Health affects of carbon monoxide poisoning. 

As professionals in the field we come into many households containing people with medical problems. This includes households with elderly or anyone with heart disease, pregnant women and their fetus, infants, children and adults with asthma, or perhaps anyone of any age experiencing temporary poor health like the flue, colds, seasonal allergies and others. 

 We have the opportunity to diagnose and/or eliminate this poison which may be contributing to someone’s poor health condition.  Let’s examine how carbon monoxide poisons us.

 Traditional science reveals carbon monoxide is inhaled into the lungs and bonds with hemoglobin in blood, which forms Carboxyhemoglobin (COHb).  This condition displaces oxygen in the blood stream and affects all major organs and muscles.

It has been accepted that carbon monoxide molecules bonds with hemoglobin in blood over 200 times more easily than oxygen molecules. Suffocation occurs from the inside out.

The health effects of CO depend upon the concentration in the air and the duration of the exposure.  Extended exposure to high concentrations will lead to unconsciousness, brain damage or death.  However, for those of more vulnerable health, a lower concentration of exposure for longer periods of time may have similar effects as high concentrations for brief periods.

 Healthy adults may show no ill effects to low concentrations of carbon monoxide.  However, headaches, a constant stuffiness or head pressure are very common symptoms of early CO poisoning and may be the prelude of a worsening condition.  These conditions can go undiagnosed. 

Respiratory problems, chronic heart disease, dizziness, vomiting, confusion, general weakness of the body or all flu-like symptoms are indicative of CO poisoning.

Recent medical studies attempting to further understand low level CO poisoning have found blood vessels are a major site of damage in the brain, especially the cells that line the inner wall of the vessels, called the endothelium.  This damage occurs relatively early during exposure to CO.  Additional studies suggest this could be happening with lower concentrations of CO over longer periods of time.

These recent studies also suggest carbon monoxide molecules in human blood also readily attach themselves to the same proteins Nitric oxide (NO) do.  NO is a much studied, naturally occurring vasodilator (widens blood vessels) and gaseous signaling molecule.  An excess of NO, however, is harmful to brain cells and other tissues.  Remember air contains oxygen (O2) and nitrogen (N). 

This imbalance makes NO available for biochemical reactions that would not normally occur within the cell, namely ones that produce tissue-damaging oxidants and free radicals.  The experiments show more NO being released by cells with exposure to greater and greater concentrations of CO. The cells eventually died.  Lower doses of CO result in less cell death but cell death none-the-less.

Hopefully, the end result of CO and human impact studies will result in improved general understanding of CO exposure and a more aggressive and preventative treatment. 

In the field, simple observations or findings may alert you to a potentially dangerous condition.  As an example, the occurrence of illness in household pets concurrent with or just preceding the onset of a patient’s own illness should alert to the possibility of CO poisoning.  Due to their smaller size and generally higher metabolic rate, pets may be more obviously and more severely affected by CO intoxication than their owners.

 Arterial blood sampling has been demonstrated to be the most traditional and accurate way of determining COHb %.  It is painful, expensive and not readily available for field use.  General practitioners and others in the health profession do not routinely draw blood samples from every patient showing symptoms that can now be associated to CO poisoning of some degree or another.

The most common misdiagnosis of CO poisoning is a “flu-like” syndrome.  Additional misdiagnosis includes food poisoning, depression, coronary artery disease, arrhythmia and functional illnesses among others.  Blood sampling for CO in the field is not practical.  However, breath analysis for CO with a Bacharach BAM unit is.

The main therapy for CO poisoning is the administering of supplemental oxygen and ventilatory support and the monitoring of heart rate.  The goal of oxygen therapy is to improve the O2 content of the blood.  O2 therapy and observations should continue long enough to prevent additional poisoning once carboxyhemoglobin unloads from the cell.  No set guideline for length of therapy is given.

Who determines CO exposure and CO generation limits in my community?

Are there national standards for carbon monoxide in single family or multi-family residences? Are there work place standards for carbon monoxide?

