Carbon Monoxide & Cyanide Poisoning

Let's talk about carbon monoxide and cyanide poisoning. These are similar poisonings. And where you will get into trouble is where you have a fire, either an industrial fire or a house fire, where there's synthetic materials that are burning that can release, in addition to carbon monoxide, cyanide gases. Cyanide is easily absorbed through the, through the lungs, through the skin, mucous membranes, and is highly deadly. In fact, when you have a victim of smoke inhalation from the fire, it's estimated that up to one third of those patients that present to the hospital actually have, in addition to carbon monoxide poisoning, they have evidence of toxic cyanide levels. It can be very difficult dealing with a patient who's had significant smoke inhalation to determine what part of their syndrome is carbon monoxide and what part is cyanide. And actually, since it's so similar and there's such a crossover and you could literally have both at the same time, it's probably best to assume that they have both. In the case of carbon monoxide poisoning, these patients need to be placed on 100% oxygen. That's because carbon monoxide will block the oxygen carrying capacity of the hemoglobin. You will not actually affect their pulse ox. Their pulse ox could be good because pulse ox is actually measuring the amount of oxygen that's attached to normal hemoglobin. So your pulse ox can be faulty and mislead you to think, hey, they're fine, when actually they're not. They've got carbon monoxide poisoning. So the half life on room air of getting the carbon monoxide to leave that hemoglobin is about five hours. If you put them on 100% oxygen, that drops by five times to one hour. And then the question is, do they need hyperbaric oxygen? And that's not so clear in the literature. We argue a little bit about it in the medical literature, but suffice it to say that pregnant women, children and any patient with neurological symptoms is pretty clear cut recommendations to go to get hyperbaric oxygen treatment, because that drops the half life of removing the carbon monoxide down to 20 minutes. And the big deal, the reason why this is important is not so much will you save their life, but what's going to happen down the road. Some of these patients will end up with significant neurological damage because of the hypoxia that is caused at the cellular level from the carbon monoxide. Now let's talk about the cyanide piece of this. And you've heard that maybe 60% of the population can actually smell cyanide like bitter almonds. I don't know if you've really noticed that in a structural fire, which is the most common scenario, that we'll probably see that here at Palm Beach County Fire Rescue. These patients also have similar issues when it comes to cellular hypoxia, but from a different standpoint. These patients, what happens is the cyanide attacks mitochondria and blocks.

The electron transport chain, which is where oxygen is used to create intracellular energy. And this is highly deadly and can kill literally within minutes. What happens to these patients is they lose the ability to actually process. Process oxygen at the cellular level. And that means that the blood ends up carrying extra oxygen because the tissues aren't using it. So you may end up having this cherry red appearance of the blood because there's extra oxygen in the blood, because the cells can no longer use it because cyanide's blocking the cells being able to use it. This leads to.

Instead of aerobic metabolism, leads to anaerobic metabolism, which gives you a lot of lactic acid. So typically, these patients are trying to blow off carbon dioxide because they got a lot of lactic acidosis going on. And the treatment for this, there's the old way of treating things, which we don't use anymore, that actually caused its own problem with hemoglobin. But we have a very safe treatment now called hydroxocobalamin. Now, hydroxocobalamin is given intravenously, and it basically sucks the cyanide out of the cells. Very safe. And the byproduct of that is actually vitamin B12. So it's harmless. There is some weird side effects from hydroxylcobalamin, such as you may have red urine. They're not bleeding in their kidneys, so you might want to warn the patients that they may see some red urine. That's just typical. Be sure that you're ready to have this for your brothers and sisters who are fighting the fire, because firefighters are actually one of the ones that are prone to getting cyanide toxicity from fighting the fire. So have that ready not just for the victims in a fire, but also for the folks fighting the fire.

In addition to Dr. Schepke's information on what carbon monoxide and cyanide difference for the poisoning is, I want to talk to you a little bit about carbon monoxide poisoning only. Florida has a unique situation with the hurricanes. And during hurricane season with power out, we usually have a lot of instances, carbon monoxide poisoning that are the result of Generators being either placed in the home or outside the home near a window or door where the exhaust actually comes into the house or apartment. These patients present the same as cyanide poisoning, but their poisoning is a direct result of clean burn burning exhaust from fuel sources. These fuel sources can be gasoline powered motors, vehicle exhaust in enclosed space and wood burning. So anything that is a clean fuel source will directly cause carbon monoxide poisoning from their exhaust.

With carbon monoxide, some of the symptoms you're going to have are like headache. They could be in a coma, they could have nausea, vomiting. It all depends on the PPMs that they're exposed to and the amount of time that they been exposed to carbon monoxide poisoning. The treatment for carbon monoxide poisoning is removing the patient from the environment, from the exposure and then putting them on high flow oxygen, 15 liters per minute non rebreather mask. Like Dr. Schepke explained in the video, it could take up to five hours. You just decreased it up to an hour for them to make a reversal. With these patients you also want to think about bringing them to a hyperbaric chamber which will be St. Mary's and that will also help with the elimination of the CO with the carbon monoxide poisoning examples that I listed. Cyanokit is not the appropriate treatment for these patients. These patients will benefit by being placed on high O2, 15L minoring of their SPCO with the Rainbow sensor and having them transported to a facility with hyperbaric capabilities.

Sa.