Emergency Medical Services – September 2024

The patient has an altered level of consciousness (ALOC) although it may be hard to describe the particular way in which she is altered, given a GCS of 15.  Your initial management focuses on evaluating for life threatening medical causes of ALOC, providing lifesaving interventions to include managing the patient’s airway if needed, and attempting to determine an underlying cause. In particular, you should evaluate for causes of ALOC that would respond to immediate field intervention.  The potential causes for ALOC are numerous and may be due to a serious medical condition, as well as to intoxication or psychiatric illness. While the patient has a reported history of untreated depression, and her spouse reports recent depressive symptoms, it would be dangerous to assume that this is the cause of her symptoms.

Initial management can begin for the patient with TP-1229.

A past medical history, physical examination (particularly for signs of trauma or infection), and evaluation of the environment may provide clues to determining a likely underlying cause. The patient herself cannot provide much information due to her lethargy. On specific questioning of the spouse, he states that she made breakfast for the family that morning, but that when he suggested taking the children ice skating to enjoy the weather, she had responded that she had a headache and would stay home with their 2-year old whom she was concerned was getting sick. She denies using any illicit drugs. On specific questioning she denies any thoughts of suicide or self-harm.

On physical examination, her skin is dry.  Pupils are mid-sized and react equally to light.  No evidence of trauma is noted.  Lungs are clear and abdomen is soft and non-tender. The monitor shows sinus tachycardia with no signs of ischemia or STEMI.

Her vital signs are HR 114, BP 102/64, RR 22, O2 saturation is 99% on RA. Blood glucose is 110 mg/dL.  IV access is obtained.

Evaluating the environment, you note a half-empty bottle of red wine on the dining table. The home is a small 2 bedroom apartment in a 1960s multi-unit building. The apartment is relatively clean but the building does not appear particularly well maintained. The patient is located on an older plush sofa pushed up towards the wall in a living room crowded with children’s toys. There is a wall heater directly behind the couch. You note that there are no smoke detectors visible in the living or dining area, or outside of the 2 closed bedroom doors. When you ask the husband, he states that they have been living in the apartment for 2 years, since the birth of their second child; but that the apartment officially belongs to his grandmother, who has rented there for 20+ years.

Concerned by the mother’s appearance, your partner asks to see the child, and the couple’s 2 year old son is found in a crib in one of the closed bedrooms.  He does not wake up when his father goes to pick him up. He is breathing quickly but is lethargic. His skin is cool to touch. Using the Pediatric Assessment Triangle, you decide that his appearance and work of breathing are abnormal, concerning for respiratory failure.

The child is difficult to arouse with an altered level of consciousness as well.  A complete assessment needs to be performed on the child and can be performed using TP 1229-P, ALOC and TP 1237-P, Respiratory Distress.

A full assessment is performed on the 2 year old. He measures Yellow, 14kg on the length-based tape. Lungs are clear. He has no rashes but does have some bruises on his lower legs. A decision is made to expedite the transport of this critical child. When the mother sees him being carried out she becomes frantic, but also seems confused and does not follow him out. Cardiac monitors demonstrate sinus tachycardia. His vital signs are HR 152, BP 94/42, RR 34, O2 saturation 96%. IV access is obtained and the child barely winces when the IV is placed.  His blood glucose is 99mg/dL.  A fluid bolus is initiated.  Given concern for impending respiratory failure by his Pediatric Assessment Triangle, high flow oxygen is initiated per TP 1237-P.

After going through AEIOUTIPS for possible causes for the patients’ symptoms, it’s important to consider that there are limited number of causes of ALOC that will simultaneously effect two persons, including a small child.

AEIOUTIPS is a mnemonic tool that can be used to review potential causes of ALOC. I have bolded-italicized the most likely etiologies in this scenario.

A – Alcohol abuse, Atypical migraine

E – Epilepsy, Electrolyte abnormalities

I – Insulin (hypoglycemia)

O – Oxygen, Overdose

U – Uremia (kidney failure)

T – Trauma, Tumor

I – Infection, Intoxication

P – Psych, Poisoning

S – Seizure, Subarachnoid hemorrhage, Sepsis, Stroke

As an astute paramedic you consider carbon monoxide poisoning. It is a cold day for Los Angeles and the patients’ home is heated by a natural-gas powered heater. Your partner confirms that the heater behind the couch is turned on. There are no smoke or carbon monoxide detectors noted in the home.  You do not have a CO oximeter but decide that given the situation and the risk vs. benefit of high-flow oxygen administration you will treat for suspected Carbon Monoxide poisoning as suggested in TP 1229, ALOC and TP 1229-P.

