Case report
What do we know about carbon monoxide poisoning and cardiac compromise? Treatment and prognosis
Intoxicação por monóxido de carbono com compromisso cardíaco: o que sabemos?
Rosa Cardiga
, Margarida Proença, Carolina Carvalho, Luís Costa, Arturo Botella, Filipa Marques, Carolina Paulino, António Carvalho, Cândida Fonseca
Corresponding author
Serviço de Medicina III, Hospital São Francisco Xavier, Centro Hospitalar de Lisboa Ocidental, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisboa, Portugal
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Treatment and prognosis" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "557.e1" "paginaFinal" => "557.e5" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Rosa Cardiga, Margarida Proença, Carolina Carvalho, Luís Costa, Arturo Botella, Filipa Marques, Carolina Paulino, António Carvalho, Cândida Fonseca" "autores" => array:9 [ 0 => array:4 [ "nombre" => "Rosa" "apellidos" => "Cardiga" "email" => array:1 [ 0 => "rosita.cardiga@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Margarida" "apellidos" => "Proença" ] 2 => array:2 [ "nombre" => "Carolina" "apellidos" => "Carvalho" ] 3 => array:2 [ "nombre" => "Luís" "apellidos" => "Costa" ] 4 => array:2 [ "nombre" => "Arturo" "apellidos" => "Botella" ] 5 => array:2 [ "nombre" => "Filipa" "apellidos" => "Marques" ] 6 => array:2 [ "nombre" => "Carolina" "apellidos" => "Paulino" ] 7 => array:2 [ "nombre" => "António" "apellidos" => "Carvalho" ] 8 => array:2 [ "nombre" => "Cândida" "apellidos" => "Fonseca" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Serviço de Medicina III, Hospital São Francisco Xavier, Centro Hospitalar de Lisboa Ocidental, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisboa, Portugal" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Intoxicação por monóxido de carbono com compromisso cardíaco: o que sabemos?" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 874 "Ancho" => 1500 "Tamanyo" => 178975 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Electrocardiogram 15 h after admission to the emergency room.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Carbon monoxide (CO) is a colorless, tasteless, odorless and non-irritant but highly toxic gas.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">1</span></a> It binds rapidly to hemoglobin with an affinity 210 times higher than for oxygen, leading to the formation of carboxyhemoglobin (COHb) and tissue hypoxia.</p><p id="par0010" class="elsevierStylePara elsevierViewall">CO poisoning is one of the most common types of poisoning; it is a frequent cause of morbidity,<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">2</span></a> and the leading cause of death by poisoning worldwide.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">While not a common cause of hospital admission in Portugal, its incidence is not negligible: 5.86/100<span class="elsevierStyleHsp" style=""></span>000 population over an eight-year period.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The clinical symptoms of CO poisoning are non-specific and can mimic a wide range of conditions, and diagnosis requires a high index of suspicion.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">1</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Headache is the most common symptom of CO poisoning, reported in 84% of cases, and 50% of patients present fatigue, nausea, mental confusion and dyspnea.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">1</span></a> Less frequent symptoms include abdominal pain, visual disturbances, chest pain and seizures.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">1</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Tissue hypoxia in CO poisoning affects all organs and systems, and involvement of the major organs worsens prognosis.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The neurological sequelae of CO poisoning have been amply described in the literature, but cardiovascular repercussions have only been presented in occasional case reports.<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">5,6</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Cardiac injury results from the binding of CO to hemoglobin and myoglobin and inhibition of mitochondrial cytochrome oxidase, resulting in tissue hypoxia and reduced adenosine triphosphate synthesis.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">7</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The most common cardiac manifestations are ischemia leading to elevated myocardial necrosis markers, electrocardiographic (ECG) alterations, particularly ST-segment depression, myocardial infarction and conduction disturbances such as atrial fibrillation and ventricular arrhythmias.