Acute Carbon Monoxide Poisoning in the Emergency Department: A Descriptive Study of 660 Cases in Tunisia

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Published May 1, 2025
https://doi.org/10.62438/tunismed.v103i5.5807
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Vol. 103 No. 5 (2025): Tunis Med May 2025

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Sabrine Khelifa
Emergency department, Center of Mahmoud Yaccoub of Urgent Medical Assistance, Tunis, Tunisia
Mohamed Kilani
Emergency department, Center of Mahmoud Yaccoub of Urgent Medical Assistance, Tunis, Tunisia
Camillia Jeddi
Emergency department, Center of Mahmoud Yaccoub of Urgent Medical Assistance, Tunis, Tunisia
Hafedh Thabet
Emergency department, Center of Mahmoud Yaccoub of Urgent Medical Assistance, Tunis, Tunisia

Abstract

Introduction: Carbon monoxide (CO) poisoning is a frequent and potentially fatal medical emergency, accounting for significant global morbidity and mortality.


Aim: This study aims to determine the epidemiological and clinical characteristics of patients presenting to the emergency department (ED) with acute CO poisoning in Tunisia.


Methods: A retrospective, descriptive, single-center study was conducted at the ED of Mahmoud Yacoub Center for Urgent Medical Assistance in Tunis over two years. Patients aged over 12 years with acute CO poisoning were included. Epidemiological data, clinical presentation, severity, laboratory findings, and management were analyzed.


Results: A total of 660 cases were included, all secondary to accidental exposure. The mean age was 35 ±15 years, with a female predominance (73%). CO poisoning was most frequent during winter (70.4%). The main source was gas water heaters (78.2%). Severe cases of CO poisoning were observed in 27.9% of patients, with neurological symptoms in 90.8% of them. The median carboxyhemoglobin level was 21% [13–29]. In univariate analysis, age ≥50, asthenia, chest pain, carboxyhemoglobin ≥25%, and hyperleukocytosis were associated with severe CO poisoning, with hyperleukocytosis remaining an independent predictor in multivariate analysis. Oxygen therapy was administered to all patients, and hyperbaric oxygen therapy was performed in 10.6%. Hospitalization was required in 21% cases. No deaths were recorded in our series.


Conclusion: CO poisoning remains a significant public health concern in Tunisia, predominantly affecting young adults, with water heaters as the leading source. Neurological and cardiac manifestations predominate in severe cases.

Keywords:

Emergency department, Carbon monoxide, poisoning, toxicology, hyperbaric oxygen therapy

