Eichhorn L, Kieback M, Michaelis D, Kemmerer M, Jüttner B, Tetzlaff K
Klinik und Poliklinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Bonn (AöR), Sigmund-Freud-Straße 25, 53127, Bonn, Deutschland.
Druckkammerzentrum Rhein Main Taunus GmbH, Wiesbaden, Deutschland.
Anaesthesist. 2019 Apr;68(4):208-217. doi: 10.1007/s00101-019-0544-8. Epub 2019 Feb 21.
The symptoms of acute carbon monoxide (CO) poisoning are unspecific, ranging from headaches to unconsciousness and death. In addition to acute symptoms, delayed severe neurological sequelae may occur. While a total of 440 deaths by CO poisoning were registered in Germany in 1999, a total of 594 patients died (0.73 per 100,000 inhabitants) in 2014 and in 2015 the number even increased to 648 deaths. A national database on clinical symptoms, course of illness or quality of care concerning CO poisoning does not yet exist.
The treatment data of patients admitted to the Hyperbaric Emergency Centre Wiesbaden (HEC) from 2013 to 2017 with CO poisoning formed the basis of the study. This was a comparative evaluation of patient demographics, poisoning sources, symptom spectrum, course of treatment and time intervals registered on the preclinical and clinical levels.
From 2013 to 2017 a total of 476 patients (282 men and 194 women) with an average non-invasively measured CO-Hb of 15% (Q = 7.6%, Q = 22.3%) were treated with hyperbaric oxygen. Heaters (n = 131), charcoal barbecues (n = 93), fires (n = 90), hookahs (n = 78) and combustion engines (n = 37) were the most frequent CO sources identified. Headaches, vertigo, nausea and syncope were the most prevalent symptoms. A median of 91 min (Q = 53 min; Q = 147 min) passed between first medical contact and BGA-validated diagnosis. In total, 151 patients were transferred directly to the HEC, whereas 325 patients were secondarily transferred. The delay in this subgroup took 183 min (median Q = 138 min; Q = 248 min). After receiving the first hyperbaric treatment, 80% were free of symptoms. Remaining symptoms included headache (10%), fatigue (8%), vertigo (5%) and nausea (3%) and 45 patients terminated further treatment. Of the patients 417 received a second hyperbaric treatment and 370 patients were treated 3 times. After the third treatment, 89% were free of symptoms and 5% still reported headaches, 3% vertigo and 2% fatigue. In total, 6 patients died and 430 patients were symptom-free after treatment.
Commonly known sources (fire, charcoal grills) aside, many poisonings by smoking a hookah were observed. This study highlights the importance of considering CO poisoning as a differential diagnosis when encountering patients, especially of younger age, with non-specific neurological symptoms, as well as the importance of early initiation of treatment. A direct correlation between CO-Hb values (whether measured noninvasively or by invasive BGA) and the initial symptoms could not be demonstrated. In total, substantial time expired between the diagnosis and start of treatment of patients transported to a primary care hospital compared to those transported directly to the HEC. Although analysis showed adequate treatment with oxygen in the preclinical interval, administration of oxygen during primary hospital stay showed room for improvement. Introducing a national CO poisoning register and uniform treatment guidelines could improve in-house clinical processes. Multicenter studies are needed to close the gaps identified in the quality of care in Germany.
急性一氧化碳（CO）中毒的症状不具有特异性，从头痛到昏迷甚至死亡。除了急性症状外，还可能出现延迟性严重神经后遗症。1999年德国登记的CO中毒死亡人数共计440人，2014年共有594名患者死亡（每10万居民中有0.73人死亡），2015年这一数字甚至增至648人死亡。目前尚无关于CO中毒的临床症状、病程或护理质量的全国性数据库。
以2013年至2017年入住威斯巴登高压氧急救中心（HEC）的CO中毒患者的治疗数据作为研究基础。这是对患者人口统计学、中毒源、症状谱、治疗过程以及临床前和临床水平记录的时间间隔进行的比较评估。
2013年至2017年，共有476名患者（282名男性和194名女性）接受了高压氧治疗，平均无创测量的碳氧血红蛋白（CO-Hb）为15%（四分位间距Q = 7.6%，Q = 22.3%）。发现最常见的CO来源是取暖器（n = 131）、炭火烧烤炉（n = 93）、火灾（n = 90）、水烟袋（n = 78）和内燃机（n = 37）。头痛、眩晕、恶心和晕厥是最常见的症状。从首次就医到经血气分析确诊的中位时间为91分钟（Q = 53分钟；Q = 147分钟）。共有151名患者直接被转至HEC，而325名患者是二次转院。该亚组的延迟时间为183分钟（中位四分位间距Q = 138分钟；Q = 248分钟）。接受首次高压氧治疗后，80%的患者症状消失。其余症状包括头痛（10%）、疲劳（8%）、眩晕（5%）和恶心（3%），45名患者终止了进一步治疗。417名患者接受了第二次高压氧治疗，370名患者接受了三次治疗。第三次治疗后，89%的患者症状消失，5%的患者仍有头痛，3%的患者仍有眩晕，2%的患者仍有疲劳。共有6名患者死亡，430名患者治疗后无症状。
除了常见的中毒源（火灾、炭火烤架）外，还观察到许多因吸食水烟导致的中毒事件。本研究强调，在遇到有非特异性神经症状的患者，尤其是年轻患者时，将CO中毒作为鉴别诊断的重要性，以及早期开始治疗的重要性。无法证明CO-Hb值（无论是无创测量还是通过有创血气分析测量）与初始症状之间存在直接关联。与直接转至HEC的患者相比，转至基层医院的患者在诊断和开始治疗之间间隔了相当长的时间。尽管分析显示在临床前阶段给予了充足的氧疗，但基层医院住院期间氧疗的实施仍有改进空间。引入全国性的CO中毒登记册和统一的治疗指南可改善医院内部的临床流程。需要开展多中心研究以填补德国护理质量方面发现的空白。
