The Center for Hyperbaric Medicine, in Seattle, maintains an on-call team that responds to emergencies 24 hours a day. Emergency patients are referred to the Center for Hyperbaric Medicine through the (24/7) Admissions Center: (206) 341-1141.
Carbon Monoxide Poisoning
Carbon Monoxide (CO) is a colorless, odorless gas. Common sources are: incomplete combustion from fossil fuels; automobiles, boats, generators, barbecues and house fires.
If a patient has vague flu-like symptoms, nausea, headache, confusion or loss of consciousness, it may be carbon monoxide poisoning. A cherry red appearance is rarely seen. Oxygen saturation monitors do not reflect accurate oxygenation.
Indications for Hyperbaric Treatment:
Patients with documented exposure to CO (COHb level greater than 2 percent in a nonsmoker and greater than 10 percent in a smoker) within the previous 24 hours and any one or more of the following:
- Loss of consciousness
- COHb level > 25 percent
- Any neurological deficits
- Cardiac ischemia
- Age > 50 years
- Metabolic acidosis (calculated base excess lower than -2.0 mmol/liter or a lactate concentration or > 2.5 mmol/liter
EMS Management of Carbon Monoxide Poisoning
100 percent oxygen by non-rebreather mask at 15 liters/min.
CO: Delay from onset of symptoms < 24 hours: intravenous hydration - normal saline 1 liter over 2 hours followed by 250 cc/hour (unless pulmonary edema is present).
Delay from onset of symptoms > 24 hours: encourage fluids. Electrocardiogram, chest X-ray, arterial blood gases, establish intravenous access.
As dictated by patient condition: endotracheal intubation, arterial catheter, urinary catheter, NG tube.
Hyperbaric Oxygen Therapy (HBO2)
Immediate recompression is the treatment of choice to:
- Reverse hypoxia
- Reverse symptoms
- Limit long term neurological sequelae
ER CO Poisoning Information Protocol
Capture this information:
- Patient demographics
- Carboxyhemoglobin level
- When was CO exposure?
- Source of CO
- Does patient speak English?
- Symptoms - common symptoms include chest pain, confusion, dizziness, fatigue, headache, memory complaints, nausea/vomiting, shortness of breath, loss of consciousness
- Was the CO poisoning accidental or intentional?
- If intentional, get results of toxicology screen
- Is patient pregnant?
- Is there evidence of cardiac injury?
- What is the current clinical status?
- Contraindications to hyperbaric exposure (relative or absolute)
- Evidence of pneumothorax
- History of seizures
- Hemodynamic instability
- Significant heart or lung disease
Emergency patients are referred to the Center for Hyperbaric Medicine through the (24/7) Admissions Center: (206) 341-1141.
[Back to Top]
Decompression Sickness and Arterial Gas Embolism
Decompression Sickness (DCS)
DCS is a micro-bubble disease that can follow exposure to high pressure (diving) or as a result of rapid ascent to high altitudes. DCS can occur even if decompression limits are observed or following uneventful dives.
Diagnosis of Decompression Sickness:
- History of recent exposure to breathing compressed air under water.
- Symptoms consistent with DCS:
- Musculoskeletal - Joint pain
- Neurological - Numbness or other sensory deficits, tingling, weakness or paralysis, ataxia or other vestibular symptoms, extreme fatigue, cognitive deficits
- Cutaneous - Skin blotching, itching
- Pulmonary - Dyspnea
- Onset ranges from immediate to 48 hours
- Magnitude of exposure is not a reliable guide to severity of disease.
Arterial Gas Embolism (AGE)
Arterial gas bubbles resulting from pulmonary over-pressurization, alveolar rupture, and entry of air bubbles into the vasculature. AGE is primarily a diving accident, but may follow escape from a submerged vehicle or may be an iatrogenic complication.
Diagnosis of Arterial Gas Embolism:
- Immediate onset of symptoms
- Panic or uncontrolled ascent during diving
- Evidence of anatomic or physiologic airway obstruction
- Symptoms consistent with AGE:
- Neurological - Stroke-like symptoms, numbness or other sensory deficits, tingling, weakness or paralysis
- Pulmonary (due to barotraumas) - Dyspnea, hemoptysis, pneumothroax (seen only occasionally)
- Cardiac (due to coronary embolization) - S-T changes, dysrhythmias, tachycardia
- Can occur in three to four feet of water
- Recent invasive medical procedure (iatrogenic)
EMS Management of Decompression Sickness and Arterial Gas Embolism
100 percent oxygen by non-rebreather mask at 15 liters/min should be administered immediately for either DCS or AGE.
DCS: Delay from onset of symptoms < 24 hours: intravenous hydration - normal saline 1 liter over 2 hours followed by 250 cc/hour (unless pulmonary edema present).
Delay from onset of symptoms > 24 hours: encourage fluids.
AGE: Electrocardiogram, chest X-ray, arterial blood gases, establish intravenous access.
DCS or AGE: As dictated by patient condition: endotracheal intubation, arterial catheter, urinary catheter, NG tube.
Hyperbaric Oxygen Therapy (HBO2)
Immediate recompression is the treatment of choice.
- Inhibits progression of the disease
- Reverses symptoms
- Limits reoccurrence of symptoms
- Prevents long-term neurologic and orthopedic sequelae.
If symptoms resolve with oxygen administration, the patient must be referred for HBO2 as symptoms frequently return.
ER Diving Injury Information Protocol
Capture this information:
- Patient demographics
- Symptoms - common symptoms include joint pain, numbness, tingling, headache, fatigue, dizziness, rash, weakness, bowel and bladder dysfunction
- Date and time of onset of first symptom
- Most serious clinically significant symptom
- Note if symptoms occurred prior to dive or at depth
- Dive history
- Date and time of last dive
- Maximum depth and time of last dive
- Total number of dives and over what time period
- Any problems with dive(s)
- Altitude exposure after dives
- Physical examination
- Any objective neurological findings? (cranial nerves, strength, sensation to light touch, gait, finger-to-nose)
- Contraindications to hyperbaric exposure (relative or absolute)
- Evidence of pneumothorax
- History of seizures
- Hemodynamic instability
- Significant heart or lung disease
Emergency patients are referred to the Center for Hyperbaric Medicine through the (24/7) Admissions Center: (206) 341-1141.
[Back to Top]