Why No Discharge Instructions for Carbon Monoxide Poisoning Survivors

Why are There no Standard Discharge Instructions for those Treated for Carbon Monoxide Poisoning?

By Attorney Gordon Johnson


In contrast to the lack of discharge instructions for carbon monoxide poisoning, when I first began doing brain injury cases in 1992,  “head injury discharge instructions” were the norm. Head injury discharge instructions are a mandated discharge paperwork that virtually anyone treated in the United States (and probably almost worldwide) is given after they have been treated/diagnosis with any sort of head injury, including concussion. The discharge instructions essentially say that head injury can get worse – not better – after leaving the emergency room; that people with head injuries should be not left alone, that they should be waken every hour or two, and if the symptoms worsen, especially with the onset of vomiting or other neurological signs, that they must be rushed back to the hospital.

carbon monoxide poisoning discharge

Here is a standard discharge instruction for head injury. Why no comparable instruction for carbon monoxide poisoning?

Now in 2017, almost all concussions are treated as seriously as more severe head injuries were treated in 1992. Patients are warned to avoid return to play, to get evaluated in subsequent days and if an athlete, not allowed to return to play until function has returned to normal. I have harped in the past that civilian injuries (a term I use to pertain to any non-sport or non-military brain injury) often don’t get as good of attention as those in sports, but if the concussion is diagnosed in the emergency room, it is almost a given that some discharge instruction will be given.

No Warnings Given Relative to Delayed Problems after Carbon Monoxide Poisoning

In total contrast is what happens with someone who is treated for carbon monoxide poisoning. Unlike in cases of concussion, everyone who is treated for carbon monoxide poisoning should leave the ER with a definitive diagnosis, because carbon monoxide poisoning is susceptible to a blood test that if done within hours of the poisoning, can give a definitive result as to whether the person suffered the poisoning. The blood test is to determine whether the survivor has carboxyhemoglobin in his or her blood. Lab results will either say COHb and a percent, or give it in terms of carbon monoxide and a percent number. The numbers will be between 0 and 60 on a 100 point scale. The reason COHb number never exceeds 60 is that such levels are almost always fatal and the heart simply stops beating from lack of oxygen. Levels below 50 can be fatal in some people, depending on pre-exposure factors.

Why Carbon Monoxide Poisoning Discharge Warnings?

Why do we need carbon monoxide poisoning discharge instructions? Because the risk factors for problems after discharge are considerably higher than after a concussion. The motivation for the discharge instruction after a concussion is the risk of a ICP pressure event that might ultimately result in coma and or death. That is a very low risk factor after most concussions.

In contrast, the delayed onset of symptoms after carbon monoxide poisoning is a high probability, certainly above 40%. While people think of a brain damage event as evolving much like what we see in a boxing match, that is so clearly not the case in carbon monoxide poisoning. In a boxing match, if a boxer is stunned or knocked down, we expect that if they are able to get back to their feet within 10 seconds, and able to survive to the end of the round, that within another 60 seconds, they are likely to be able to conpete in the fight. While traumatic brain injuries also have evolving symptoms that do not involve ICP pressure events, the probability of permanent neuropsychiatric impairment is much closer to 10% than to 50%.

What do survivors of carbon monoxide poisoning need to be warned about? The onset of delayed symptoms (sometimes called DNS for delayed neurological sequelae) where the bodies immune system goes haywire in response to the perceived threat of poisoning. The vast majority of disability from carbon monoxide poisoning comes from the over reaction of the immunological system, not the hypoxia from carbon monoxide poisoning (lack of oxygen to the cell.) Just because a COHb level has been lowered to something close to normal, does not mean that the crisis the poisoning has set off has ended. For most of those who survive, the crisis is just beginning.

Think of the example of what happens inside of building which has sprinklers for fire protection. If someone were to light a cigarette lighter near the ceiling tile in such a building, odds are the cigarette lighter could do no more damage than charred a few tiles. Yet if the heat from that cigarette lighter or smoke generated thereby sets off the sprinkler system in the building, substantial damage to the building is guaranteed to result. It will not be the damage an uncontrolled fire would cause, but it will be substantial. Likewise, the sensing of the body of carbon monoxide in an abnormal concentration, sets off the bodies immune system in a way, that doesn’t get shut down, as soon as the threat of damage to cells from lack of oxygen ends. That reaction may continue for days, weeks and months. How a given person’s immune system responds to the threat, not how high the COHb level is, largely dictates whether they will be part of the 40% or more who have permanent brain damage, or the rest, who may have a full recovery.

What is most important to remember is that carbon monoxide is a poison. It is not just a matter of taking away something the body needs, but of inserting something into the body that is dangerous to the body. If only the oxygen deprivation issue is addressed, and not the poisoning aspect, then puzzling but significant disability will show up in survivors. Our medical system must plan for those long term issues and must warn the survivors.

Ultimately, almost all survivors of carbon monoxide poisoning should be given hyperbaric oxygen treatment, because only hyperbaric oxygen therapy seems capable of turning off the sprinkler system. In future blogs, we will address the nature of the delayed symptoms, what the discharger instructions should say and how important hyperbaric oxygen is for to avoid delayed onset symptoms.

Next – Carbon Monoxide Lawsuits

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