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一酸化炭素中毒

著者: 入江仁 津軽保健生活協同組合健生病院救急集中治療部

監修: 箕輪良行 みさと健和病院 救急総合診療研修顧問

著者校正/監修レビュー済:2019/10/03
患者向け説明資料

概要・推奨   

  1. CO中毒患者の症状や身体所見は非特異的であり、病歴と身体診察で鑑別疾患から除外することは困難である。病歴からCO中毒を疑う場合にはCO-Hb血中濃度を測定することを強く推奨する(推奨度1)
  1. CO-Hb血中濃度を測定するに当たり、スクリーニングであれば静脈血を用いることも、推奨されるかもしれない(推奨度2)
  1. CO中毒と診断した場合、合併症である心筋障害について評価することが強く勧められる(推奨度1)
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  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契
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  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
入江仁 : 特に申告事項無し[2021年]
監修:箕輪良行 : 特に申告事項無し[2021年]

改訂のポイント:
  1. 定期レビューを行い、CO-Hb測定可能なパルスオキシメーターの有用性についてと、遅発性脳症の危険因子について加筆修正を行った。

病態・疫学・診察

症状のまとめ  
  1. 一酸化炭素(CO)中毒による死亡者数はわが国で年間数千人といわれている。原因としては火災や暖房器具の不具合が多いが、近年ではインターネットを通じた集団自殺の事例もある。
  1. CO中毒の診断は
  1. COに曝露された病歴
  1. 中毒を疑う症状や身体所見
  1. 一酸化炭素ヘモグロビン(CO-Hb)濃度の上昇
からなされる。
  1. 通常のパルスオキシメーターは酸化ヘモグロビンとCO-Hbとを区別できないため、CO中毒を経皮的血中酸素飽和度の数値から評価することはできない。なお、近年ではCO-Hbを測定できるパルスオキシメーターもあり、これにより高気圧酸素療法開始までの時間を短縮できたとする報告がある。但し、実際のCO-Hb濃度に対する正確性は確立されておらず、血液ガス検査での確認が必要とされる[1]
  1. CO-Hb濃度は重症度と相関しないことがあるため注意を要する。低濃度環境での長時間曝露や病院前から酸素投与が開始されている場合では、CO-Hb濃度のみでは重症度を過小評価する恐れがある。
病歴・診察のポイント  
  1. CO中毒の急性期症状は低酸素によるものであるが、頻度が大きいのは頭痛、めまい、嘔吐といった非特異的症状である。疑わなければ診断することが困難な症例も多い。

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11月30日(火)までにお申込みいただくと、
通常12ヵ月の使用期間が2ヶ月延長となり、14ヵ月ご利用いただけるようになります。

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文献 

著者: Jason J Rose, Ling Wang, Qinzi Xu, Charles F McTiernan, Sruti Shiva, Jesus Tejero, Mark T Gladwin
雑誌名: Am J Respir Crit Care Med. 2017 Mar 1;195(5):596-606. doi: 10.1164/rccm.201606-1275CI.
Abstract/Text Carbon monoxide (CO) poisoning affects 50,000 people a year in the United States. The clinical presentation runs a spectrum, ranging from headache and dizziness to coma and death, with a mortality rate ranging from 1 to 3%. A significant number of patients who survive CO poisoning suffer from long-term neurological and affective sequelae. The neurologic deficits do not necessarily correlate with blood CO levels but likely result from the pleiotropic effects of CO on cellular mitochondrial respiration, cellular energy utilization, inflammation, and free radical generation, especially in the brain and heart. Long-term neurocognitive deficits occur in 15-40% of patients, whereas approximately one-third of moderate to severely poisoned patients exhibit cardiac dysfunction, including arrhythmia, left ventricular systolic dysfunction, and myocardial infarction. Imaging studies reveal cerebral white matter hyperintensities, with delayed posthypoxic leukoencephalopathy or diffuse brain atrophy. Management of these patients requires the identification of accompanying drug ingestions, especially in the setting of intentional poisoning, fire-related toxic gas exposures, and inhalational injuries. Conventional therapy is limited to normobaric and hyperbaric oxygen, with no available antidotal therapy. Although hyperbaric oxygen significantly reduces the permanent neurological and affective effects of CO poisoning, a portion of survivors still have substantial morbidity. There has been some early success in therapies targeting the downstream inflammatory and oxidative effects of CO poisoning. New methods to directly target the toxic effect of CO, such as CO scavenging agents, are currently under development.

