Clinical Commander

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tox.co-poisoning.core.v1

Carbon monoxide poisoning

toxicologyacuteadultpediatricpregnancyacuteinpatient
Start encounter →Print handoutPRODUCTION

Manifest is a batch-23 scaffold (defineBatch23ScaffoldManifest); evidenceIds is the placeholder ev_co_poisoning_guideline_review_required. Terminology arrays are intentionally empty — manifest does not yet supply ICD-10/SNOMED/LOINC codes; populate before AUTHORED. Package directory carbon-monoxide-poisoning exists but no _design-brief.md, regimen.ts validation, or evidence.ts citations yet checked into dossier. No regimen axes — hydroxocobalamin (Cyanokit), 100% O2, and HBO are clinical staples but no verified RxCUI seeds present. PRODUCTION blockers: full atoms split, evidence PMIDs, terminology codes, RxNav-validated cyanide co-exposure regimen, dedicated tests. Deepened 2026-04-27: regimen ladder (100% O2 → HBO referral) + hydroxocobalamin rescue for fire victims, ED + ICU playbooks, 6 severity triggers (COHb >25, LOC, end-organ damage, pregnancy, lactate >10 with fire, cardiac arrest), siblings vs burn-management and toxic alcohols. RxCUIs for O2 and hydroxocobalamin not in seed data — left undefined per spec rule.

Entry points (4)

  • symptom
    Smoke / fire / faulty heater / generator exposure (AACT 2023)
    co_exposure_history
  • symptom
    Altered mental status with possible CO source (AACT 2023)
    altered_mental_status
  • symptom
    Cluster headache/nausea in shared environment (winter, family) (AACT 2023)
    unexplained_headache_nausea_cluster
  • lab_abnormality
    Elevated carboxyhemoglobin on CO-oximetry (AACT 2023)
    cohb_elevated

Required inputs (12)

  • agerequired
    demographic • used at CONTEXT
    Pediatric thresholds for HBO; older adults higher cardiac risk (AACT 2023)
  • exposure_source_durationrequired
    history • used at CONTEXT
    Closed-space exposure + duration informs severity (AACT 2023)
  • pregnancy_statusrequired
    history • used at CONTEXT
    HBO indicated at COHb >15% in pregnancy (fetal Hb affinity) (AACT 2023)
  • loss_of_consciousnessrequired
    history • used at CONTEXT
    Any LOC is a HBO indication regardless of COHb level (AACT 2023)
  • fire_smoke_inhalationrequired
    history • used at CONTEXT
    Co-exposure to cyanide → empiric hydroxocobalamin trigger (AACT 2023)
  • spo2required
    vital • used at CONTEXT
    Pulse oximetry is FALSELY normal in CO — must use CO-oximetry (AACT 2023)
  • carboxyhemoglobinrequired
    lab • used at INITIAL_WORKUP
    COHb on CO-oximetry; severity + HBO threshold (AACT 2023)
  • arterial_phrequired
    lab • used at INITIAL_WORKUP
    Acidosis flags severe tissue hypoxia (AACT 2023)
  • lactaterequired
    lab • used at INITIAL_WORKUP
    Elevated lactate in CO + raises cyanide co-exposure suspicion (AACT 2023)
  • troponin
    lab • used at INITIAL_WORKUP
    CO-induced myocardial injury — drives cardiology consult + monitoring (AACT 2023)
  • ecgrequired
    imaging • used at INITIAL_WORKUP
    Ischemia is a HBO indication; baseline rhythm (AACT 2023)
  • persistent_neuro_symptoms
    symptom • used at RISK_STRATIFICATION
    Persistent neuro signs after 100% O2 → HBO consideration (AACT 2023)

12-phase flow (12)

  1. 1FRAME
    Confirm CO exposure scenario; flag cyanide co-exposure in fire victims (AACT 2023)
    inputs: exposure_source_duration, fire_smoke_inhalation
    advance: Exposure context documented
  2. 2ENTRY
    Recognize symptom cluster (headache, nausea, dizziness, AMS) in CO-plausible context (AACT 2023)
    inputs: age
    advance: Trigger present + demographics captured
  3. 3CONTEXT
    Capture pregnancy, comorbidities, LOC history, smoke/fire exposure (AACT 2023)
    inputs: pregnancy_status, loss_of_consciousness, spo2
    advance: Risk modifiers documented (note SpO2 unreliable in CO)
  4. 4RED_FLAGS
    Screen for LOC, seizure, ECG ischemia, severe acidosis, COHb >25% (>15% pregnant), persistent neuro deficit (AACT 2023)
    inputs: arterial_ph, carboxyhemoglobin
    advance: HBO indications evaluated; transfer initiated if any present
  5. 5INITIAL_WORKUP
    CO-oximetry COHb, ABG, lactate, ECG, troponin, glucose, electrolytes; cyanide level if fire (AACT 2023)
    inputs: carboxyhemoglobin, arterial_ph, lactate, ecg
    actions: carbon_monoxide, panel.abg, panel.cardiac
    advance: COHb + acid-base + cardiac biomarkers returned
  6. 6BRANCHING_WORKUP
    If fire exposure → cyanide pathway (empiric hydroxocobalamin/Cyanokit); if cardiac sx → echo + cards consult (AACT 2023)
    inputs: troponin, fire_smoke_inhalation
    advance: Co-exposure pathway selected if applicable
  7. 7DIFFERENTIAL
    Rule out hypoglycemia, stroke, opiate toxicity, sepsis, methemoglobinemia, alternative cause of cluster symptoms (AACT 2023)
    advance: CO confirmed as principal contributor
  8. 8RISK_STRATIFICATION
    Apply HBO criteria (Weaver NEJM 2002): LOC, neuro deficit, COHb >25%, pregnant >15%, ECG ischemia, persistent symptoms after 100% O2
    inputs: carboxyhemoglobin, persistent_neuro_symptoms, ecg
    advance: HBO indication status decided + transfer arranged if indicated
  9. 9TREATMENT
    100% high-flow O2 (NRB or intubation) immediately; HBO if criteria met; supportive care; treat cyanide if suspected (AACT 2023)
    advance: O2 therapy active and HBO transfer arranged or excluded
  10. 10DISPOSITION
    HBO chamber transfer, ICU if severe, observation if mild and asymptomatic after O2; pregnancy MFM consult (AACT 2023)
    advance: Disposition assigned
  11. 11MONITORING
    Serial COHb, neuro exam, telemetry, troponin trend, lactate clearance (AACT 2023)
    inputs: carboxyhemoglobin, troponin
    actions: panel.cardiac, panel.abg
    advance: COHb declining + symptoms resolving
  12. 12FOLLOWUP
    Neurocognitive assessment 1–2 months for delayed neuropsychiatric syndrome; home CO detector education; source remediation; psych if intentional (AACT 2023)
    advance: Discharge plan + education + neurocognitive follow-up booked