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">8</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">The authors present a case of CO poisoning with cardiac compromise with the aim of highlighting the seriousness of this complication, which is frequently overlooked, and the need for thorough investigation and monitoring in all cases of CO poisoning. The indication for hyperbaric therapy is also discussed in this context.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0055" class="elsevierStylePara elsevierViewall">A 27-year-old woman, with no relevant clinical history or cardiovascular risk factors and not taking any medication, was admitted to the emergency room (ER) due to an episode of lipothymia, during which she was unable to move for around two hours following a bath. She denied loss of consciousness, tonic–clonic movements, loss of sphincter control, chest pain or palpitations. She reported holocranial headache for the previous two weeks, which she quantified as 6 on a scale of 1 to 10, associated with nausea and vomiting.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">9</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">From an epidemiological standpoint, the patient was accompanied by two other women who lived in the same building and had similar symptoms. They also reported that a dog living in the same place was suffering from collapse and vomiting. There was no other relevant history.</p><p id="par0065" class="elsevierStylePara elsevierViewall">On physical examination, the patient was conscious, cooperative, and oriented in time and space, with blood pressure 109/69 mmHg, regular heart rate (HR) 109 bpm, and no other significant alterations.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Blood gas analysis on room air revealed pH 7.392, pCO<span class="elsevierStyleInf">2</span> 32 mmHg, pO<span class="elsevierStyleInf">2</span> 101 mmHg, HCO<span class="elsevierStyleInf">3</span> 20.8 mmol/l, COHb 29.2% and lactate 3.5 mmol/l.</p><p id="par0075" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows changes in laboratory values over the patient's three-day hospital stay. Of note are the rises in markers of myocardial necrosis (peak troponin 6.13 μg/l, 9 h after the event), and in NT-proBNP, which normalized on the third day.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">The ECG on admission to the ER (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>) showed sinus rhythm, HR 110 bpm, normal P-wave amplitude and duration, with a 1:1 A/V ratio, PR interval 131 ms, QRS duration 90 ms, and ST-segment depression of 2 mm in V4 and 1 mm in V5.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">The ECG 15 h after ER admission (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>) showed sinus rhythm and normal HR of 78 bpm.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">Transthoracic echocardiography showed no left ventricular dilatation, hypertrophy or wall motion abnormalities, good global systolic function and ejection fraction of 65%; good right ventricular systolic function and tricuspid annular plane systolic excursion of 16 mm; the other cardiac chambers were normal. There were no valve abnormalities, pericardial effusion or intracavitary masses.</p><p id="par0095" class="elsevierStylePara elsevierViewall">Given the clinical and epidemiological context, myocardial and central nervous system ischemia due to CO poisoning following prolonged exposure was assumed. Normobaric oxygen therapy was started while the indication for hyperbaric oxygen therapy was discussed with the specialist responsible for the hyperbaric chamber, who suggested maintaining conservative treatment and monitoring for 72 h.</p><p id="par0100" class="elsevierStylePara elsevierViewall">The patient's clinical course was favorable and she was discharged, asymptomatic, on the third day. Laboratory tests revealed a fall in markers of myocardial necrosis and normalization of NT-proBNP (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). Blood gas analysis on room air showed pH 7.436, pCO<span class="elsevierStyleInf">2</span> 35 mmHg, pO<span class="elsevierStyleInf">2</span> 120 mmHg, COHb 0.5% and HCO<span class="elsevierStyleInf">3</span> 23 mmol/l.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0105" class="elsevierStylePara elsevierViewall">The case presented describes a less common complication of CO poisoning – myocardial and central nervous system ischemia. The former is often overlooked, with few and conflicting reports in the literature on the therapeutic approach to adopt.</p><p id="par0110" class="elsevierStylePara elsevierViewall">A search in Medline for articles on this subject published since January 1st, 2000 produced 299 articles with the search term “carbon monoxide poisoning”, 18 articles with “carbon monoxide poisoning and neurological effects” and 12 articles with “carbon monoxide poisoning and myocardial injury”, which demonstrates the low level of attention paid to this subject.