PMID 27753502  Am J Respir Crit Care Med. 2017 Mar 1;195(5):596-606. d・・・
著者: Adam Harper, James Croft-Baker
雑誌名: Age Ageing. 2004 Mar;33(2):105-9. doi: 10.1093/ageing/afh038.
Abstract/Text Carbon monoxide poisoning represents a potentially preventable and reversible cause of mortality and morbidity if sources and cases can be identified. The elderly have been shown to be particularly at risk. Concerns continue to be raised about potential unrecognised cases of carbon monoxide poisoning. These concerns arise from difficulties in knowing who to suspect as a potential victim of poisoning as well as how, when and what to test. In general carbon monoxide has no helpful unique clinical presentation and is known to mimic common illnesses as well as exacerbate established diseases. As a gas it is undetectable by the human senses and is potentially present in most households. This paper reviews the issues associated with carbon monoxide poisoning including pointers to early diagnosis and discussion of pathophysiology and management.

PMID 14960423  Age Ageing. 2004 Mar;33(2):105-9. doi: 10.1093/ageing/a・・・
著者: Louise W Kao, Kristine A Nañagas
雑誌名: Emerg Med Clin North Am. 2004 Nov;22(4):985-1018. doi: 10.1016/j.emc.2004.05.003.
Abstract/Text CO is an insidious poison with many sources of exposure. CO poisoning produces diverse signs and symptoms, which often are subtle and can be misdiagnosed easily. Failure to diagnose CO poisoning may result insignificant morbidity and mortality and allow continued exposure to a dangerous environment. In the ED, a high index of suspicion must be maintained for occult CO exposure. Headache, particularly when associated with certain environments, and flulike illness in the wintertime with symptomatic cohabitants should raise the index of suspicion in the ED significantly for occult CO poisoning. Emergency treatment of CO poisoning begins with inhalation of supplemental oxygen and aggressive supportive care. HBOT accelerates dissociation of CO from hemoglobin and may prevent DNS. Absolute indications for HBOT for CO poisoning remain controversial, although most would agree that HBOT is indicated in patients who are comatose, are neurologically abnormal, have a history of loss of consciousness with their exposure, or have cardiac dysfunction. Pregnancy with an elevated CO-Hgb level (>15-20%) also is widely considered an indication for treatment. HBOT may be considered in patients who have persistent symptoms despite NBO, metabolic acidosis, abnormalities on neuropsychometric testing, or significantly elevated levels. The ideal regimen of oxygen therapy has yet to be determined, and significant controversy exists regarding HBOT protocols. The emergency physician may be confronted with the difficult decision regarding disposition and even transfer to a hyperbaric facility. Often the local medical toxicologist, poison control center, or hyperbaric unit can assist the emergency physician with the decision-making process.

PMID 15474779  Emerg Med Clin North Am. 2004 Nov;22(4):985-1018. doi: ・・・
著者: C Tomaszewski
雑誌名: Postgrad Med. 1999 Jan;105(1):39-40, 43-8, 50.
Abstract/Text Each year, particularly during the heating season, thousands of people are poisoned by carbon monoxide, with potentially devastating outcomes. Initial diagnosis can be difficult because symptoms closely resemble those of influenza and are often misinterpreted. Dr Tomaszewski discusses diagnosis and treatment, including the benefits and risks of hyperbaric oxygen therapy.

