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## Complete Summary

#### GUIDELINE TITLE

Clinical policy: critical issues in the management of adult patients
presenting to the emergency department with acute carbon monoxide
poisoning.

#### BIBLIOGRAPHIC SOURCE(S)

Wolf SJ, Lavonas EJ, Sloan EP, Jagoda AS, American College of Emergency
Physicians. Clinical policy: critical issues in the management of adult
patients presenting to the emergency department with acute carbon
monoxide poisoning. Ann Emerg Med 2008 Feb;51(2):138-52. \[71
references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=18206551)

#### GUIDELINE STATUS

This is the current release of the guideline.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Acute carbon monoxide (CO) poisoning

#### GUIDELINE CATEGORY

Management

#### CLINICAL SPECIALTY

Emergency Medicine\
Internal Medicine

#### INTENDED USERS

Physicians

#### GUIDELINE OBJECTIVE(S)

-   To evaluate the literature and make recommendations about the
    management of carbon monoxide (CO) poisoning

-   To address the following critical questions:

    1.  Should hyperbaric oxygen (HBO~2~) therapy be used for the
        treatment of patients with acute CO poisoning

    2.  Can clinical or laboratory criteria identify CO-poisoned
        patients who are most or least likely to benefit from this
        therapy?

#### TARGET POPULATION

Adult patients presenting to the emergency department with acute carbon
monoxide (CO) poisoning

**Note**: This clinical policy is not intended for application to a
pediatric population, for fetal exposures, for patients with chronic CO
poisoning, or patients with delayed presentations (greater than 24 hours
after cessation of exposure) of CO poisoning.

#### INTERVENTIONS AND PRACTICES CONSIDERED

Use of hyperbaric oxygen (HBO~2~) therapy

#### MAJOR OUTCOMES CONSIDERED

**Treatment Outcomes**

-   Neurologic sequelae

-   Group mean neuropsychological tests scores

-   Symptoms of carbon monoxide (CO) poisoning

-   Cognitive sequelae

-   Physical and emotional health

-   Interference with activities of daily living

-   Survival to hospital discharge

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Hand-searches of Published Literature (Secondary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

MEDLINE searches for articles published between January 1980 and January
2006 were performed using a combination of key words and their
variations, including \"carbon monoxide poisoning,\" and \"hyperbaric
oxygen.\" Searches were limited to English-language sources. Additional
articles were reviewed from the bibliography of articles cited and from
published textbooks and review articles. Subcommittee members also
supplied articles from their own files.

#### NUMBER OF SOURCE DOCUMENTS

Four articles

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

**Strength of Evidence**

**[Literature Classification Schema\^]{.underline}**

  ---------------------------------------------------------------------------
  **Design/\   **Therapy\***        **Diagnosis\*\***   **Prognosis\*\*\***
  Class**                                               
  ------------ -------------------- ------------------- ---------------------
  1            Randomized,          Prospective cohort  Population
               controlled trial or  using a criterion   prospective cohort
               meta-analyses of     standard            
               randomized trials                        

  2            Nonrandomized trial  Retrospective       Retrospective cohort\
                                    observational       Case control

  3            Case series\         Case series\        Case series\
               Case report\         Case report\        Case report\
               Other (e.g.,         Other (e.g.,        Other (e.g.,
               consensus, review)   consensus, review)  consensus, review)
  ---------------------------------------------------------------------------

\^ Some designs (e.g., surveys) will not fit this schema and should be
assessed individually.

\*Objective is to measure therapeutic efficacy comparing
[\>]{.underline}2 interventions.

\*\*Objective is to determine the sensitivity and specificity of
diagnostic tests.

\*\*\* Objective is to predict outcome including mortality and
morbidity.

**Approach to Downgrading Strength of Evidence\***

  ---------------------------------------------------------------------------
  ** **                      **Design/Class**                  
  -------------------------- ------------------ -------------- --------------
  **Downgrading**            **1**              **2**          **3**

  None                       I                  II             III

  1 level                    II                 III            X

  2 levels                   III                X              X

  Fatally flawed             X                  X              X
  ---------------------------------------------------------------------------

\*See \"Description of Methods Used to Analyze the Evidence\" field for
more information.

#### METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review with Evidence Tables

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

All articles used in the formulation of this clinical policy were graded
by at least 2 subcommittee members for strength of evidence and
classified by the subcommittee members into 3 classes of evidence on the
basis of the design of the study, with design 1 representing the
strongest evidence and design 3 representing the weakest evidence for
therapeutic, diagnostic, and prognostic clinical reports, respectively
(see Appendix A in the original guideline document and the \"Rating
Scheme for the Strength of the Evidence\" field). Articles were then
graded on 6 dimensions thought to be most relevant to the development of
a clinical guideline: blinded versus nonblinded outcome assessment,
blinded or randomized allocation, direct or indirect outcome measures
(reliability and validity), biases (e.g., selection, detection,
transfer), external validity (i.e., generalizability), and sufficient
sample size. Articles received a final grade (Class I, II, III) on the
basis of a predetermined formula taking into account design and quality
of study (see Appendix B in the original guideline document and the
\"Rating Scheme for the Strength of the Evidence\" field). Articles with
fatal flaws were given an \"X\" grade and not used in formulating
recommendations in this policy. Evidence grading was done with respect
to the specific data being extracted, and the specific critical question
being reviewed. Thus, the level of evidence for any one study may vary
according to the question, and it is possible for a single article to
receive different levels of grading as different critical questions are
answered. Question-specific level of evidence grading may be found in
the Evidentiary Table included at the end of the original guideline
document.