</p><p id="par0115" class="elsevierStylePara elsevierViewall">A study based on autopsies performed by the Portuguese National Institute of Legal Medicine over a six-year period from 2005 to 2011 recorded 111 deaths from CO poisoning – 55 in the North region, 12 in the Central region and 44 in the South region. Most deaths were the result of accidents in the home with open fires, charcoal braziers and gas water heaters, as was the case with our patient.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">10</span></a> The study did not specify the degree of injury to different organs.</p><p id="par0120" class="elsevierStylePara elsevierViewall">Hampson et al. demonstrated that there was no significant difference in short-term mortality from CO poisoning between patients treated with normobaric or hyperbaric oxygen therapy, the aim of the latter being to prevent permanent organ damage.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">11</span></a> The indications for hyperbaric oxygen therapy remain the subject of debate and are currently restricted (<a class="elsevierStyleCrossRef" href="#tbl0030">Table 2</a>).</p><elsevierMultimedia ident="tbl0030"></elsevierMultimedia><p id="par0125" class="elsevierStylePara elsevierViewall">According to the latest international guidelines hyperbaric oxygen therapy should be used in all patients with severe CO poisoning, severity being assessed on indicators of organ damage rather than simply on levels of COHb (<a class="elsevierStyleCrossRef" href="#tbl0030">Table 2</a>).<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">12,1</span></a> The myocardial ischemia observed in our patient is one of these indicators.</p><p id="par0130" class="elsevierStylePara elsevierViewall">Satran et al. demonstrated that myocardial injury is common in moderate to severe CO poisoning. In a prospective study between January 1, 1994 and January 1, 2002, with follow-up to November 11, 2005, they reviewed the cardiovascular manifestations of 230 consecutive patients admitted for moderate to severe CO poisoning to a hospital with facilities for hyperbaric oxygen therapy. Mean age was 47.2 years and 72% were male. Of the total study population, 37% (85 patients) had myocardial injury assessed by ECG or biomarkers despite a low incidence of cardiac risk factors, as was the case in our patient. The study showed that cardiac damage is often underestimated in CO poisoning: serial assessment of cardiac biomarkers was not performed in 20% of patients and echocardiograms were performed in only 53 of those with positive markers.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">13</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">Henry et al. assessed long-term mortality (follow-up 3–11 years) in the same population of 85 patients admitted for CO poisoning with associated myocardial injury. Of these, 38% died, compared to 15% of those with no myocardial injury (odds ratio 2.1; 95% confidence interval 1.2–3.7; p=0.009). They concluded that the risk of mortality in patients with CO poisoning and cardiac involvement is twice that of patients without myocardial injury and three times that of controls with no history of CO poisoning.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">14</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">In the case presented, prolonged CO exposure, elevated markers of myocardial necrosis and loss of consciousness, indicators of central nervous system and myocardial damage, led us to classify the CO poisoning as severe and to consider hyperbaric oxygen therapy. However, the severity of organ damage is based on the assessment of a specialist in hyperbaric medicine, who in this case, given the patient's clinical stability, advised maintaining normobaric oxygen therapy and close monitoring.</p><p id="par0145" class="elsevierStylePara elsevierViewall">The clinical course was favorable on high flow oxygen therapy, and the patient survived and was still asymptomatic in cardiovascular terms at 400 days of follow-up.</p><p id="par0150" class="elsevierStylePara elsevierViewall">Despite the scarcity of data in the literature, CO poisoning is common. Prognosis can be poor, and appears to be dictated by the extent of involvement of the myocardium as well as of the central nervous system. There have been few studies and the guidelines, as their authors acknowledge, are unclear due to lack of evidence, particularly concerning the benefits of hyperbaric oxygen therapy and its indications.</p><p id="par0155" class="elsevierStylePara elsevierViewall">Cardiac involvement is often underdiagnosed or overlooked, which highlights the need to raise awareness of this complication among health professionals, and of its implications for prognosis.