Carbon monoxide (CO) is a by-product of incomplete combustion of carbon-containing subtances.  It is a colorless, orderless, and tasteless gas. Exposure is most commonly from automobile exhaust, faulty heaters, or structural fires. It is estimated that confirmed cases of unintentional, non-fire related CO poisoning results in over 15,000 emergency department visits and nearly 500 deaths per year in the United States¹.

CO binds to hemoglobin in red blood cells forming carboxyhemoglobin.  The formation of carboxyhemoglobin prevents oxygen from binding to hemoglobin, leading to hypoxia by disrupting normal oxygen delivery to cells. CO poisoning can manifest through a broad range of symptoms dependent on the concentration of CO and the duration of exposure.

Although patients are physiologically hypoxic, oxygen saturation by pulse oximetry will typically read as normal because the SpO₂ reading will incorporate both the percentage of hemoglobin that is saturated with oxygen (oxyhemoglobin) as well as carboxyhemoglobin in the reading.

Exposure to elevated levels of carbon monoxide result in toxic effects, with faster onset of symptoms at higher concentrations of the gas in the environment. Early symptoms may be “flu-like” and include headache, dizziness, vomiting, and fatigue. Severe exposures to high levels, or prolonged exposure to mildly or moderately elevated levels can result in confusion, loss of consciousness, focal neurological deficits, and eventually death.  The classically taught “cherry-red” skin finding is seen in only a small percentage (less than 5%) of living patients.

²NEJM. Carbon Monoxide Poisoning. 2009;360(12): 1217-1225

California law requires CO detectors in residential dwellings³. However, not everyone is compliant. CO poisonings occur each year, particularly during winter months when heaters begin to be used.

The first step in treating CO poisoning is recognition of the signs and symptoms.  One important clue is when more than one person in a household or location is symptomatic, such as in this case. One may not be able to make a definitive diagnosis at the scene, but if suspected, the patient should be removed from the source of carbon monoxide and carbon monoxide poisoning should be treated with high-flow oxygen as per TP 1238 and TP 1238-P. High-flow oxygen will expedite the displacement and elimination of carbon monoxide from hemoglobin. Paramedics should also assess for ongoing hazards and other potential victims. If a carbon monoxide detector is available, paramedics should consider obtaining a measured carbon monoxide level and reporting results to the receiving hospital as this information is useful for diagnosis and treatment decisions. Initiating treatment should be a clinical decision and not rely on measured confirmation of carbon monoxide exposure or a carboxyhemoglobin level since duration of exposure and severity of the elevation influence outcome.

Young children may not be able to communicate symptoms of carbon monoxide poisoning.  For this reason, their symptoms may be non-specific and present as ‘fussiness’.  Young children are more at risk to develop severe symptoms from CO exposure at lower levels in a shorter period due to affinity of CO molecule for fetal hemoglobin and the higher metabolic rate which may result in more rapid poisoning. The management of CO poisoning is the same, regardless of age.

In addition, given the history provided in this case, it is reasonable to consider the possibility of intoxication and/or child abuse/intentional poisoning in the child pending confirmation or elimination of your suspicion for CO poisoning. However, it would be inappropriate to assume/accept these causes and therefore not explore other possible causes of the child or mother’s symptoms, especially those that warrant immediate treatment.

You administer high-flow oxygen at 15L/min to both patients and immediately remove them from the home. The child is transported first and a second ambulance is requested to transport the mother. The potentially faulty heater is turned off and a field CO monitor is brought and detects mild to moderately elevated levels of CO within the house.  Neither the first responders nor the patients’ husband/father developed symptoms.  The patients are transported 20 minutes to the nearest hospital that is also a Pediatric Medical Center given the 2 year-old’s altered mental status and the desire to keep the family together for family-centered care. At the hospital, the suspicion for CO exposure, and for intoxication/abuse is communicated to both of the hospital patient care teams. Remember that different teams/providers will likely care for the two patients. It should not be assumed that the teams will have the time to discuss the two patients’ cases, so information should be transmitted to both teams.  By the time of arrival, the mother is slightly improved and asking about her child.  The child is minimally responsive but still altered.  Given your stated concern for CO poisoning, CO-oximetry was ordered on both patients (this is a special test in most hospitals and is not performed without suspicion) and shows elevated levels in both mother and child, confirming the diagnosis of CO poisoning. Both patients are treated with high-flow oxygen and demonstrate rapid improvement over the next 4 hours. Discussion is had regarding possible transport for hyperbaric oxygen; but given the rapid improvement in the child’s neurologic function and lack of signs of cardiac ischemia in either, the decision is made instead to continue them on high-flow oxygen. They are both admitted to the hospital and, thanks to your quick thinking and action, make a full recovery and are discharged the next evening.