PMID 9924492  Postgrad Med. 1999 Jan;105(1):39-40, 43-8, 50.
著者: Christopher R Henry, Daniel Satran, Bruce Lindgren, Cheryl Adkinson, Caren I Nicholson, Timothy D Henry
雑誌名: JAMA. 2006 Jan 25;295(4):398-402. doi: 10.1001/jama.295.4.398.
Abstract/Text CONTEXT: Carbon monoxide (CO) poisoning is a common cause of toxicological morbidity and mortality. Myocardial injury is a frequent consequence of moderate to severe CO poisoning. While the in-hospital mortality for these patients is low, the long-term outcome of myocardial injury in this setting is unknown.
OBJECTIVE: To determine the association between myocardial injury and long-term mortality in patients following moderate to severe CO poisoning.
DESIGN, SETTING, AND PARTICIPANTS: Prospective cohort study of 230 consecutive adult patients treated for moderate to severe CO poisoning with hyperbaric oxygen and admitted to the Hennepin County Medical Center, a regional center for treatment of CO poisoning, between January 1, 1994, and January 1, 2002. Follow-up was through November 11, 2005.
MAIN OUTCOME MEASURE: All-cause mortality.
RESULTS: Myocardial injury (cardiac troponin I level > or =0.7 ng/mL or creatine kinase-MB level > or =5.0 ng/mL and/or diagnostic electrocardiogram changes) occurred in 85 (37%) of 230 patients. At a median follow-up of 7.6 years (range: in-hospital only to 11.8 years), there were 54 deaths (24%). Twelve of those deaths (5%) occurred in the hospital as a result of a combination of burn injury and anoxic brain injury (n = 8) or cardiac arrest and anoxic brain injury (n = 4). Among the 85 patients who sustained myocardial injury from CO poisoning, 32 (38%) eventually died compared with 22 (15%) of 145 patients who did not sustain myocardial injury (adjusted hazard ratio, 2.1; 95% confidence interval, 1.2-3.7; P = .009).
CONCLUSION: Myocardial injury occurs frequently in patients hospitalized for moderate to severe CO poisoning and is a significant predictor of mortality.

PMID 16434630  JAMA. 2006 Jan 25;295(4):398-402. doi: 10.1001/jama.295・・・
著者: Neil B Hampson, Claude A Piantadosi, Stephen R Thom, Lindell K Weaver
雑誌名: Am J Respir Crit Care Med. 2012 Dec 1;186(11):1095-101. doi: 10.1164/rccm.201207-1284CI. Epub 2012 Oct 18.
Abstract/Text 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.

PMID 23087025  Am J Respir Crit Care Med. 2012 Dec 1;186(11):1095-101.・・・
著者: Neil B Hampson, Diana Bodwin
雑誌名: J Emerg Med. 2013 Mar;44(3):625-30. doi: 10.1016/j.jemermed.2012.08.033. Epub 2012 Nov 5.
Abstract/Text BACKGROUND: Intentional carbon monoxide (CO) poisoning is responsible for two-thirds of the deaths from CO poisoning in this country and an estimated 15,000 Emergency Department visits annually.
OBJECTIVES: In an attempt to optimize medical management of such patients, this study was conducted to examine the frequency and types of toxic co-ingestions that may accompany CO inhalation.
METHODS: Records of all patients treated with hyperbaric oxygen for acute, intentional CO poisoning at a regional referral center for hyperbaric medicine in Seattle from 1980 to 2005 were reviewed. For those where co-ingestions were identified, information about type of poison(s) and results of toxicology screens was recorded and analyzed.
RESULTS: Over the 25-year period examined, 433 patients were treated for intentional CO poisoning and records were available for 426. Of those, 188 (42%) had ingested one or more poisons in addition to CO. Ethanol was most common, but a wide variety of other drug classes were also identified. Toxicology screening studies of some type were performed in 49 patients.
CONCLUSIONS: Toxic co-ingestions seem to be relatively common in patients treated for intentional CO poisoning. For this reason, providers should be vigilant and open to clinical signs that can't be explained with CO exposure alone, and ready to treat clinical issues that arise from co-ingestions.