</p><p id="par0160" class="elsevierStylePara elsevierViewall">New randomized studies are required to establish evidence-based guidelines.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Ethical disclosures</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Protection of human and animal subjects</span><p id="par0165" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this investigation.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Confidentiality of data</span><p id="par0170" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Right to privacy and informed consent</span><p id="par0175" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conflicts of interest</span><p id="par0180" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres552155" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec569518" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres552154" "titulo" => "Resumo" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec569519" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:3 [ "identificador" => "sec0020" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0030" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0035" "titulo" => "Right to privacy and informed consent" ] ] ] 8 => array:2 [ "identificador" => "sec0040" "titulo" => "Conflicts of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-10-09" "fechaAceptado" => "2015-01-02" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec569518" "palabras" => array:3 [ 0 => "Carbon monoxide poisoning" 1 => "Myocardial ischemia" 2 => "Hyperbaric oxygen" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec569519" "palabras" => array:3 [ 0 => "Intoxicação por monóxido de carbono" 1 => "Isquemia do miocárdio" 2 => "Oxigénio hiperbárico" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Carbon monoxide (CO) poisoning is one of the most common types of poisoning and the leading cause of death by poisoning worldwide. Cardiac injury caused by CO poisoning has been little described despite being a predictor of poor prognosis.</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We present the case of a healthy 24-year-old woman, admitted to our emergency room due to an episode of lipothymia without loss of consciousness. She reported holocranial headache for the previous two weeks associated with nausea and vomiting.</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Laboratory tests revealed blood gas analysis: pH 7.392, pCO<span class="elsevierStyleInf">2</span> 32 mmHg, pO<span class="elsevierStyleInf">2</span> 101 mmHg, lactate 3.5 mmol/l, HCO<span class="elsevierStyleInf">3</span> 20.8 mmol/l; COHb 29.2%; serial troponin I 1.21→5.25→6.13→3.65 μg/l; myoglobin 1378→964→352 μg/l; and NT-proBNP 1330 pg/l. The electrocardiogram showed sinus rhythm, heart rate 110 bpm, and ST-segment depression of 2 mm in V4 and 1 mm in V5. Transthoracic echocardiography revealed a left ventricle with normal wall motion and preserved ejection fraction.</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Given the clinical and epidemiological context, myocardial and central nervous system ischemia due to prolonged CO exposure was assumed and normobaric oxygen therapy was immediately started. In view of evidence of injury to two major organ systems the indication for hyperbaric oxygen therapy was discussed with a specialist colleague, who suggested maintaining conservative treatment with oxygen therapy and in-hospital monitoring for 72 h. The patient was discharged on the third day and was still asymptomatic at 400 days of follow-up.</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Besides symptoms and signs of central nervous system dysfunction, myocardial damage should also always be considered in the context of CO poisoning. Hyperbaric therapy is still controversial and the lack of objective data highlights the need for new randomized studies.</p></span>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">A intoxicação por monóxido de carbono (MC) é um dos tipos de intoxicação mais frequente e a principal causa de morte por intoxicação no mundo. A lesão cardíaca provocada pela intoxicação por MC tem sido pouco descrita apesar de ser um fator preditor de mau prognóstico.</p><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Apresentamos o caso de uma mulher de 24 anos, saudável, que recorre ao serviço de urgência por lipotimia sem perda de conhecimento. Referia cefaleia holocraniana associada a náuseas e vómitos com duas semanas de evolução. Analiticamente: gasimetria pH 7,392; pCO<span class="elsevierStyleInf">2</span> 32 mmHg, pO<span class="elsevierStyleInf">2</span> 101 mmHg, lactatos 3,5 mmol/L, HCO<span class="elsevierStyleInf">3</span> 20,8 mmol/L, COHb 29,2%; troponina I seriada 1,21→5,25→6,13→3,65 ug/L, mioglobina 1378→964→352 ug/L, NT-ProBNP 1330 pg/L. Eletrocardiograma: ritmo sinusal, frequência cardíaca 110 bpm, depressão do segmento ST de 2 mm em V4 e 1 mm em V5. Ecocardiograma transtorácico: ventrículo esquerdo sem alterações da cinética segmentar e boa função sistólica global.