The PBiSMe emitted red fluorescence (570 nm) can switch to turn-off (570 nm) and blue fluorescence (465 nm) in response to CN^- and HS^-, respectively. Other nucleophilic reagents, such as reactive sulfur species (RSS) and anions, have no contact or interference with the probe; instead, a unique approach is undertaken to exclusively interact with CN^- and HS^- over a wide pH range. The measured detection limits for CN^- (0.43 μM) and HS^- (0.22 μM) ions are lower than the World Health Organization's (WHO) recommended levels in drinking water. We confirmed 1:1 stoichiometry ratio using Job's plot and observed good quantum yield for both analytes. The probe-coated paper strips were used to detect the H₂S gas produced by food spoilage (such as eggs, raw meat, and fish) via an eye-catching visual response. Moreover, fluorescence bioimaging studies of living cells was done to confirm the probe's potential by monitoring the presence of CN^- and HS^- in a living system.

Carbon monoxide and its role in human physiology: A brief historical perspective

Carbon monoxide is a molecule with notoriety in modern culture and extensive documentation regarding its toxic physiological effects, long predating its formal discovery in the 18th century. Upon its discovery as a molecule in 1772, subsequent investigations into its properties have provided mechanisms describing its toxicity and insights into its function as an endogenously produced molecule and as a therapeutic agent. This brief review aims to provide a historical perspective on this molecule and recognize research regarding its physiological functions and therapeutic applications, often overshadowed by its reputation as a lethal substance. Historicizing science is an acknowledgment of the pioneers and helps us better conceptualize the issues.

Quantitatively analysis and detection of CN- in three food samples by a novel nopinone-based fluorescent probe

Cyanide (CN^-) is one of the most lethal chemical substance and exists in the organisms and environment. Due to the CN^- and CN^--containing chemicals being widely applied in industrial fields and threatening human health, the sensitive and selective detection techniques towards CN^- are still essential. Based on this, a "turn-on" fluorescent probe 2-(4-(5,5-dimethyl-4,5,6,7-tetrahydro-3H-4,6-methanobenzo[d]imidazol-2-yl)styryl)-3-ethylbenzo[d]thiazol-3-ium iodide (NCy) was designed and synthesized for monitoring CN^-. NCy had a distinguishable color change towards CN^- from colorless to yellow under 365 nm UV-light. NCy possessed the merits including low LOD (75 nM), good selectivity, and wide suitable pH range (4-10). The sensing mechanism of NCy towards CN^- was proved by HRMS, ¹H NMR titration and DFT analysis. Furthermore, the probe NCy was successfully utilized in detecting endogenous CN^- in three food samples (green potato, cassava, and bitter almond) quantitatively. In bioimaging aspect, NCy was also successfully applied in detecting the exogenous CN^- in living zebrafish.

SnO2 Nanoparticles-CeO2 Nanorods Enriched with Oxygen Vacancies for Bifunctional Sensing Performances toward Toxic CO Gas and Arsenate Ions

In this paper, we present a novel, one-step synthesis of SnO₂ nanoparticle-CeO₂ nanorod sensing material using a surfactant-mediated hydrothermal method. The bifunctional utility of the synthesized sensing material toward room-temperature sensing of CO gas and low-concentration optosensing of arsenic has been thoroughly investigated. The CeO₂-SnO₂ nanohybrid was characterized using sophisticated analytical techniques such as transmission electron microscopy, X-ray diffraction analysis, energy-dispersive X-ray analysis, X-ray photoelectron spectroscopy, and so forth. The CeO₂-SnO₂ nanohybrid-based sensor exhibited a strong response toward CO gas at room temperature. Under a low concentration (3 ppm) of CO gas, the CeO₂-SnO₂ sensing material showed an excellent response time of 21.1 s for 90% of the response was achieved with a higher recovery time of 59.6 s. The nanohybrid sensor showed excellent low-concentration (1 ppm) sensing behavior which is ∼6.7 times higher than that of the pristine SnO₂ sensors. The synergistically enhanced sensing properties of CeO₂-SnO₂ nanohybrid-based sensors were discussed from the viewpoint of the CeO₂-SnO₂ n-n heterojunction and the effect of oxygen vacancies. Furthermore, the SnO₂-CeO₂ nanoheterojunction showed luminescence centers and prolonged electron-hole recombination, thereby resulting in quenching of luminescence in the presence of arsenate ions. The photoluminescence of CeO₂-SnO₂ is sensitive to the arsenate ion concentration in water and can be used for sensing arsenate with a limit of detection of 4.5 ppb in a wide linear range of 0 to 100 ppb.