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References

  1. Moberg ME, Hamilton EB, Zeng SM, Bryazka D, Zhao JT, Feldman R, et al. Global, regional, and national mortality due to unintentional carbon monoxide poisoning, 2000–2021: results from the Global Burden of Disease Study 2021. Lancet Public Health 2023;8:e839–49
  2. Raphael JC. Reconnaître et traiter les intoxications oxycarbonées aiguës en 2005. Réanimation (Paris). 2005;14:716–20.
  3. Brianchon T. État des lieux des intoxications au monoxyde de carbone en Haute Vienne de 2006 à nos jours [thesis : medicine]. Limoges : University of Limoges; 2011.
  4. Ben Bousleh R. Evolution of the acute poisonings in the center of urgent medical assistance care: comparative study 2004-2015 [thesis : medicine]. Tunis: Faculty of medicine of Tunis; 2017.
  5. Schaub E, Pellegrini M, Pugin D. Carbon monoxide poisoning: an update for 2009. Rev Med Suisse. 2009;5:1606–9.
  6. Hardy KR, Thom SR. Pathophysiology and Treatment of Carbon Monoxide Poisoning. J Toxicol Clin Toxicol. 1994;32:613–29.
  7. Lippi G, Rastelli G, Meschi T, Borghi L, Cervellin G. Pathophysiology, clinics, diagnosis and treatment of heart involvement in carbon monoxide poisoning. Clin Biochem. 2012;45:1278–85.
  8. Mattiuzzi C, Lippi G. Worldwide epidemiology of carbon monoxide poisoning. Hum Exp Toxicol. 2020;39:387–92.
  9. Hampson NB, Weaver LK. Carbon monoxide poisoning: a new incidence for an old disease. Undersea Hyperb Med. 2007;34:163–8.
  10. Burette P, Vanmeerbeek M, Boüüaert C, Giet D. Family practitioner and carbon monoxide poisoning. Rev Med Liege. 2006;61:285–90.
  11. Pan KT, Shen CH, Lin FG, Chou YC, Croxford B, Leonardi G, et al. Prognostic factors of carbon monoxide poisoning in Taiwan: a retrospective observational study. BMJ Open. 2019;9:e031135.
  12. Kaya H, Coşkun A, Beton O, Zorlu A, Kurt R, Yucel H, et al. COHgb levels predict the long-term development of acute myocardial infarction in CO poisoning. Am J Emerg Med. 2016;34:840–4.
  13. Benboudiaf S, Abbas C, Youcef AA, Chellal A. Étude rétrospective des cas d’intoxications oxycarbonées sous l’angle médico-légal au service de toxicologie du CHU de Sétif. Toxicologie Analytique et Clinique. 2024;36:S60.
  14. Jerraya H. Intoxication aigue au monoxyde de carbone : facteurs pronostiques et évaluations thérapeutiques. A propos de 100 cas hospitalisés en réanimation [thesis : medicine]. Tunis: Faculty of medicine of Tunis; 2005.
  15. Tabka N. L’intoxication aiguë par l’oxyde de carbone à propos de deux cent treize cas observés au centre anti-poison de Tunis en trois ans [thesis : medicine]. Tunis: Faculty of medicine of Tunis; 1978.
  16. Dueñas-Laita A, Ruiz-Mambrilla M, Gandía F, Cerdá R, Martín-Escudero JC, Pérez-Castrillón JL, et al. Epidemiology of Acute Carbon Monoxide Poisoning in a Spanish Region. J Toxicol Clin Toxicol. 2001;39:53–7.
  17. Hampson NB, Dunn SL, UHMCS/CDC CO Poisoning Surveillance Group. Symptoms of carbon monoxide poisoning do not correlate with the initial carboxyhemoglobin level. Undersea Hyperb Med. 2012;39:657–65.
  18. Rose JJ, Wang L, Xu Q, McTiernan CF, Shiva S, Tejero J, et al. Carbon Monoxide Poisoning: Pathogenesis, Management, and Future Directions of Therapy. Am J Respir Crit Care Med. 2017;195:596–606.
  19. Ouahmane Y, Mounach J, Satte A, Bourazza A, Soulaymani A, Elomari N. Les intoxications graves au monoxyde de carbone (CO) avec atteinte neurologique, étude de 19 cas. Toxicologie Analytique et Clinique. 2018;30:50–60.
  20. Raphael JC, Elkharrat D, Jars-Guincestre MC, Chastang C, Chasles V, Vercken JB, et al. Trial of normobaric and hyperbaric oxygen for acute carbon monoxide intoxication. Lancet. 1989;2:414–9.
  21. Ernst A, Zibrak JD. Carbon monoxide poisoning. N Engl J Med. 1998;339:1603–8.
  22. Donati SY, Gainnier M, Chibane-Donati O. Intoxication au monoxyde de carbone. EMC - Anesth-Réanimation 2005;2(1):46–67 [Article 36-986-A-10].
  23. Palma Anselmo M, Maia R, Telles de Freitas P. Cardiogenic shock and globus pallidus injury as a presentation of carbon monoxide poisoning. Ann Burns Fire Disasters. 2024;37:130–3.
  24. Nielsen VG, Arkebauer MR, Vosseller K. Redox-based thrombelastographic method to detect carboxyhemefibrinogen-mediated hypercoagulability. Blood Coagul Fibrinolysis. 2011;22:657–61.