</p><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Associando-se a clínica ao contexto epidemiológico assumiu-se isquemia do miocárdio e do sistema nervoso central por exposição prolongada ao MC. Iniciou-se prontamente oxigenoterapia normobárica. Perante a evidência de compromisso de dois órgãos nobres, foi discutida com o colega especialista nesta área a indicação para tratamento com oxigénio hiperbárico, sugeriu manter tratamento conservador com oxigenoterapia e vigilância em internamento durante 72 h. Teve alta ao terceiro dia e mantém-se assintomática aos 400 dias de follow-up.</p><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Tal como os sintomas e sinais de disfunção do sistema nervoso central, a lesão do miocárdio deve ser sistematicamente equacionada no contexto de intoxicação por MC. A indicação para terapêutica em câmara hiperbárica permanece controversa e com indicações pouco objetivas, a apelar a novos estudos aleatorizados.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Cardiga R, Proença M, Carvalho C, et al. Intoxicação por monóxido de carbono com compromisso cardíaco: o que sabemos? Rev Port Cardiol. 2015;34:557.e1–557.e5.</p>" ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 874 "Ancho" => 1500 "Tamanyo" => 181900 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Electrocardiogram on admission to the emergency room.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 874 "Ancho" => 1500 "Tamanyo" => 178975 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Electrocardiogram 15 h after admission to the emergency room.</p>" ] ] 2 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">D1: one day after event; D2: two days after event; D3: three days after event; H0: at emergency room admission; H6: 6 h after event; H9: 9 h after event; H20: 20 h after event.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">H0 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">H6 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">H9 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">H20 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">D1 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">D2 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">D3 \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Hemoglobin (g/dl) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">14.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">13.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Leukocytes (×10<span class="elsevierStyleSup">9</span>/l)/neutrophils (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">25.8/93.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">17.6/13.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10.1/47.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9.8/5.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">C-reactive protein (mg/dl) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><0.29 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.55 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.38 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><0.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Creatininemia (mg/dl) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.61 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.53 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.67 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Troponinemia (μg/l) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5.25 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.65 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.69 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.46 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.62 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Creatine kinase (U/l) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2164 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3058 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">791 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Myoglobinemia (μg/l) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1378 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">964 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">352 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">96 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">19 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">24 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">NT-proBNP (pg/ml) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1330 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">384 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">48 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab891420.