Colorimetric and turn-on fluorescent chemosensor with large stokes shift for sensitively probing cyanide anion in real samples and living systems

Cyanide anion is a ubiquitous chemical substance in the ecosystem, however, human daily life is severely threatened by its toxicity at any time. In this paper, a novel colorimetric and turn-on chemosensor 4-(4-(2,2-difluoro-6-methyl-2H-1,3,2-dioxaborinin-4-yl)buta-1,3-dien-1-yl)-N,N-dimethylaniline (NBF) for detecting cyanide anion was synthesized based on the 4-(dimethylamino)cinnamaldehyde and β-diketone difluoroboron complex. This fluorescent probe exhibited excellent spectroscopy properties such as large stokes shift, long emission wavelength, and good sensitivity. The detection limit of NBF towards cyanide ion was determined as low as 2.23 μM. Additionally, the detection mechanism towards cyanide ion was confirmed to be the nucleophilic addition interaction by high resolution mass spectrum (HRMS), ¹H Nuclear Magnetic Resonance (NMR) titration, and quantum chemistry theory calculation. In addition, the probe NBF had been successfully utilized in detecting cyanide ions in water and food samples as well as imaging in the biological system, which broadened its practical application prospects.

Intelligent Nanomedicine Approaches Using Medical Gas-Mediated Multi-Therapeutic Modalities Against Cancer

The emerging area of gas-mediated cancer treatment has received widespread attention in the medical community. Featuring unique physical, chemical, and biological properties, nanomaterials can facilitate the delivery and controllable release of medicinal gases at tumor sites, and also serve as ideal platforms for the integration of other therapeutic modalities with gas therapy to augment cancer therapeutic efficacy. This review presents an overview of anti-cancer mechanisms of several therapeutic gases: nitric oxide (NO), hydrogen sulfide (H₂S), carbon monoxide (CO), oxygen (O₂), and hydrogen (H₂). Controlled release behaviors of gases under different endogenous and exogenous stimuli are also briefly discussed, followed by their synergistic effects with different therapeutic modes. Moreover, the potential challenges and future prospects regarding gas therapy based on nanomaterials are also described, aiming to facilitate the advancement of gas therapeutic nanomedicine in new frontiers for highly efficient cancer treatment.

Cost impact of hydroxocobalamin in the treatment of patients with known or suspected cyanide poisoning due to smoke inhalation from closed-space fires

BACKGROUND & OBJECTIVES

Cyanide poisoning can occur due to exposure to smoke in closed-space fires. With no point of care cyanide test at the scene of a fire, first responders and clinicians base decisions to treat with cyanide antidote on patient history, clinical signs, and other indirect data points that have not been proven to correspond with actual systemic levels of cyanide. The aim of this exploratory study was to determine the economic implications of treating patients with known or suspected cyanide poisoning due to smoke inhalation with hydroxocobalamin.

METHODS

A decision analysis model was developed from the US hospital perspective. Healthcare resource utilization was estimated from a retrospective evaluation of clinical outcomes in hydroxocobalamin-treated patients and in historical controls without hydroxocobalamin use (Nguyen, et al. 2017). Epidemiologic parameters and costs were estimated from the published literature, and publicly-available hospital charges were identified. Outcomes reported in the analysis included expected healthcare resource utilization in the US population and per-patient costs with and without the use of hydroxocobalamin. A cost-to-charge ratio was applied so that all costs would reflect hospital costs rather than hospital charges. Deterministic sensitivity analysis was performed to identify the most influential model parameters. All costs were reported in 2017 US dollars.

RESULTS

Use of hydroxocobalamin reduces healthcare resource utilization and contributes to decreased per-patient hospital costs ($15,381 with hydroxocobalamin treatment versus $22,607 with no cyanide antidote). The most substantive cost-savings resulted from decreased hospital length of stay (i.e., intensive care unit [ICU] and non-ICU). Costs attributed to mechanical ventilation also decreased with use of hydroxocobalamin. A univariate sensitivity analysis demonstrated that the most impactful variables in the cost analysis were related to hospital length of stay (ICU followed by non-ICU stay), followed by the daily cost of ICU stay.