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

This policy is a product of the American College of Emergency Physicians
(ACEP) clinical policy development process, including expert review, and
is based on the existing literature; where literature was not available,
consensus of emergency physicians, toxicologists, and physicians with
hyperbaric medicine expertise was used.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Clinical findings and strength of recommendations regarding patient
management were made according to the following criteria:

**Strength of Recommendations**

**Level A recommendations**. Generally accepted principles for patient
management that reflect a high degree of clinical certainty (i.e., based
on strength of evidence Class I or overwhelming evidence from strength
of evidence Class II studies that directly address all of the issues)

**Level B recommendations**. Recommendations for patient management that
may identify a particular strategy or range of management strategies
that reflect moderate clinical certainty (i.e., based on strength of
evidence Class II studies that directly address the issue, decision
analysis that directly addresses the issue, or strong consensus of
strength of evidence Class III studies)

**Level C recommendations**. Other strategies for patient management
that are based on preliminary, inconclusive, or conflicting evidence,
or, in the absence of any published literature, based on panel consensus

There are certain circumstances in which the recommendations stemming
from a body of evidence should not be rated as highly as the individual
studies on which they are based. Factors such as heterogeneity of
results, uncertainty about effect magnitude and consequences, strength
of prior beliefs, and publication bias, among others, might lead to such
a downgrading of recommendations.

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

External Peer Review\
Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Expert review comments were received from individual physicians with
topic expertise and from individual members of the American Academy of
Clinical Toxicology, American College of Medical Toxicology, Divers
Alert Network, and Undersea and Hyperbaric Medical Society. Expert
review comments were also received from members of American College of
Emergency Physician\'s (ACEP\'s) Toxicology Section and Hyperbaric
Medicine Section. Their responses were used to further refine and
enhance this policy.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

Definitions for the strength of evidence (Class I-III) and strength of
recommendations (Level A-C) are repeated at the end of the Major
Recommendations.

**Should hyperbaric oxygen (HBO~2~) therapy be used for the treatment of
patients with acute carbon monoxide (CO) poisoning?**

**Can clinical or laboratory criteria identify CO-poisoned patients who
are most or least likely to benefit from this therapy?**

***Level A recommendations***. None specified.

***Level B recommendations***. None specified.

***Level C recommendations***.

1.  HBO~2~ is a therapeutic option for CO-poisoned patients; however,
    its use cannot be mandated.

2.  No clinical variables, including carboxyhemoglobin levels, identify
    a subgroup of CO-poisoned patients for whom HBO~2~ is most likely to
    provide benefit or cause harm.

[**Definitions**:]{.underline}

**Strength of Evidence**

**[Literature Classification Schema\^]{.underline}**

  ---------------------------------------------------------------------------
  **Design/\   **Therapy\***        **Diagnosis\*\***   **Prognosis\*\*\***
  Class**                                               
  ------------ -------------------- ------------------- ---------------------
  1            Randomized,          Prospective cohort  Population
               controlled trial or  using a criterion   prospective cohort
               meta-analyses of     standard            
               randomized trials                        

  2            Nonrandomized trial  Retrospective       Retrospective cohort\
                                    observational       Case control

  3            Case series\         Case series\        Case series\
               Case report\         Case report\        Case report\
               Other (e.g.,         Other (e.g.,        Other (e.g.,
               consensus, review)   consensus, review)  consensus, review)
  ---------------------------------------------------------------------------

\^ Some designs (e.g., surveys) will not fit this schema and should be
assessed individually.

\*Objective is to measure therapeutic efficacy comparing
[\>]{.underline}2 interventions.

\*\*Objective is to determine the sensitivity and specificity of
diagnostic tests.

\*\*\* Objective is to predict outcome including mortality and
morbidity.

**Approach to Downgrading Strength of Evidence\***

  ---------------------------------------------------------------------------
  ** **                      **Design/Class**                  
  -------------------------- ------------------ -------------- --------------
  **Downgrading**            **1**              **2**          **3**

  None                       I                  II             III

  1 level                    II                 III            X

  2 levels                   III                X              X

  Fatally flawed             X                  X              X
  ---------------------------------------------------------------------------

\*See \"Description of Methods Used to Analyze the Evidence\" field for
more information.

