MisdiagnosisMisdiagnosisNot your basic Not your basic acute sinusitisacute sinusitis

Mary ThomasonMary Thomason

March 8, 2006March 8, 2006

No Financial DisclosuresNo Financial Disclosures

Case PresentationCase Presentation 55 yo female with PMH significant for 55 yo female with PMH significant for

presumed acute sinusitis in March/April of presumed acute sinusitis in March/April of 2005 requiring 6 weeks of antibiotics who 2005 requiring 6 weeks of antibiotics who presented with HA and nasal congestion.presented with HA and nasal congestion.

12/2/05 at urgent care 12/2/05 at urgent care dx: Acute Sinusitis tx: 2 Z-Paksdx: Acute Sinusitis tx: 2 Z-Paks

12/6/05 in clinic12/6/05 in cliniccc: headache dx:? tx: complete cc: headache dx:? tx: complete

antibiotics antibiotics and follow up in one and follow up in one weekweek

Case PresentationCase Presentation

12/16/05 clinic followup12/16/05 clinic followup

cc: headache and nasal congestioncc: headache and nasal congestion

dx: persistent URI symptomsdx: persistent URI symptoms

tx: nasal steroids and sinus CT tx: nasal steroids and sinus CT scanscan

12/19/05 radiology12/19/05 radiology

CT scan negative for acute CT scan negative for acute sinusitis or sinusitis or congestioncongestion

Case PresentationCase Presentation

12/30/05 clinic follow up12/30/05 clinic follow up Dx: Carbon Monoxide (CO) Dx: Carbon Monoxide (CO)

PoisoningPoisoning

ObjectivesObjectives

Recognize symptoms of CO exposureRecognize symptoms of CO exposure Diagnosis of CO exposureDiagnosis of CO exposure Treatment of CO exposureTreatment of CO exposure Prevention of CO exposurePrevention of CO exposure

PhysiologyPhysiology

CO diffuses CO diffuses rapidly over the rapidly over the alveolar alveolar membranemembrane

Binds reversibly Binds reversibly with 200-fold with 200-fold affinity to Hgbaffinity to Hgb

Shifts the Shifts the oxyhemoglobin oxyhemoglobin dissociation curvedissociation curve

StatisticsStatistics

Leading cause of accidental Leading cause of accidental poisoning death in the USpoisoning death in the US

Estimated 15,000 treated annually in Estimated 15,000 treated annually in EDED

Approximate 500 deaths annuallyApproximate 500 deaths annually

JAMA vol. 293, no. 10, 3/9/05, 1183-86JAMA vol. 293, no. 10, 3/9/05, 1183-86

CO SourcesCO Sources

FurnacesFurnaces GeneratorsGenerators Gas heatersGas heaters Motor vehicles (cars, trucks, Motor vehicles (cars, trucks,

tractors, boats)tractors, boats) FiresFires

ExposuresExposures

Majority of CO Majority of CO exposures occur exposures occur in the fall and in the fall and winter monthswinter months

64.3% occur in 64.3% occur in the homethe home

18.5% due to 18.5% due to faulty furnacesfaulty furnaces

9% motor vehicles9% motor vehiclesJAMA vol. 293, no. 10, 3/9/05, JAMA vol. 293, no. 10, 3/9/05, 1183-861183-86

CO Exposure After CO Exposure After KatrinaKatrina

51 cases reported 51 cases reported by HBO2 facilities by HBO2 facilities of AL, LA, MSof AL, LA, MS

46 nonfatal, 5 46 nonfatal, 5 deathsdeaths

The source for all The source for all but one of the but one of the non-fatal cases non-fatal cases was exhaust from was exhaust from a portable a portable generator. generator. MMWR vol. 54, no. 39, 10/7/05, MMWR vol. 54, no. 39, 10/7/05,

996-998996-998

Symptoms of Mild Symptoms of Mild PoisoningPoisoning

Throbbing temporal or frontal HAThrobbing temporal or frontal HA FatigueFatigue WeaknessWeakness LightheadednessLightheadedness Nausea/VomitingNausea/Vomiting Shortness of BreathShortness of Breath

Symptoms of Moderate Symptoms of Moderate PoisoningPoisoning

Severe HASevere HA Tachycardia/TachypneaTachycardia/Tachypnea Flushing, perspirationFlushing, perspiration Diminished manual Diminished manual

dexterity/prolonged reaction timedexterity/prolonged reaction time Impaired judgment/confusionImpaired judgment/confusion Vision changes (darkened, blurred)Vision changes (darkened, blurred) TinnitusTinnitus