ALL EFFECTS CAN VARY SIGNIFICANTLY BASED UPON AGE, SEX, WEIGHT AND OVERALL STATE OF HEALTH. 

Traditional studies on carbon monoxide poisoning involved healthy young adults.  When we find carbon monoxide inside the buildings we are servicing and it exceeds the levels outside, our role becomes more vital. Who is in the building?  Are they all young, and health adults?  Casual inquiries about the general health of the inhabitants may reveal minor or compounded illness symptoms associated to the levels you measured.  

It is vital that a cooperative relationship guide all activity associated with carbon monoxide incidences.  Just as consistent step-by-step procedures be used when in a home or building, a diagnostic checklist concerning poor health patterns or symptoms should also be used.  This checklist may be useful to everyone in the field as well as health care professionals or emergency responders.  Carbon monoxide is everybody’s business.

The following are key signs and symptoms of carbon monoxide and other combustion by-product poisoning.

 If carbon monoxide is measured within the living or working space of a building, the following diagnostic approach may aid in the discovery of its generation activity and perhaps its affect on the inhabitants.  This discovery begins with questions. 

If a caller reports a carbon monoxide alarm, the dispatcher must find out if anyone at the location has any of the above symptoms and may choose to further explore the symptoms through the following questionnaire.  In some jurisdictions, a carbon monoxide alarm reported means immediate dispatching of a response team regardless of the symptoms.

It is not uncommon to find in basements, where bedrooms have been added and there now is a nearness of people and combustion systems with draft hoods, (which also rely upon air for combustion from that same area) carbon monoxide poisoning symptoms with some people.

 Regardless of our role in the industry, we have opportunities to discover the source or sources of carbon monoxide.  But we have got to look at the house or the building as a system.

Responding to a carbon monoxide alarm.

 Dispatch

As soon as the 911 phone system gets a call, trained professionals are ready to respond to the dispatchers call.  When the call concerns a home alarm of some type, dispatchers around North America have had to determine if it is a:

 1.)    Smoke alarm or a CO alarm.

2.)    Where the people are calling from (a house on fire is no place for phone calls)

3.)    Has anyone passed out, vomiting or showing any other CO poisoning signs

4.)    Does the CO alarm have a reset button?  Has it been reset?  Are you still calling from the house?

 Instruction must take place immediately as verbal questioning warrants.  If they haven’t left the building and the alarm has sounded again after reset, they should do so immediately if physically possible. 

If one or more of the people in the building have headaches or are vomiting or showing any other physical indications of CO poisoning, they should all get to fresh air immediately if possible. 

If someone has fainted or is unconscious and/or cannot be moved outside the affected area, windows and doors should be opened, especially in the room where the unconscious victim is.  Get everyone outside. 

Instruct them not to go around opening windows, doors and turning off appliances if everyone can get outside immediately.  Go to a neighbor’s house if possible.  The calling adult should wait for the first response team in front of the building.  Complete cooperation with the first responders is vital. 

Many times the service department of a regulated gas utility company is notified in direct phone link to all 911 CO alarm calls.  The cooperation between the gas utility companies and the fire departments in most areas has been professionally responsive.  This same cooperative effort appears to be absent in many rural areas where non-regulated fuel supply exists.

  FIRST RESPONSE

There are many possible sources of CO in a building.  When you respond to CO, the protection of the inhabitants and all response personnel is predominant.  Your emergency response team must share in and understand the importance of each investigative step.  Each team member should have his or her own test instrument.

 Before testing the buildings’ air for carbon monoxide we must have an instrument calibrated to manufacturers specifications and turned on outside the building. 

(Auto zero instruments will register increases above this false zero start.)  If you are using the Monoxor IIâ, you may manually zero the display.  Keep in mind, this is only to be done in environments where no CO is in the air and only needs that adjustment every few months.  There is little drift in the instruments display if we understand its’ boundaries of operation and we’re careful and observant during its’ use.