CONCLUSIONS

Use of hydroxocobalamin in patients with known or suspected cyanide poisoning from closed-space fire smoke inhalation may decrease hospital costs and contribute to more efficient healthcare resource utilization.

Prediction of troponin I and N-terminal pro-brain natriuretic peptide levels in acute carbon monoxide poisoning using advanced electrocardiogram analysis, Alexandria, Egypt

The study aimed at assessing the diagnostic ability of advanced electrocardiogram (ECG) analysis to predict the levels of NT-proBNP and Troponin I. ECG and the blood NT-proBNP and Troponin I were taken from 50 acutely carbon monoxide poisoned patients and 21 control subjects matched with age and sex. The severity of the studied cases was classified into mild, moderate, and severe using clinical classification. ECG parameters (RR interval, corrected QT (QTc) interval, P wave dispersion (Pwd)), and cardiac biomarkers (NT-proBNP and Troponin I) were significantly higher in cases than in control (p= 0.015, 0.008, 0.002, <0.001, and <0.001 respectively). Cut-off values resulted from combined ROC curves analysis can predict blood Troponin I more than 0.05 ng/ml and NT-proBNP more than 125 pg/ ml (with 88% and 84% accuracy respectively). In addition, two regression equations were developed using all studied ECG parameters to predict Troponin I and NT-proBNP (with 68% and 43% accuracy respectively). RR average, PR average, QRS average, QTd, QTc, and Pwd could be used to predict Troponin I and NT-proBNP levels with good accuracy in carbon monoxide poisoning patients.

Antidotes for childhood toxidromes

Background

Poisoning causes significant morbidity and sometimes mortality in children worldwide. The clinical skill of toxidrome recognition followed by the timely administration of an antidote specific for the poison is essential for the management of children with suspected poisoning. This is a narrative review on antidotes for toxidromes in paediatric practice.

Methods

A literature search was conducted on PubMed with the keywords “antidote”, “poisoning”, “intoxication”, “children” and “pediatric”. The search was customized by applying the appropriate filters (species: humans; age: birth to 18 years) to obtain the most relevant articles for this review article.

Results

Toxidrome recognition may offer a rapid guide to possible toxicology diagnosis such that the specific antidote can be administered in a timely manner. This article summarizes toxidromes and their respective antidotes in paediatric poisoning, with an emphasis on the symptomatology and source of exposure. The antidote and specific management for each toxidrome are discussed. Antidotes are only available for a limited number of poisons responsible for intoxication. Antidotes for common poisonings include N-acetyl cysteine for paracetamol and sodium thiosulphate for poisoning by cyanide.

Conclusion

Poisoning is a common cause of paediatric injury. Physicians should be familiar with the recognition of common toxidromes and promptly use specific antidotes for the management of childhood toxidromes.

Plasmapheresis for the management of acute cyanide poisoning: A case report and review of literature

In case of mild to moderate cyanide poisoning, especially when standard antidote kits are not readily available, plasmapheresis can be utilized as an alternative option alongside supportive measures.

A brief history of carbon monoxide and its therapeutic origins

It is estimated that 10% of carbon throughout the cosmos is in the form of carbon monoxide (CO). Earth's earliest prebiotic atmosphere included the trinity of gasotransmitters CO, nitric oxide (NO), and hydrogen sulfide (H₂S), for which all of life has co-evolved with. The history of CO can be loosely traced to mythological and prehistoric origins with rudimentary understanding emerging in the middle ages. Ancient literature is focused on CO's deadly toxicity which is understandable in the context of our primitive relationship with coal and fire. Scientific inquiry into CO appears to have emerged throughout the 1700s followed by chemical and toxicological profiling throughout the 1800s. Despite CO's ghastly reputation, several of the 18th and 19th century scientists suggested a therapeutic application of CO. Since 2000, the fundamental understanding of CO as a deadly nuisance has undergone a paradigm shift such that CO is now recognized as a neurotransmitter and viable pharmaceutical candidate. This review is intended to provide a brief history on the trace origins pertaining to endogenous formation and therapeutic application of CO.