Copyright © 2013 Elsevier Inc. All rights reserved.
PMID 23137961  J Emerg Med. 2013 Mar;44(3):625-30. doi: 10.1016/j.jeme・・・
著者: M Touger, E J Gallagher, J Tyrell
雑誌名: Ann Emerg Med. 1995 Apr;25(4):481-3.
Abstract/Text STUDY OBJECTIVE: To test the hypothesis that venous carboxyhemoglobin (V-COHb) levels accurately predict arterial (A-COHb) levels.
DESIGN: Prospective comparison of A-COHb and V-COHb levels in patients with suspected carbon monoxide (CO) poisoning.
SETTING: Municipal hospital emergency department with contiguous multiplace hyperbaric chamber staffed 24 hours a day.
PARTICIPANTS: Unselected convenience sample of 61 adults with suspected CO toxicity.
INTERVENTION: Simultaneous sampling of arterial and venous blood.
RESULTS: Correlation between V-COHb and A-COHb showed an r value of .99 (95%CI, .99 to .99), and an r2 value of .98. Agreement between V-COHb and A-COHb levels was examined by use of a plot of arteriovenous differences against the mean of the two measurements. The mean arteriovenous difference was .15% COHb (95%CI, .13% to .45%), with 95% of the differences ranging from 2.4% COHb to -2.1% COHb.
CONCLUSION: Venous COHb levels predict arterial levels with a high degree of accuracy. Patients with suspected CO poisoning can be screened with the use of venous blood, without the need for arterial puncture.

PMID 7710152  Ann Emerg Med. 1995 Apr;25(4):481-3.
著者: Neil B Hampson, Niels M Hauff
雑誌名: Crit Care Med. 2008 Sep;36(9):2523-7. doi: 10.1097/CCM.0b013e31818419d8.
Abstract/Text OBJECTIVE: Carbon monoxide (CO) poisoning is common in the United States, accounting for approximately 2,700 deaths annually. Few publications have described the mortality rate of CO-poisoned patients who survive to reach a hospital and die despite maximal medical care. Further, while risk factors for cognitive sequelae in survivors of CO poisoning have become clearer recently, factors associated with death are less well defined. This study was conducted to 1) determine the short-term mortality risk for patients treated with hyperbaric oxygen for CO poisoning, and 2) determine whether any factors related to the poisoning episode are predictive of mortality.
DESIGN/SETTING/PATIENTS: A departmental database and medical records of 1,505 consecutive patients treated with hyperbaric oxygen at a single institution from 1978 to 2005 were reviewed.
MEASUREMENTS: Demographic and clinical data were extracted for analysis. Mortality data, including cause of death, were obtained through a search of the National Death Index of the National Center for Health Statistics.
MAIN RESULTS: A total of 38 patients experienced short-term mortality from their episode of CO poisoning, yielding a death rate of 2.6% in medically treated patients. Characteristics significantly associated with mortality included fire as a source of CO, loss of consciousness, carboxyhemoglobin level, arterial pH, and presence of endotracheal intubation during hyperbaric treatment.
CONCLUSIONS: The mortality rate for medically treated CO-poisoned patients in this series was 2.6%, similar to the limited combined experience previously reported in the literature. Factors most strongly associated with mortality were severe metabolic acidosis and need for endotracheal intubation.

PMID 18679118  Crit Care Med. 2008 Sep;36(9):2523-7. doi: 10.1097/CCM.・・・
著者: Stephen J Wolf, Eric J Lavonas, Edward P Sloan, Andy S Jagoda, American College of Emergency Physicians
雑誌名: Ann Emerg Med. 2008 Feb;51(2):138-52. doi: 10.1016/j.annemergmed.2007.10.012.
Abstract/Text This clinical policy focuses on critical issues concerning the management of adult patients presenting to the emergency department (ED) with acute symptomatic carbon monoxide (CO) poisoning. The subcommittee reviewed the medical literature relevant to the questions posed. The critical questions are: Should hyperbaric oxygen (HBO2) therapy be used for the treatment of patients with acute CO poisoning; and Can clinical or laboratory criteria identify CO-poisoned patients who are most or least likely to benefit from this therapy. Recommendations are provided on the basis of the strength of evidence of the literature. Level A recommendations represent patient management principles that reflect a high degree of clinical certainty; Level B recommendations represent patient management principles that reflect moderate clinical certainty; and Level C recommendations represent other patient management strategies that are based on preliminary, inconclusive, or conflicting evidence, or based on committee consensus. This clinical policy is intended for physicians working in hospital-based EDs.

