Calling all RN-RT's and Resp. Nurses..I have a Carbon Monoxide Poisioning and COPD?

[mttzakr26]

I am a first semester student who needs from guidance on this scenerio: How is a patient with COPD who has Carbon Monoxide Poisoning treated clinically??

Normally, you'd want to administer the highest amount of oxygen possible to that patient, using a Non-Rebreather, but in COPD, wouldnt this be definetly a problem because with devices that deliver a moderate to high FiO2 levels....wouldn't you knock out the hypoxic drive as well??

[HouTx, BSN, MSN, EdD]

Immediate resuscitation is the priority. It will take quite a while a while to have an effect on the hypoxic drive.

[nurseprnRN, BSN, RN]

Well, maybe yes, maybe no on that. I've seen COPDrs stop breathing in a half an hour when given more O's than their carotid sinuses have seen in years. Perhaps, though, when you're talking immediate resuscitation, that's quite a while. In any case, you'd have somebody eyeballing them all the time in an ICU, not somewhere where they can quietly lie down and stop breathing with nothing but tele, especially since an SpO2 monitor will be worthless. (OP, why is that? Do you know?)

Hyperbaric oxygenation with the availability to intubate to maintain respiratory function is a good option to drive the CO off the hemoglobin and then titrate back down to baseline.

[mttzakr26]

Well and SpO2 monitor wont be totally useless...I mean it's another clue....I mean if you see a pt with a bright rosy red flushed appearence, diffculty breathing, and confused...thats SpO2 is another pretty solid indicator that something other than O2 is binding with that patients. Hemoglobin.....unfortunately....that Gas is CO which will win the battle in a wrestling match with Oxygen 10 times out of 10.

But to be clear, My scenerio is a simulation that i'll be doing, and this is the problem im prepping for.

Being a first semester student...im learning the importance of critical thinking.

In the scenerio though, i'm only going to have certain delivery devices available: non-rebreather, venti mask, simple mask, nasal cannula.

And in the scenerio: it's basically, a patient gets pulled from a house fire, has a bright rosy red "flushed" appearence, has difficulty breathing etc as a high moderate to low severe level of poisoning. My thinking is that because it's Carbon Monoxide poisoning, I need to deliver as much O2 as possible to the patient....I'll worry about hypoxic drive later because I have to get this CO out.

My thinking is also that as long as my patient is not on high FiO2 too long, I can hopefully bring the Oxygen down when the patient recovers and of course, i'll be monitoring the ABG's as well, because to me right now, the Carbon Monoxide takes precedent.

But I dont know if im way off base or not

[nurseprnRN, BSN, RN]

That SpO2 is worthless precisely because of that nice red color. SpO2 monitors work by looking at the color of the RBCs in the capillary bed, having been told when they were manufactured that a red hemoglobin molecule is an oxygenated one. If they see nice redness, they will give a false reading which, while reassuring to people who don't know any better, gives exactly zero accurate estimation of blood oxygenation.

Otherwise, since this is a simulation, you would indeed give him as much oxygen as possible (100% nonrebreather) to try to drive up dissolved oxygen in the blood as well as trying to dislodge CO molecules, and watch him like a hawk for every minute during transport. And of course, a really good history in report to the ER.

[Esme12, ASN, BSN, RN]

REMEMBER.....Not all COPD patients are CO2 retainers. SPO2 is useless in this situation.

What do you need to know...what are the symptoms of CO poisoning? How will your patient present? What are important things to think about when a patient has Co poisoning?

I have a great reference to help you....it is MEDSCAPE.....it requires registration but it is completely free.....

Remember these patients regardless of their Cherry red appearance are hypoxic at the tissue level. The half life of CO at room air is 3-4 hours....with high concentration O2 that time is cut to a half life of 30 to 90 mins.

With the displacement of the oxyhemaglobin curve and it's affinity to bind with hemoglobin these patient are very acidotic. The use of a hyperbaric chamber with this population of patients needs to considered very carefully if they have Emphysematous blebs that will cause pnemothorax when placed in the high pressure chamber.

The administration of O2 in the emergent phase is important...as that is the immediate need...but careful monitoring of the patients ABG's and LOC is imperative with ready access to intubate if necessary.

[nurseprnRN, BSN, RN]

The hyperbaric chamber does not increase risk of bleb rupture-- the pressure isn't just inside the lungs, it's all around the whole body, so it cancels out, as it were. The patients' inspired gases are not under pressure unless they are intubated and need positive pressure ventilation to get air into the chest-- they breathe their 100% O2 the same way they do outside the chamber.

Yet another interesting place to work. ?

[Esme12, ASN, BSN, RN]

Yes it does raise the RISK of bleb rupture.....which is why I attached the link to the medical Journal article above....

Quote

The gold standard treatment for severe CO poisoning is hyperbaric oxygen therapy. This markedly raises the arterial oxygen level, and in COPD patients prone to CO2 retention would clearly cause significant elevation of pCO2. Furthermore emphysematous bullae may rupture under an elevated pressure, hence COPD is a relative contra-indication to hyperbaric oxygen therapy.

A search of Pubmed found nothing published on the management of carbon monoxide poisoning in patients with chronic obstructive lung disease, and clearly a careful balance needs to be found between the level of administered oxygen, the patient's pCO₂, and the required rate of clearance of CO.

We suggest that patients with carbon monoxide poisoning and a significant smoking history – even if not formally diagnosed with COPD – have regular ABG analysis during treatment to ensure that they are not developing a dangerous respiratory acidosis. Carbon dioxide retention in such patients limits the use of uncontrolled high-flow oxygen, and thus in certain circumstances early intubation may need to be considered. The use of hyperbaric oxygen therapy in such patients should be considered only with extreme caution.

Cases Journal | Full text | Carbon monoxide poisoning in a patient with carbon dioxide retention: a case report

[nurseprnRN, BSN, RN]

I just read that case study. That patient was not treated c hyperbaric therapy, and while it is known to be true that bullae may rupture with increased pressure (as mentioned by the author and well-known to anyone who put someone on a ventilator with positive-pressure ventilation), hyperbaric therapy does not result in increased respiratory tree pressure because it does not cause positive pressure ventilation.

Hyperbaric therapy does deliver increased partial pressure of oxygen, driving oxygen into the blood across the alveolar-arterial interface, but it's not because of increased mechanical pressure. Gas (albeit 100% at high atmospheric pressure) entering the lungs is still brought in by negative pressure in the chest due to diaphragmatic excursion. The atmospheric pressure in the chamber presses in on the outside of the chest wall at the same pressure as the air entering the lungs, resulting in no net pressure increase to put bullae at risk.

There is no reference in the bib for this case study to indicate that hyperbarics would increase risk of bullus rupture, and the authors state there are no studies (or weren't at the time they published this in 2008) about hyperbarics and COPD. Or did I miss something?

[Esme12, ASN, BSN, RN]

I actually seen it once....any other studies I'm haven't look it has always been in emergency medicine a consideration and a risk. No this patient didn't suffer a pneumo in the study....just that it remains a consideration and a risk....that the risk while minimal remains a consideration.

[nurseprnRN, BSN, RN]

Esme12 said:

I actually seen it once....any other studies I'm haven't look it has always been in emergency medicine a consideration and a risk. No this patient didn't suffer a pneumo in the study....just that it remains a consideration and a risk....that the risk while minimal remains a consideration.

Link isn't up anymore. Interesting, though. I did hyperbaric "dives" for about a year and never had this mentioned in our training and never saw it happen. You never know.