Toxic Blood Hydrogen Cyanide Concentration as a Vital Sign of a Deceased Room Fire Victim-Case Report

Carbon monoxide (CO) and hydrogen cyanide (HCN) are two common toxic products of combustion. HCN concentrations of fire victims are not routinely determined in most legal medicine services in Romania. We present the case of a room fire victim in which we evaluated the concentrations of HCN and carboxyhemoglobin (COHb), their contribution to the mechanism of death, and the possibility that HCN concentration can be interpreted as vital sign. COHb was determined by spectrophotometry. HCN was spectrophotometrically determined with ninhydrin in postmortem blood samples after its removal with 20% phosphoric acid and uptake into a solution of potassium carbonate. The presence of ethyl alcohol was determined by gas chromatography. The COHb concentration was 6.15%, while the blood HCN concentration was 1.043 µg × mL⁻¹ and the total HCN was 1.904 µg × ml⁻¹. A blood alcohol content of 4.36 g‰ and a urine alcohol content of 5.88 g‰ were also found. Although the fire produced a considerable amount of soot, and there were signs of inhalation of soot particles, the COHb level cannot be interpreted as a vital sign. Toxic concentrations of HCN and total HCN can be interpreted as a vital sign and indicates a contributive effect of HCN in the mechanism of death.

A novel highly sensitive dual-channel chemical sensor for sequential recognition of Cu2+ and CN− in aqueous media and its bioimaging applications in living cells

A simple and unique dual-channel chemical probe (DH) was designed and synthesized, which not only realized sequential recognition of Cu2+ and CN− by colorimetric and fluorometric methods, but also realized fluorescence detection of CN−.

Cyanide poisoning in inhalation injuries

Cyanide gas forms during the combustion of synthetic polymers and should be considered in patients presenting with inhalation injuries. A persistently high lactate following adequate resuscitation may be an indicator of cyanide exposure. As cyanide poisoning can be rapidly fatal, prompt recognition and treatment of this condition is vital.

Long-Term Neuropsychiatric Sequelae in a Survivor of Cyanide Toxicity Patient With Arterialization

Cyanide is one of the most rapidly acting poisons and accounts for many suicidal and homicidal deaths. Some natural products such as silk and wool can release cyanide when burned. Most patients who survive cyanide poisoning experience neurological sequelae. This report describes the case of a healthy 45-year-old Yemeni woman who was present during the burning of furniture in a closed space in her home. Upon admission, she displayed signs of inhalational injury, a black discoloration around her mouth and nostrils, and a first-degree burn on the left side of her neck. She experienced neuropsychiatric sequelae of cyanide poisoning, with deficits evolving over three months. Even after three months of treatment and continuous follow-up, she still showed signs of mild cognitive memory impairment along with word-finding difficulties and focal dystonia of her right hand. Full neurological and cognitive assessments are crucial to determine the neuropsychiatric sequelae of acute cyanide toxicity. Magnetic resonance imaging (MRI) can show the extent and structure of lesions in cyanide-sensitive regions of the brain, but it is not always diagnostic. The arterialization of venous blood gases may serve as an early clue to the diagnosis of cyanide poisoning.

Retrospective assessment of acute poisoning incidents by nonpharmaceutical agents in Jordan: Data from Pharmacy One™ Poison Call Center, 2014 to 2018-Part I

The Pharmacy One™ Poising Call Center (P1 PCC), located in Amman, Jordan, was created to address deficiencies identified by the pharmacy service, including in the management of poisoning cases. The aims of this study were to analyze the patterns of poisoning cases reported to the P1 PCC and to describe the role of the P1 PCC pharmacist in ensuring preparedness and managing the response to poisoning cases. In addition, the information from these interventions was used to survey human poisoning in Jordan. This is a retrospective descriptive study of acute poisoning incidents in the Jordanian population, as recorded by the P1 PCC during the period 2014-2018. Inquiries received by the P1 PCC were recorded on a predesigned form. The year, patient demographics, toxic agent involved, and circumstances of the poisoning event were all fully documented utilizing Oracle and Excel spreadsheets. A total of 1992 poisoning incidents were reported to the P1PCC, predominately (68.59%) via 911 phone calls. Reports were predominantly from males (1.67:1). Children were the second most common age group after adolescents (22.62% and 42.49%, respectively). The most frequent causative nonpharmaceutical agents were household products (17%) in preschool children and animal bites (20%) in adolescents. Most of the poisoning incidents (74.63%) occurred at home. Unintentional poisoning (54.12%), with mild medical outcomes (61.45%), accounted for most of the poisoning incidents caused by exposure to household products. These data may represent the most recent picture of poisoning incidents in Jordan. Emergency medical services were provided by experienced pharmacy practitioners at the P1 PCC, to respond to emergency needs in the community in a professional manner. Therefore, the need for unnecessary hospitalization and the cost of ambulance dispatch were minimized, which are highly valuable outcomes.