PMID 18206551  Ann Emerg Med. 2008 Feb;51(2):138-52. doi: 10.1016/j.an・・・
著者: Nick A Buckley, David N Juurlink, Geoff Isbister, Michael H Bennett, Eric J Lavonas
雑誌名: Cochrane Database Syst Rev. 2011 Apr 13;(4):CD002041. doi: 10.1002/14651858.CD002041.pub3. Epub 2011 Apr 13.
Abstract/Text BACKGROUND: Poisoning with carbon monoxide (CO) remains an important cause of accidental and intentional injury worldwide. Several unblinded non-randomized trials have suggested that the use of hyperbaric oxygen (HBO) prevents the development of neurological sequelae. This has led to the widespread use of HBO in the management of patients with carbon monoxide poisoning.
OBJECTIVES: To examine randomised trials of the efficacy of hyperbaric oxygen (HBO) compared to normobaric oxygen (NBO) for the prevention of neurologic sequelae in patients with acute carbon monoxide poisoning.
SEARCH STRATEGY: We searched the following electronic databases; Cochrane Injuries Group Specialised Register (searched June 2010), Cochrane Central Register of Controlled Trials (The Cochrane Library 2010, Issue 2), MEDLINE (Ovid SP) 1950 to June 2010, EMBASE (Ovid SP) 1980 to June 2010, ISI Web of Science: Science Citation Index Expanded (SCI-EXPANDED) 1970 to June 2010, ISI Web of Science: Conference Proceedings Citation Index-Science (CPCI-S) 1990 to June 2010.
SELECTION CRITERIA: All randomised controlled trials of HBO compared to NBO, involving non-pregnant adults who are acutely poisoned with carbon monoxide (regardless of severity).
DATA COLLECTION AND ANALYSIS: Two authors independently extracted from each trial information on: the number of randomised patients, types of participants, the dose and duration of the intervention, and the prevalence of neurologic symptoms at follow-up.
MAIN RESULTS: Seven randomised controlled trials of varying quality were identified; one was excluded because it did not evaluate clinical outcomes. Of the six remaining trials involving 1361 participants, two found a beneficial effect of HBO for the reduction of neurologic sequelae at one month, while four others did not. One of these is an incomplete publication (an abstract of an interim analysis). Although pooled random effects meta-analysis does not suggest a significant benefit from HBOT (OR for neurological deficits 0.78, 95%CI 0.54 to 1.12), significant methodologic and statistical heterogeneity was apparent among the trials, and this result should be interpreted cautiously. Moreover, design or analysis flaws were evident in all trials. Importantly, the conclusions of one positive trial may have been influenced by failure to adjust for multiple hypothesis testing, while interpretation of the other positive trial is hampered by a high risk of bias introduced during the analysis including an apparent change in the primary outcome. Both were also stopped early 'for benefit', which is likely to have inflated the observed effect. In contrast three negative trials had low power to detect a benefit of HBO due to exclusion of severely poisoned patients in two and very poor follow-up in the other. One trial that was said to be finished around eight years ago has not reported the final analysis in any forum.
AUTHORS' CONCLUSIONS: Existing randomised trials do not establish whether the administration of HBO to patients with carbon monoxide poisoning reduces the incidence of adverse neurologic outcomes. Additional research is needed to better define the role, if any, of HBO in the treatment of patients with carbon monoxide poisoning. This research question is ideally suited to a multi-center randomised controlled trial.

PMID 21491385  Cochrane Database Syst Rev. 2011 Apr 13;(4):CD002041. d・・・
著者: D A Silver, M Cross, B Fox, R M Paxton
雑誌名: Clin Radiol. 1996 Jul;51(7):480-3.
Abstract/Text Of 107 patients admitted to the South Western Hyperbaric Medical Centre with acute carbon monoxide poisoning for hyperbaric oxygen therapy 19 had cerebral imaging performed: 17 patients had CT, one patient had MRI and CT and one patient MRI alone. The role of brain CT is established in determining the prognosis from acute carbon monoxide poisoning. Brain imaging was indicated because of unconsciousness on admission and failure or delayed improvement in neurological status after initiation of hyperbaric oxygen therapy. Of the 18 patients who underwent brain CT, seven were found to have the characteristic changes of bilateral low attenuation areas within the globus pallidus and six had low attenuation changes within cerebral white matter. In two patients there were both globus pallidus and cerebral white matter changes. Out of the total of the 19 patients who were studied, four patients died, 10 recovered fully and five had variable disabilities ranging from short term memory loss to more severe cognitive impairment and physical disability. The role of CT and the practicalities of hyperbaric oxygen therapy for acute carbon monoxide poisoning are discussed in the light of the experience from a regional dedicated medical diving centre.