Symptoms of Severe Symptoms of Severe PoisoningPoisoning

SyncopeSyncope SeizuresSeizures MIMI DysrhythmiasDysrhythmias Respiratory failure/ pulmonary Respiratory failure/ pulmonary

edemaedema ComaComa DeathDeath

Delayed EffectsDelayed Effects

DepressionDepression Dementia/Memory LossDementia/Memory Loss PsychosisPsychosis Peripheral neuropathyPeripheral neuropathy ParkinsonismParkinsonism Visual impairmentVisual impairment ChoreaChorea

Diagnosis of CO Diagnosis of CO poisoningpoisoning

Have a high clinical suspicionHave a high clinical suspicion Determine the COHb level when the Determine the COHb level when the

pt is first seen and repeat q2-4 hours pt is first seen and repeat q2-4 hours until pt is asymptomatic or the value until pt is asymptomatic or the value is normal.is normal.

If symptomatic or COHb greater than If symptomatic or COHb greater than 20% monitor with ECG, lytes, CK, UA, 20% monitor with ECG, lytes, CK, UA, ABG to evaluate for sequellaABG to evaluate for sequella

Poisindex (accessed feb 2006)Poisindex (accessed feb 2006)

Range of ToxicityRange of Toxicity

Normal COHb is 1-3%Normal COHb is 1-3% Cigarette smokers increase their levels by 5% Cigarette smokers increase their levels by 5%

per pack per day (may tolerate up to 10%)per pack per day (may tolerate up to 10%) Toxic affects appear at 15-20%Toxic affects appear at 15-20% COHb levels above 25% are considered severe COHb levels above 25% are considered severe Toxicity however is determined Toxicity however is determined

symptomatically (cardiovascular and mental symptomatically (cardiovascular and mental status)status)

NEJM vol. 347, no. 14, 10/3/02, 1054-55NEJM vol. 347, no. 14, 10/3/02, 1054-55

When to HospitalizeWhen to Hospitalize

Neurologic signsNeurologic signs Abnormal ECGAbnormal ECG Metabolic AcidosisMetabolic Acidosis

TreatmentTreatment

Decontamination –Decontamination –move to fresh airmove to fresh air

Administer 100% Administer 100% oxygen (x 6 hours)oxygen (x 6 hours)

Consider hyperbaric Consider hyperbaric oxygen for severely oxygen for severely poisoned (coma, poisoned (coma, seizures, MI) and seizures, MI) and pregnant patients at pregnant patients at 3 atmospheres 3 atmospheres absolute.absolute. NEJM vol. 347, no. 14, 10/3/02, 1057-67NEJM vol. 347, no. 14, 10/3/02, 1057-67

Guideline to prevent CO Guideline to prevent CO exposureexposure

Service heating system/water heater yearlyService heating system/water heater yearly Install a battery-operated CO detector and Install a battery-operated CO detector and

check the batteries twice yearlycheck the batteries twice yearly Do not use charcoal grill or camp stove Do not use charcoal grill or camp stove

inside the home, garage, or near a windowinside the home, garage, or near a window Do not run vehicle inside garageDo not run vehicle inside garage Do no use stove or fire place that isn’t Do no use stove or fire place that isn’t

ventedvented Do not heat your home with a gas ovenDo not heat your home with a gas ovenJAMA vol. 293, no. 10, 3/9/05, 1183-86JAMA vol. 293, no. 10, 3/9/05, 1183-86

SummarySummary

Leading cause of accidental poisoning death Leading cause of accidental poisoning death in the USin the US

Mild symptoms are similar to a viral illness, Mild symptoms are similar to a viral illness, therefore a high index of suspicion is therefore a high index of suspicion is requiredrequired

CO poisoning is diagnosed symptomatically, CO poisoning is diagnosed symptomatically, but CO level testing can be helpfulbut CO level testing can be helpful

The mainstay of treatment is oxygen therapyThe mainstay of treatment is oxygen therapy Prevention is the keyPrevention is the key

Questions?Questions?

ReferencesReferences PoisindexPoisindex NEJM vol. 347, no. 14, 10/3/02, 1054-55NEJM vol. 347, no. 14, 10/3/02, 1054-55 NEJM vol. 347, no. 14, 10/3/02, 1057-67NEJM vol. 347, no. 14, 10/3/02, 1057-67 MMWR vol. 54, no. 39, 10/7/05, 996-998MMWR vol. 54, no. 39, 10/7/05, 996-998 JAMA vol. 293, no. 10, 3/9/05, 1183-86JAMA vol. 293, no. 10, 3/9/05, 1183-86 JAMA vol. 295, no. 4, 1/25/06, 398-402 JAMA vol. 295, no. 4, 1/25/06, 398-402 American Journal of Emergency Medicine, American Journal of Emergency Medicine,

Vol. 23, 3/23/05, 838-841Vol. 23, 3/23/05, 838-841