**Strength of Recommendations**

**Level A recommendations**. Generally accepted principles for patient
management that reflect a high degree of clinical certainty (i.e., based
on strength of evidence Class I or overwhelming evidence from strength
of evidence Class II studies that directly address all of the issues)

**Level B recommendations**. Recommendations for patient management that
may identify a particular strategy or range of management strategies
that reflect moderate clinical certainty (i.e., based on strength of
evidence Class II studies that directly address the issue, decision
analysis that directly addresses the issue, or strong consensus of
strength of evidence Class III studies)

**Level C recommendations**. Other strategies for patient management
that are based on preliminary, inconclusive, or conflicting evidence,
or, in the absence of any published literature, based on panel consensus

There are certain circumstances in which the recommendations stemming
from a body of evidence should not be rated as highly as the individual
studies on which they are based. Factors such as heterogeneity of
results, uncertainty about effect magnitude and consequences, strength
of prior beliefs, and publication bias, among others, might lead to such
a downgrading of recommendations.

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is identified and graded for each
recommendation (see \"Major Recommendations\" field).

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Appropriate management of adult patients presenting to the emergency
department with acute carbon monoxide poisoning

#### POTENTIAL HARMS

Not stated

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

Recommendations offered in this policy are not intended to represent the
only diagnostic and management options that the emergency physician
should consider. The American College of Emergency Physicians (ACEP)
clearly recognizes the importance of the individual clinician\'s
judgment. Rather, this clinical policy defines for the physician those
strategies for which medical literature exists to provide support for
answers to the crucial questions addressed in this policy.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better

#### IOM DOMAIN

Effectiveness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Wolf SJ, Lavonas EJ, Sloan EP, Jagoda AS, American College of Emergency
Physicians. Clinical policy: critical issues in the management of adult
patients presenting to the emergency department with acute carbon
monoxide poisoning. Ann Emerg Med 2008 Feb;51(2):138-52. \[71
references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=18206551)

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2008 Feb

#### GUIDELINE DEVELOPER(S)

American College of Emergency Physicians - Medical Specialty Society

#### SOURCE(S) OF FUNDING

American College of Emergency Physicians

#### GUIDELINE COMMITTEE

Clinical Policies Subcommittee (Writing Committee)

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Clinical Policies Subcommittee (Writing Committee)*: Stephen J. Wolf,
MD (Chair); Eric J. Lavonas, MD; Edward P. Sloan, MD, MPH; Andy S.
Jagoda, MD

*American College of Emergency Physicians Clinical Policies Committee
(Oversight Committee)*: Andy S. Jagoda, MD, (Chair 2003-2006, Co-Chair
2006-2007); Wyatt W. Decker, MD (Co-Chair 2006-2007); Deborah B.
Diercks, MD; Jonathan A. Edlow, MD; Francis M. Fesmire, MD; Steven A.
Godwin, MD; Sigrid A. Hahn, MD; John M. Howell, MD; J. Stephen Huff, MD;
Thomas W. Lukens, MD, PhD; Donna L. Mason, RN, MS, CEN (ENA
Representative 2004-2006); Michael Moon, RN, CNS, MSN, CEN (ENA
Representative 2004); Anthony M. Napoli, MD (EMRA Representative
2004-2006); Devorah Nazarian, MD; Jim Richmann, RN, BS, MA(c), CEN (ENA
Representative 2006-2007); Scott M. Silvers, MD; Edward P. Sloan, MD,
MPH; Molly E. W. Thiessen (EMRA Representative 2006-2007); Robert L.
Wears, MD, MS (Methodologist); Stephen J. Wolf, MD; Cherri D. Hobgood,
MD (Board Liaison 2004-2006); David C. Seaberg, MD, CPE (Board Liaison
2006-2007); Rhonda R. Whitson, RHIA, Staff Liaison, Clinical Policies
Committee and Subcommittees

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Relevant industry relationships for the following carbon monoxide
poisoning subcommittee members are as follows: Dr. Lavonas was the
Medical Director of Hyperbaric Medicine at Carolinas Medical Center,
Charlotte, NC during the development of this clinical policy.

Relevant industry relationships are those relationships with companies
associated with products or services that significantly impact the
specific aspect of disease addressed in the critical question.

#### ENDORSER(S)

Emergency Nurses Association - Medical Specialty Society

#### GUIDELINE STATUS

This is the current release of the guideline.

#### GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) from the
[American College of Emergency Physicians Web
site](http://www.acep.org/workarea/downloadasset.aspx?id=33724).

Print copies: Available from the American College of Emergency
Physicians, P.O. Box 619911, Dallas, TX 75261-9911, or call toll free:
(800) 798-1822.

#### AVAILABILITY OF COMPANION DOCUMENTS

None available

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI Institute on April 16, 2008. The
information was verified by the guideline developer on May 16, 2008.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to
the guideline developer\'s copyright restrictions. For more information,
please refer to the [American College of Emergency Physicians Web
site](http://www.acep.org/aboutus.aspx?id=30296).

### DISCLAIMER

#### NGC DISCLAIMER

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/3/2008