PMID 8689822  Clin Radiol. 1996 Jul;51(7):480-3.
著者: J S Jones, J Lagasse, G Zimmerman
雑誌名: Am J Emerg Med. 1994 Jul;12(4):448-51.
Abstract/Text Selective necrosis and degeneration of the globus pallidus are characteristic autopsy findings in patients with severe carbon monoxide (CO) poisoning. The objective of this study was to show that computed tomography (CT) may demonstrate these morphological changes in the brain during life, and provide a clue to prognosis. The authors reviewed the medical records of 19 consecutive patients with acute CO poisoning who underwent CT examination during hospitalization. Abnormal CT findings were found in 10 of the 19 patients (53%). The most common abnormal findings were low-density areas in the basal ganglia. These lesions were found in 7 of the 10 cases, and varied from small (limited to the globus pallidus) to large (extending to the internal capsule). Of the 10 patients with abnormal CT scans, 9 survived to hospital discharge but all had some degree of functional neurological impairment. Eighty-nine percent (8 of 9) of the patients with normal CT scans were discharged neurologically intact. Awareness of the potential for basal ganglia lesions in CO poisoning should lead to more accurate CT interpretation and may have significant prognostic implications.

PMID 8031431  Am J Emerg Med. 1994 Jul;12(4):448-51.
著者: Lindell K Weaver, Karen J Valentine, Ramona O Hopkins
雑誌名: Am J Respir Crit Care Med. 2007 Sep 1;176(5):491-7. doi: 10.1164/rccm.200701-026OC. Epub 2007 May 11.
Abstract/Text RATIONALE: Carbon monoxide poisoning is common and causes cognitive sequelae. Hyperbaric oxygen (HBO(2)) reduces cognitive sequelae incidence, but which patients may benefit from HBO(2) is unclear.
OBJECTIVES: Risk factor determination for 6-wk cognitive sequelae from CO poisoning and risk modification with HBO(2).
METHODS: Patients were from a randomized controlled trial, enrolling acutely CO-poisoned patients more than 15 years of age. Patients eligible but not enrolled in the randomized trial, and not receiving HBO(2), were followed during the study interval. In patients not receiving HBO(2), we performed univariate analyses including risk factors identified by randomized trial subgroup analyses. A multivariable analysis was performed using univariate results with and without HBO(2).
MEASUREMENTS AND MAIN RESULTS: In 163 patients not receiving HBO(2), 68 (42%) manifested sequelae. Risk factors for sequelae from subgroup analyses were loss of consciousness, age of 36 years or more, and carboxyhemoglobin levels greater than or equal to 25%. By univariate analyses, risks for sequelae were age of 36 years or more (odds ratio [OR], 2.6; 95% confidence interval [CI], 1.3-4.9; P = 0.005), and exposure intervals greater than or equal to 24 hours (OR, 2.4; 95% CI, 1.2-4.8; P = 0.019). Including 75 patients receiving HBO(2), cognitive sequelae was reduced in patients age of 36 years or more (OR, 0.3; 95% CI, 0.2-0.6; P < 0.001). Exposure intervals greater than or equal to 24 hours are an independent risk factor for sequelae (OR, 2.0; 95% CI, 1.0-3.8; P = 0.046).
CONCLUSIONS: HBO(2) oxygen is indicated for patients with acute CO poisoning who are 36 years or older or have exposure intervals greater than or equal to 24 hours. In addition, subgroup analyses support that patients with loss of consciousness or higher carboxyhemoglobin levels warrant HBO(2).