  25. Penney DG. Hemodynamic response to carbon monoxide. Environ Health Perspect 1988;77:121–30.
  26. Gandini C, Castoldi AF, Candura SM, Locatelli C, Butera R, Priori S, et al. Carbon Monoxide Cardiotoxicity. J Toxicol Clin Toxicol 2001;39:35–44.
  27. Satran D, Henry CR, Adkinson C, Nicholson CI, Bracha Y, Henry TD. Cardiovascular Manifestations of Moderate to Severe Carbon Monoxide Poisoning. J Am Coll Cardiol. 2005;45:1513–6.
  28. Henry CR. Myocardial Injury and Long-term Mortality Following Moderate to Severe Carbon Monoxide Poisoning. JAMA. 2006;295:398.
  29. Burney RE, Wu SC, Nemiroff MJ. Mass carbon monoxide poisoning: Clinical effects and results of treatment in 184 victims. Ann Emerg Med. 1982;11:394–9.
  30. Selini E. Intoxication aigue au monoxyde de carbone en Seine-maritime. [thesis : medicine]. Rouen: University of Rouen; 2002.
  31. Hemery R. Evaluation des mesures de prévention mises en place après une intoxication au monoxyde de carbone, dans le Nord Pas de Calais [thesis : medicine]. Lille: Faculty of Medicine H. Warembourg; 2015
  32. Wesley Ely E, Moorehead B, Haponik EF. Warehouse workers’ headache: Emergency evaluation and management of 30 patients with carbon monoxide poisoning. Am J Med. 1995;98:145–55.
  33. Afzal M, Agarwal S, Elshaikh RH, Babker AMA, Choudhary RK, Prabhakar PK, et al. Carbon Monoxide Poisoning: Diagnosis, Prognostic Factors, Treatment Strategies, and Future Perspectives. Diagnostics. 2025;15:581.
  34. Hampson NB, Hauff NM. Carboxyhemoglobin levels in carbon monoxide poisoning: do they correlate with the clinical picture? Am J Emerg Med 2008;26:665–9.
  35. Pepe G, Castelli M, Nazerian P, Vanni S, Del Panta M, Gambassi F, et al. Delayed neuropsychological sequelae after carbon monoxide poisoning: predictive risk factors in the Emergency Department. A retrospective study. Scand J of Trauma Resusc and Emerg Med. 2011;19:16.
  36. Bağcı Z, Arslan A, Arslan D. The Value of Neutrophil:Lymphocyte Ratio and Platelet:Lymphocyte Ratio in Predicting Clinical Severity in Children with Carbon Monoxide Poisoning. Indian J Pediatr. 2021;88:1121–6.
  37. Grieb G, Simons D, Schmitz L, Piatkowski A, Grottke O, Pallua N. Glasgow Coma Scale and laboratory markers are superior to COHb in predicting CO intoxication severity. Burns. 2011;37:610–5.
  38. Reumuth G, Alharbi Z, Houschyar KS, Kim B-S, Siemers F, Fuchs PC, et al. Carbon monoxide intoxication: What we know. Burns. 2019;45:526–30.
  39. Shen CH, Peng CK, Chou YC, Pan KT, Chang SC, Chang SY, et al. Predicting duration of mechanical ventilation in patients with carbon monoxide poisoning: A retrospective study. J Crit Care. 2015;30:19–24.
  40. Chenoweth JA, Albertson TE, Greer MR. Carbon Monoxide Poisoning. Crit Care Clin. 2021;37:657–72.
  41. Gandini C, Castoldi AF, Candura SM, Locatelli C, Butera R, Priori S, et al. Carbon Monoxide Cardiotoxicity. J Toxicol Clin Toxicol 2001;39:35–44.
  42. Satran D, Henry CR, Adkinson C, Nicholson CI, Bracha Y, Henry TD. Cardiovascular Manifestations of Moderate to Severe Carbon Monoxide Poisoning. J Am Coll Cardiol. 2005;45:1513–6.
  43. Henry CR. Myocardial Injury and Long-term Mortality Following Moderate to Severe Carbon Monoxide Poisoning. JAMA. 2006;295:398.
  44. Burney RE, Wu SC, Nemiroff MJ. Mass carbon monoxide poisoning: Clinical effects and results of treatment in 184 victims. Ann Emerg Med. 1982;11:394–9.
  45. Selini E. Intoxication aigue au monoxyde de carbone en Seine-maritime. [thèse : médecine]. Rouen: Université de Rouen; 2002.
  46. Hemery R. Evaluation des mesures de prévention mises en place après une intoxication au monoxyde de carbone, dans le Nord Pas de Calais [thèse : médecine]. Lille: Faculté de Médecine H. Warembourg; 2015.
  47. Wesley Ely E, Moorehead B, Haponik EF. Warehouse workers’ headache: Emergency evaluation and management of 30 patients with carbon monoxide poisoning. Am J Med. 1995;98:145–55.
  48. Reumuth G, Alharbi Z, Houschyar KS, Kim B-S, Siemers F, Fuchs PC, et al. Carbon monoxide intoxication: What we know. Burns. 2019;45:526–30.
  49. Shen CH, Peng CK, Chou YC, Pan KT, Chang SC, Chang SY, et al. Predicting duration of mechanical ventilation in patients with carbon monoxide poisoning: A retrospective study. J Crit Care. 2015;30:19–24.
  50. Chenoweth JA, Albertson TE, Greer MR. Carbon Monoxide Poisoning. Crit Care Clin. 2021;37:657–72.