Acute and Chronic Carbon Monoxide Toxicity from Tobacco Smoking

Introduction: Carbon monoxide (CO) is produced from incomplete combustion of hydrocarbons and is a by-product of tobacco smoking. Chronic cigarette smokers often have carboxyhemoglobin (COHb) concentrations as high as 10%. We report a case of severely elevated COHb and polycythemia because of tobacco smoking and provide a review of the literature regarding elevated COHb in smokers. Materials and Methods: A comprehensive search of PubMed and Google Scholar was performed looking for articles on tobacco smoking and CO, COHb, CO poisoning, cigarettes, pipes, cigars and water pipes/hookah smokers. Result: COHb levels in frequent cigarette smokers generally range from 4.2% presmoking to 8.6% postsmoking. A heavy cigarette smoker presented twice with symptoms of CO toxicity and was found to have levels 21.8 to 24.2%. Cigar smokers have been found to have COHb ranging as high as 13.0 to 38.6% in case reports. Waterpipe or “hookah” smokers generally have COHb levels 10.1% +/−2.5% and case reports, and series of even higher levels associated with CO toxicity symptoms are common. Waterpipe smokers have been found to have COHb levels as high as 39.2% after smoking. Conclusions: Many active duty military and military veterans are tobacco smokers and these patients and their health care providers should be aware of the adverse effects of CO toxicity from tobacco smoking. Patients may have symptoms such as headaches, syncope, and ataxia in the setting of acute CO toxicity; however, the chronic effects of CO may not be completely understood. Future work could explore chronic CO toxicity and its effects on strength and exercise tolerance in military personnel and provide education to service members, veterans, and health care providers.

Carbon Monoxide and Cyanide Poisoning in the Burned Pregnant Patient: An Indication for Hyperbaric Oxygen Therapy

Carbon monoxide (CO) is a small molecule poison released as a product of incomplete combustion. Carbon monoxide binds hemoglobin, reducing oxygen delivery. This effect is exacerbated in the burned pregnant patient by fetal hemoglobin that binds CO 2.5- to 3-fold stronger than maternal hemoglobin. With no signature clinical symptom, diagnosis depends on patient injury history, elevated carboxyhemoglobin levels, and alterations in mental status. The standard of care for treatment of CO intoxication is 100% normobaric oxygen, which decreases the half-life of CO in the bloodstream from 5 hours to 1 hour. Hyperbaric oxygen (HBO2) is a useful adjunct to rapidly reduce the half-life of CO to 20 minutes and the incidence of delayed neurologic sequelae. Because of the slow disassociation of CO from hemoglobin in the fetus, there is a far stronger indication for HBO2 in the burned pregnant patient than in other burn patient populations.Cyanide intoxication is often a comorbid disease with CO in inhalation injury from an enclosed fire, but may be the predominant toxin. It acts synergistically with CO to effectively lower the lethal doses of both cyanide and CO. Diagnosis is best made in the presence of high lactate levels, carboxyhemoglobin concentrations greater than 10%, injury history of smoke inhalation from an enclosed fire, and alterations in consciousness. While treatment with hydroxocobalamin is the standard of care and has the effect of reducing concomitant CO toxicity, data indicate cyanide may also be displaced by HBO2.Carbon monoxide and cyanide poisoning presents potential complications impacting care. This review addresses the mechanism of action, presentation, diagnosis, and treatment of CO and cyanide poisonings in the burned pregnant patient and the use of HBO2 therapy.

