Unclear Information About a Treatment Recommendation
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In Table 2, Eichhorn et al. (1) state for the Amercian College of Emergency Physicians (fourth line) “no recommendation” which is regrettably misleading. According to the evidence-based transparent recommendations of this professional society, patients with carbon monoxide poisoning should either receive hyperbaric oxygen therapy (HBOT) or normobaric treatment with high oxygen flow (normobaric oxygen therapy, NBOT) (2). Likewise, the authors of a comprehensive Cochrane review are opposed to regular use of HBOT (3). HBOT offers no proven advantages for patients with carbon monoxide poisoning compared to NBOT. Thus, it is at least ambiguously worded when the review states at various points that HBOT is recommended for certain patient populations, even though this statement lacks supporting evidence.
From the perspective of clinical emergency medicine, we can confirm that it is challenging to diagnose carbon monoxide poisoning based on unspecific signs and symptoms, especially if carbon monoxide exposure is not obvious. In particular in patients complaining, for example, only about nausea or vomiting, and who were not brought to an emergency department by emergency medical services, carbon monoxide poisoning can easily be overlooked. Therefore, adequate emergency care and reducing the risk of potential long-term complications require a high level of awareness of a possible carbon monoxide poisoning at first patient contact.
At the latest in the emergency department, the source of exposure has to be identified to prevent further cases of carbon monoxide poisoning from unsecured sources. The fire department should be alerted to take urgent hazard prevention action, if necessary.
Case reports have indicated that non-invasive mechanical ventilation could be a useful alternative to HBOT (4).
All in all, the randomized studies that have been published so far have not shown the superiority of HBOT over NBOT. Therefore, we welcome and support the recommendation that the decision to initiate hyperbaric oxygen therapy to treat carbon monoxide poisoning should always be critically reviewed and made on a case-by-case basis.
Dr. med. Bernd A. Leidel
Charité – Universitätsmedizin Berlin, Berlin, Germany
Prof. Dr. med. Harald Dormann
Klinikum Fürth, Fürth, Germany,
for the German Society of Interdisciplinary Emergency and Acute Medicine (DGINA, Deutsche Gesellschaft für Interdisziplinäre Notfall- und Akutmedizin)
Prof. Dr. med. Hans-Jörg Busch
Uniklinik Freiburg, Freiburg, Germany,
for the German Society of Medical Intensive Care Medicine and
Emergency Medicine (DGIIN, Deutsche Gesellschaft für Internistische Intensiv- und Notfallmedizin)
Prof. Dr. med. Stefan Kluge
Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
for the German Society of Pneumology and Respiratory Medicine (DGP, Deutsche Gesellschaft für Pneumologie und Beatmungsmedizin )
Conflict of interest statement
The authors declare that no conflict of interest exists.
|1.||Eichhorn L, Thudium M, Jüttner B: The diagnosis and treatment of carbon monoxide poisoning. Dtsch Arztebl Int 2018; 115: 863–70 VOLLTEXT|
|2.||Wolf SJ, Maloney GE, Shih RD, Shy BD, Brown MD: Clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with acute carbon monoxide poisoning: www.acep.org/patient-care/clinical-policies/carbon-monoxide-poisoning (last accessed on 8 January 2019).|
|3.||Buckley NA, Juurlink DN, Isbister G, Bennett MH, Lavonas EJ: Hyperbaric oxygen for carbon monoxide poisoning. Cochrane Database Syst Rev 2011; 4: CD002041 CrossRef|
|4.||Roth D, Mayer J, Schreiber W, Herkner H, Laggner AN: Acute carbon monoxide poisoning treatment by non-invasive CPAP-ventilation, and by reservoir face mask: two simultaneous cases. Am J Emerg Med 2018; 36: 1718.e5–1718.e6. CrossRef|