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Changes in laboratory values during hospital stay.</p>" ] ] 3 => array:7 [ "identificador" => "tbl0030" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Loss of consciousness \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Neurological deficits \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Ischemic cardiac changes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Metabolic acidosis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Carboxyhemoglobin >25% \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab891421.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Indications for hyperbaric oxygen therapy.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">12</span></a></p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:14 [ 0 => array:3 [ "identificador" => "bib0075" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Carbon monoxide intoxication: an updated review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "L.D. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 7 | 3 | 10 |
| 2024 October | 104 | 33 | 137 |
| 2024 September | 88 | 18 | 106 |
| 2024 August | 82 | 32 | 114 |
| 2024 July | 48 | 31 | 79 |
| 2024 June | 38 | 21 | 59 |
| 2024 May | 67 | 27 | 94 |
| 2024 April | 59 | 29 | 88 |
| 2024 March | 44 | 30 | 74 |
| 2024 February | 69 | 38 | 107 |
| 2024 January | 75 | 25 | 100 |
| 2023 December | 59 | 31 | 90 |
| 2023 November | 53 | 28 | 81 |
| 2023 October | 69 | 27 | 96 |
| 2023 September | 60 | 19 | 79 |
| 2023 August | 57 | 16 | 73 |
| 2023 July | 73 | 8 | 81 |
| 2023 June | 50 | 15 | 65 |
| 2023 May | 79 | 31 | 110 |
| 2023 April | 47 | 10 | 57 |
| 2023 March | 70 | 30 | 100 |
| 2023 February | 62 | 23 | 85 |
| 2023 January | 81 | 18 | 99 |
| 2022 December | 78 | 25 | 103 |
| 2022 November | 76 | 28 | 104 |
| 2022 October | 63 | 20 | 83 |
| 2022 September | 85 | 30 | 115 |
| 2022 August | 80 | 40 | 120 |
| 2022 July | 110 | 31 | 141 |
| 2022 June | 78 | 29 | 107 |
| 2022 May | 84 | 40 | 124 |
| 2022 April | 69 | 23 | 92 |
| 2022 March | 51 | 45 | 96 |
| 2022 February | 46 | 30 | 76 |
| 2022 January | 58 | 44 | 102 |
| 2021 December | 58 | 36 | 94 |
| 2021 November | 64 | 32 | 96 |
| 2021 October | 60 | 46 | 106 |
| 2021 September | 50 | 33 | 83 |
| 2021 August | 62 | 37 | 99 |
| 2021 July | 38 | 41 | 79 |
| 2021 June | 48 | 26 | 74 |
| 2021 May | 52 | 77 | 129 |
| 2021 April | 83 | 45 | 128 |
| 2021 March | 106 | 19 | 125 |
| 2021 February | 109 | 26 | 135 |
| 2021 January | 67 | 15 | 82 |
| 2020 December | 82 | 11 | 93 |
| 2020 November | 75 | 33 | 108 |
| 2020 October | 79 | 14 | 93 |
| 2020 September | 72 | 18 | 90 |
| 2020 August | 42 | 7 | 49 |
| 2020 July | 75 | 2 | 77 |
| 2020 June | 70 | 19 | 89 |
| 2020 May | 77 | 15 | 92 |
| 2020 April | 92 | 21 | 113 |
| 2020 March | 80 | 13 | 93 |
| 2020 February | 120 | 40 | 160 |
| 2020 January | 87 | 11 | 98 |
| 2019 December | 67 | 6 | 73 |
| 2019 November | 72 | 13 | 85 |
| 2019 October | 46 | 7 | 53 |
| 2019 September | 80 | 10 | 90 |
| 2019 August | 45 | 6 | 51 |
| 2019 July | 59 | 18 | 77 |
| 2019 June | 48 | 5 | 53 |
| 2019 May | 39 | 12 | 51 |
| 2019 April | 26 | 17 | 43 |
| 2019 March | 30 | 9 | 39 |
| 2019 February | 16 | 7 | 23 |
| 2019 January | 34 | 6 | 40 |
| 2018 December | 28 | 10 | 38 |
| 2018 November | 90 | 10 | 100 |
| 2018 October | 212 | 16 | 228 |
| 2018 September | 69 | 12 | 81 |
| 2018 August | 59 | 9 | 68 |
| 2018 July | 31 | 5 | 36 |
| 2018 June | 18 | 9 | 27 |
| 2018 May | 48 | 9 | 57 |
| 2018 April | 40 | 4 | 44 |
| 2018 March | 33 | 7 | 40 |
| 2018 February | 32 | 1 | 33 |
| 2018 January | 43 | 9 | 52 |
| 2017 December | 46 | 7 | 53 |
| 2017 November | 53 | 14 | 67 |
| 2017 October | 39 | 23 | 62 |
| 2017 September | 28 | 12 | 40 |
| 2017 August | 34 | 12 | 46 |
| 2017 July | 29 | 11 | 40 |
| 2017 June | 27 | 22 | 49 |
| 2017 May | 47 | 7 | 54 |
| 2017 April | 19 | 4 | 23 |
| 2017 March | 41 | 58 | 99 |
| 2017 February | 37 | 6 | 43 |
| 2017 January | 42 | 9 | 51 |
| 2016 December | 31 | 13 | 44 |
| 2016 November | 51 | 5 | 56 |
| 2016 October | 39 | 7 | 46 |
| 2016 September | 50 | 5 | 55 |
| 2016 August | 15 | 4 | 19 |
| 2016 July | 22 | 8 | 30 |
| 2016 June | 20 | 11 | 31 |
| 2016 May | 13 | 5 | 18 |
| 2016 April | 45 | 1 | 46 |
| 2016 March | 39 | 19 | 58 |
| 2016 February | 65 | 29 | 94 |
| 2016 January | 54 | 23 | 77 |
| 2015 December | 61 | 20 | 81 |
| 2015 November | 66 | 28 | 94 |
| 2015 October | 116 | 59 | 175 |
| 2015 September | 166 | 75 | 241 |
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