Vertical Clinging and Leaping Ahead: How Bamboo Has Shaped the Anatomy and Physiology of Hapalemur

Hapalemur sps. and Prolemur simus (bamboo lemurs, collectively) stand out from the relatively homogeneous lemurids because they are bamboo feeders and vertical clingers and leapers. This unique diet presents equally unique challenges, like its verticality, toughness, and toxicity. The bamboo lemurs share the generalized anatomy of the other lemurids, but also display some well-documented skeletal adaptations, perhaps to overcome the problems presented by their specialization. Soft-tissue adaptations, however, remain largely unexplored. Explored here are possible soft-tissue adaptations in Hapalemur griseus. We compare H. griseus with other lemurids, Propithecus, Galago, Tarsier, and a tree shrew. Based on the available anatomical and physiological data, we hypothesize that Hapalemur and Prolemur species will have differences in hindlimb morphology when compared with other lemurids. We predict that H. griseus will have more hindlimb muscle mass and will amplify muscle mass differences with increased type II muscle fibers. Relative hindlimb muscle mass in H. griseus is less than other prosimians sampled, yet relative sural muscle mass is significantly heavier (P < 0.01) in H. griseus. Results show that the soleus muscle of H. griseus has a higher amount of type II (fast) fibers in plantarflexors. These findings indicate although H. griseus shares some generalized lemurid morphology, its diet of bamboo may have pushed this generalized lemurid to an anatomical extreme. We suspect additional bamboo-specific adaptations in their anatomy and physiology will be uncovered with further examination into the anatomy of the bamboo lemurs. Anat Rec, 2019. © 2019 Wiley Periodicals, Inc. Anat Rec, 303:295-307, 2020. © 2019 American Association for Anatomy.

Troubleshooting a dialysis line: when blue runs red

We present the case of a critically ill woman whose dialysis line was noted to be circulating bright red blood. Located in the right internal jugular vein, the line had previously been working normally with the change occurring shortly after the patient was liberated from positive pressure mechanical ventilation. An arterial malposition was ruled out and subsequent investigations revealed the presence of a left-sided partial anomalous pulmonary venous connection (PAPVC) that had been previously undiagnosed. The identification of a left-sided PAPVC from blood gas measurements taken from a right internal jugular vein dialysis catheter in this case provides an informative opportunity to consider the intricate physiological relationship between the respiratory and cardiovascular systems in critically ill patients requiring invasive procedures and treatments.

Acute clinical manifestations in toxic smoke inhalation victims: systematic review of observational studies

Abstract Introduction: Lung injuries from toxic smoke inhalation are the main causes of death in fire victims; however, information regarding the acute effects on the respiratory system after smoke inhalation and its constituents in closed environments are still scarce in literature. Objective: To investigate the acute clinical manifestations observed in victims of smoke inhalation during enclosed-space fires by means of systematic review. Methods: A systematic search was conducted in the following databases: MEDLINE (via PubMed), Lilacs, Scopus and Web of Science. There were no appliedrestrictions in terms of thepublication date. In addition, a manual search was performed on the references of published studies. Observational studies assessing the prevalence of acute clinical manifestations in victims of toxic smoke inhalation in closed environments were included. Results: Of the 4,603 articles identified, eight were included, comprising a total of 233 patients. The signs and symptoms were identified and ranked according to frequency. Dyspnea (58.80%, six studies), carbonaceous sputum (54.51%, four studies), hoarseness (39.91%, three studies), wheezing (34.33%, five studies) and sore throat (33.90%, two studies) were the most frequent acute clinical manifestations of smoke inhalation. Besides these, chest pain and pulmonary edema were observed, respectively in 13.30%, 5.15% of the studies. Conclusion: The results suggest that dyspnea, carbonaceous sputum, hoarseness, wheezing and sore throat were the most frequent acute clinical manifestations in victims of smoke inhalation. Further studies of a higher level of evidence and greater methodological rigor are required.

Medical and biological factors affecting mortality in elderly residential fire victims: a narrative review of the literature

For older people (aged over 65 years), the risk of dying in a residential fire is doubled compared to the general population. Obvious causes of death mainly include smoke inhalation and burn injuries. That older people are more fragile and have more concurrent diseases is inherent, but what is it that makes them more vulnerable? It is known that the number of elderly people is increasing globally and that the increased risk of death in fires can be explained, at least in part, by physical and/or cognitive disabilities as well as socioeconomic and behavioural factors. The possibility that medical illnesses and an aging organism/tissues might explain this increased risk has not been shown to the same extent. Therefore, this narrative literature review focuses on medical and biological explanations. An initial search using the terms ‘elderly’, ‘fatal’, ‘residential’ and ‘fire’ yielded some interesting articles. Using a broader snowball search also accepting grey literature, several additional risk factors could be identified. Cardiovascular diseases, in particular atherosclerotic heart disease, greatly increases the vulnerability to, for example, carbon monoxide and probably also other asphyxiating gases. Cardiovascular diseases and lack of physical fitness may also increase vulnerability to heat. Burned elderly patients are also at a higher risk of death than younger patients, but it is controversial whether it is age itself or the pre-existing illnesses that come with age that increase the risk. Immunosenescence, malnutrition and female gender are other risk factors for poorer outcome after burns, all of which are common among older people.