PMID 17496229  Am J Respir Crit Care Med. 2007 Sep 1;176(5):491-7. doi・・・
著者: Sang-Beom Jeon, Chang Hwan Sohn, Dong-Woo Seo, Bum Jin Oh, Kyoung Soo Lim, Dong-Wha Kang, Won Young Kim
雑誌名: JAMA Neurol. 2018 Apr 1;75(4):436-443. doi: 10.1001/jamaneurol.2017.4618.
Abstract/Text Importance: Preventing delayed neurological sequelae is a major goal of treating acute carbon monoxide poisoning, but to our knowledge there are no reliable tools for assessing the probability of these sequelae.
Objectives: To determine whether acute brain lesions on diffusion-weighted imaging are related to subsequent development of delayed neurological sequelae after acute carbon monoxide poisoning.
Design, Setting, and Participants: This registry-based observational study was conducted at a university hospital in Seoul, Korea, between April 1, 2011, and December 31, 2015. Of 700 patients (aged ≥18 years) with acute carbon monoxide poisoning, 433 patients (61.9%) who underwent diffusion-weighted imaging at an emergency department were considered for the study. Patients who developed cardiac arrest before diffusion-weighted imaging (n = 3), had persistent neurological symptoms at discharge (n = 8), committed suicide soon after discharge (n = 1), and were lost to follow-up (n = 34) were excluded.
Exposure: The presence of unambiguous, high-signal-intensity, acute brain lesions on diffusion-weighted imaging (b = 1000 s/mm2).
Main Outcomes and Measures: Development of delayed neurological sequelae defined as any neurological symptoms or signs that newly developed within 6 weeks of discharge.
Results: Of the 387 included patients (143 women [37.0%]; median age, 42.0 years [interquartile range, 32.0-56.0 years]), acute brain lesions on diffusion-weighted imaging were observed in 104 patients (26.9%). Among these, 77 patients (19.9%) had globus pallidus lesions, 13 (3.4%) had diffuse lesions, and 57 (14.7%) had focal lesions (37 patients [9.6%] had >1 pattern concurrently). Lesions were supratentorial and infratentorial in 101 and 23 patients, respectively. Delayed neurological sequelae occurred in 101 patients (26.1%). Multivariable logistic regression analysis indicated that the presence of acute brain lesions was independently associated with development of delayed neurological sequelae (adjusted odds ratio, 13.93; 95% CI, 7.16-27.11; P < .001). The sensitivity and specificity of acute brain lesions to assess the probability of delayed neurological sequelae were 75.2% (95% CI, 66.8%-83.7%) and 90.2% (95% CI, 86.8%-93.7%), respectively. In addition, the positive and negative predictive values were 73.1% (95% CI, 64.6%-81.6%) and 91.2% (95% CI, 87.9%-94.5%), respectively.
Conclusions and Relevance: The presence of acute brain lesions was significantly associated with the development of delayed neurological sequelae. Diffusion-weighted imaging during the acute phase of carbon monoxide poisoning may therefore help identify patients at risk of developing these debilitating sequelae.

PMID 29379952  JAMA Neurol. 2018 Apr 1;75(4):436-443. doi: 10.1001/jam・・・
著者: G Koren, T Sharav, A Pastuszak, L K Garrettson, K Hill, I Samson, M Rorem, A King, J E Dolgin
雑誌名: Reprod Toxicol. 1991;5(5):397-403.
Abstract/Text We report the results of the first prospective, multicenter study of acute carbon monoxide (CO) poisoning in pregnancy. We collected and followed cases of CO poisoning occurring during pregnancy between December 1985 and March 1989. The sources of CO were malfunctioning furnaces (n = 16), hot water heaters (n = 7), car fumes (n = 6), and methylene chloride inhalation (n = 3). Pregnancy outcome was adversely affected in 3 of 5 pregnancies with severe toxicity; two stillbirths, and one cerebral palsy with tomographic findings consistent with ischemic damage. All adverse outcome occurred in cases treated with high flow oxygen, whereas the 2 cases of severe toxicity with normal outcomes followed hyperbaric oxygen therapy. All 31 babies exposed in utero to mild or moderate CO poisoning exhibited normal physical and neurobehavioral development. Severe maternal CO toxicity was associated with significantly more adverse fetal cases when compared to mild maternal toxicity (P less than 0.001). It is concluded that while severe CO poisoning poses serious short- and long-term fetal risk, mild accidental exposure is likely to result in normal fetal outcome. Because fetal accumulation of CO is higher and its elimination slower than in the maternal circulation, hyperbaric oxygen may decrease fetal hypoxia and improve outcome.

PMID 1806148  Reprod Toxicol. 1991;5(5):397-403.

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