            1.                   Cylinder, Calibration Gas (For CO calibration, use Bacharach P/N 24-0492. Recommended flow is 

                         2-3 liters/minute at approx. 10 psi)

2.                   Regulator, P/N 51-2974

3.                   Tubing, P/N 03-6351

4.                   Tee, P/N 03-5532

5.                   Flowmeter, P/N 06-6163

We have established our outside air reference and we record it.  If the calling consumer is not waiting in front of the building, our decision to enter becomes immediate: There may be someone inside.

If the caller is waiting for you outside the building, one of you will find out about all other inhabitants’ location and general health conditions while another one of your team enters the building, CO measuring device in hand. 

Before entering any building on a CO or CO alarm call, some emergency responders are required (or it is local department policy) to wear self-contained breathing apparatus (SCBA).  In some jurisdictions, it is not uncommon to find SCBA’s worn if the inside atmosphere contains over 35 PPM or even 50 PPM. 

Inside we are measuring air and looking for people or animals.  Confusion is one of the symptoms of CO poisoning and even though the caller informed you everyone was out of the building, our duty is to check again.  We record our inside measurements. 

Outside, our team member is still with the caller. Obviously, we would first address those most sick and administer oxygen and call for back-up support if needed. 

If none of the building inhabitants are demonstrating debilitating CO poisoning symptoms, obtain a breath sample from whoever has been in the building the longest time and perhaps the healthiest person in the group.  We attach the Breath Analyzer Module to our Monoxor IIâ. 

Have the subject inhale completely and hold breath for 15-20 seconds.  Subject should exhale about one-half of breath into the atmosphere and then, following instrument instructions, breathe the remaining breath into the mouthpiece of the BAM.  The balloon should be inflated in this manner until it reaches approximately 5” in diameter.

The expired breath will move through the test instrument and concentration in PPM will be displayed on the digital display.  This reading is not COHb %.  We have to convert that PPM measurement.  The accompanying chart will demonstrate the approximate equivalencies of PPM and COHb%.  If a poisoning of any degree is verified, your procedures for poisoning response should be followed.

  Smokers may record a variance of COHb.  This range usually is within 2% to 6% COHb.  However, the amount of measured COHb in a smoker depends upon how soon after a cigarette smoked the sample is taken and how heavy a smoker the victim is.  Higher measurements may occur if a test is taken within the first ten minutes after a cigarette as opposed to one hour or more.  The amount of cigarettes per day and smoke actually inhaled also has an effect on this measurement.  (Often times in Bacharach seminar, a smoker volunteers for this breath test and the measurement is above 6% and not unusual to be over 10%)

 It is suggested that samples be taken from several people in the building.  Record all measurements.

 People living in urban areas where auto exhaust is high and background CO measurements regularly record above 9 PPM may also have breath samples around 2% even if they are non-smokers.  The human body produces some CO naturally; about ½ to 1% is a normal reading for a non-smoker who lives in fresh air.  If the average healthy person inhales 70 PPM for around 3 hours, a measurement should find around 10% COHb. 

Once you have quantified the CO health of all people, your next steps are determined by the supporting activities of fuel suppliers and other responders.  In some rural areas, the First Responders also must perform CO source investigations and test individual appliances within the building.  If you have source investigation support by qualified technicians, your paperwork and possible victim placements are all that are required. 

There are many scenarios for each situation.  If windows or doors were left open, the house may have ventilated before you arrived.  Your interior measurements may indicate little or no CO.  It is always recommended that appliances be tested before you allow the occupants back into the building. 

Breath analysis may confirm the presence of CO but measurements inside may indicate no CO.  Complete testing of the building must be performed.  This will take time.  The housing of the inhabitants is then of concern.  The decision then is how and when and by whom is the next set of tests to be performed and who pays for it. 

We may find that leaving a Bacharach Bodyguardâ4 with CO data-log capabilities in the building for several days will give us additional information about times of day when CO is highest in the building under normal operating conditions.  Noting the higher concentrations, when they occurred and finding out what systems were running, what weather conditions existed, how many people were home and other information can enlighten the source investigation team.  If we don’t measure, we don’t know.

Next