Elderly people have an increased risk of dying in house fires for several known reasons. This review explores possible medical/biological explanations and finds heart disease to be an important explanation.

Neurobehavioral and Cardiovascular Effects of Potassium Cyanide Administered Orally to Mice

The Food and Drug Administration Animal Rule requires evaluation of cardiovascular and central nervous system (CNS) effects of new therapeutics. To characterize an adult and juvenile mouse model, neurobehavioral and cardiovascular effects and pathology of a single sublethal but toxic, 8 mg/kg, oral dose of potassium cyanide (KCN) for up to 41 days postdosing were investigated. This study describes the short- and long-term sensory, motor, cognitive, and behavioral changes associated with oral dosing of a sublethal but toxic dose of KCN utilizing functional observation battery and Tier II CNS testing in adult and juvenile mice of both sexes. Selected tissues (histopathology) were evaluated for changes associated with KCN exposure with special attention to brain regions. Telemetry (adult mice only) was used to evaluate cardiovascular and temperature changes. Neurobehavioral capacity, sensorimotor responsivity or spontaneous locomotor activity, and rectal temperature were significantly reduced in adult and juvenile mice at 30 minutes post-8 mg/kg KCN dose. Immediate effects of cyanide included bradycardia, adverse electrocardiogram arrhythmic events, hypotension, and hypothermia with recovery by approximately 1 hour for blood pressure and heart rate effects and by 2 hours for body temperature. Lesions consistent with hypoxia, such as mild acute tubular necrosis in the kidneys corticomedullary junction, were the only histopathological findings and occurred at a very low incidence. The mouse KCN intoxication model indicates rapid and completely reversible effects in adult and juvenile mice following a single oral 8 mg/kg dose. Neurobehavioral and cardiovascular measurements can be used in this animal model as a trigger for treatment.

A new application of the traditional Fenton process to gold cyanide synthesis using acetonitrile as a cyanide source

We introduced a general Fenton-reaction synthesis of metal cyanide solids using acetonitrile as a green cyanide source. This Fenton-improved cyanation method gets rid of CN⁻ ions and UV-light efficiently, which is green and facile.

Acute Cyanide Poisoning: Hydroxocobalamin and Sodium Thiosulfate Treatments with Two Outcomes following One Exposure Event

Cyanide is rapidly reacting and causes arrest of aerobic metabolism. The symptoms are diffuse and lethal and require high clinical suspicion. Remediation of symptoms and mortality is highly dependent on quick treatment with a cyanide antidote. Presently, there are two widely accepted antidotes: sodium thiosulfate and hydroxocobalamin. These treatments act on different components of cyanide's metabolism. Here, we present two cases resulting from the same source of cyanide poisoning and the use of both antidotes separately used with differing outcomes.

Formation of highly toxic hydrogen cyanide upon ruby laser irradiation of the tattoo pigment phthalocyanine blue

Since laser treatment of tattoos is the favored method for the removing of no longer wanted permanent skin paintings, analytical, biokinetics and toxicological data on the fragmentation pattern of commonly used pigments are urgently required for health safety reasons. Applying dynamic headspace—gas chromatography with mass spectrometric detection (DHS—GC/MS) and comprehensive two-dimensional gas chromatography coupled to time-of-flight mass spectrometry (GCxGC—ToF-MS), we identified 1,2-benzene dicarbonitrile, benzonitrile, benzene, and the poisonous gas hydrogen cyanide (HCN) as main fragmentation products emerging dose-dependently upon ruby laser irradiation of the popular blue pigment copper phthalocyanine in suspension. Skin cell viability was found to be significantly compromised at cyanide levels of ≥1 mM liberated during ruby laser irradiation of >1.5 mg/ml phthalocyanine blue. Further, for the first time we introduce pyrolysis-GC/MS as method suitable to simulate pigment fragmentation that may occur spontaneously or during laser removal of organic pigments in the living skin of tattooed people. According to the literature such regular tattoos hold up to 9 mg pigment/cm² skin.