What medications or interventions are given to someone with carbon monoxide (CO) poisoning in an Emergency Medical Services (EMS) setting, beyond oxygen therapy?

Management of Carbon Monoxide Poisoning in EMS Setting Beyond Oxygen Therapy

High-flow 100% oxygen via non-rebreather mask should be immediately administered to all patients with suspected carbon monoxide poisoning, but additional interventions are necessary to manage these patients comprehensively in the EMS setting. 1

Initial Assessment and Monitoring

• Obtain carboxyhemoglobin (COHb) levels at the scene using fingertip pulse CO oximetry if available, though laboratory confirmation will be needed upon hospital arrival 1
• Standard pulse oximetry readings are unreliable in CO poisoning as they cannot differentiate between oxyhemoglobin and carboxyhemoglobin, often showing falsely normal SpO2 readings despite significant hypoxemia 2
• Monitor cardiac status with ECG for all patients with moderate to severe poisoning, as CO causes myocardial injury through tissue hypoxia and direct cellular damage 1, 2
• Assess neurological status continuously, as neurological symptoms don't correlate well with COHb levels 2, 3

Supportive Care Interventions

• Establish IV access for all symptomatic patients to allow for fluid resuscitation and medication administration if needed 4
• Provide aggressive supportive care including airway management and ventilatory support for patients with respiratory depression or altered mental status 5, 6
• Monitor and correct acid-base disturbances, as metabolic acidosis commonly occurs in moderate to severe CO poisoning 4, 3
• Consider CPAP or non-invasive ventilation for patients with pulmonary edema resulting from CO-induced cardiac dysfunction 1

Cardiac Management

• Obtain 12-lead ECG and monitor for cardiac ischemia, as CO has direct toxic effects on myocardium 1, 2
• Treat hypotension with IV fluids and consider vasopressors if fluid resuscitation is inadequate 4, 3
• Manage cardiac dysrhythmias according to standard ACLS protocols 6

Neurological Management

• Assess and document neurological status using Glasgow Coma Scale 1, 3
• Position unconscious patients appropriately to protect the airway 5
• Consider benzodiazepines for seizure activity, which may occur in severe poisoning 4, 7
• Document any periods of unconsciousness, as this is a key indicator for potential hyperbaric oxygen therapy once the patient reaches definitive care 7, 6

Special Considerations

• Pregnant patients require special attention as fetal hemoglobin has higher affinity for CO than maternal hemoglobin, placing the fetus at greater risk 1, 6
• Patients with pre-existing cardiovascular or pulmonary disease are at higher risk for complications and require more aggressive management 7
• Consider co-exposures in fire victims (cyanide, other toxic gases) which may require additional interventions 3

Transport Considerations

• All patients with significant CO exposure should be transported to facilities with appropriate capabilities for managing CO poisoning 1
• Consider direct transport to facilities with hyperbaric oxygen therapy capabilities for patients with severe poisoning, unconsciousness, neurological deficits, cardiac ischemia, pregnancy with elevated COHb, or very high COHb levels 4, 6
• Communicate findings and interventions clearly to receiving facility, including duration of exposure, COHb levels if measured, periods of unconsciousness, and treatment provided 3

Common Pitfalls to Avoid

• Do not rely solely on COHb levels to determine severity, as clinical symptoms may not correlate with measured levels 2, 3
• Do not delay oxygen administration while waiting for COHb measurement 1
• Do not use calculated oxygen saturation from standard blood gas analyzers without CO-oximetry capabilities 2
• Do not overlook cardiac complications, which can occur even with relatively low COHb levels 1, 2