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tox.co-poisoning.core.v1PRODUCTION
tox.co-poisoning.core.v1

Carbon monoxide poisoning

toxicologyacuteadultpediatricpregnancy
Hard-required inputs
0 / 10
Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Confirm CO exposure scenario; flag cyanide co-exposure in fire victims (AACT 2023)

Inputs
2
Actions
0
Advance rule
Set
Advance when

Exposure context documented

Patient inputs (12)

Pediatric thresholds for HBO; older adults higher cardiac risk (AACT 2023)

Closed-space exposure + duration informs severity (AACT 2023)

HBO indicated at COHb >15% in pregnancy (fetal Hb affinity) (AACT 2023)

Any LOC is a HBO indication regardless of COHb level (AACT 2023)

Co-exposure to cyanide → empiric hydroxocobalamin trigger (AACT 2023)

Pulse oximetry is FALSELY normal in CO — must use CO-oximetry (AACT 2023)

COHb on CO-oximetry; severity + HBO threshold (AACT 2023)

Acidosis flags severe tissue hypoxia (AACT 2023)

Elevated lactate in CO + raises cyanide co-exposure suspicion (AACT 2023)

Ischemia is a HBO indication; baseline rhythm (AACT 2023)

CO-induced myocardial injury — drives cardiology consult + monitoring (AACT 2023)

Persistent neuro signs after 100% O2 → HBO consideration (AACT 2023)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (6)

6 need judgement
  • informationallife_threateningfire_smoke_inhalation_lactate_high
    Fire / smoke inhalation + lactate >10 mmol/L unexplained (AACT 2023)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningcardiac_arrest_post_co
    Cardiac arrest in CO context (with or without ROSC) (AACT 2023)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverecohb_over_25_or_pregnancy_over_15 (AACT 2023)
    COHb >25% (>15% in pregnancy) (AACT 2023)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereloc_during_co_exposure (AACT 2023)
    Any loss of consciousness during CO exposure (regardless of COHb on arrival) (AACT 2023)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresevere_acidosis_or_end_organ_damage
    pH <7.2 OR ECG ischemia OR positive troponin OR persistent neuro deficit after 4-6 h normobaric O2 (AACT 2023)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepregnancy_with_co
    Pregnancy + any CO exposure with symptoms OR COHb ≥15-20% (AACT 2023)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

RISK_STRATIFICATIONoptionalDrives risk stratification
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Recommended regimen

CO poisoning — oxygen elimination + HBO indication evaluation (AACT 2023)
axis: co_poisoning_oxygen_and_HBOstep 1 - Step 1 — 100% normobaric O2 immediately
Selected step "Step 1 — 100% normobaric O2 immediately" — Any suspected or confirmed CO exposure
  • oxygen_100_percent
    first line
    oxygen_therapy
    100% via tight non-rebreather mask 15 L/min, OR ETT with FiO2 1.0 • inhaled • continuous until COHb <5% AND symptoms resolved
    triggers: suspected_CO_exposure, COHb_elevated_any_level
    COHb half-life: 5 hours room air → 60-90 min on 100% O2 → 20-30 min in HBO at 2.5-3 atm. NRB delivers ~70-90% FiO2; ETT with FiO2 1.0 is gold standard (AACT 2023)
    rxcui 7806

ed playbook — drug actions (3)

  1. 1. oxygen_100_percent_NRB
    100% via tight NRB mask 15 L/min • inhaled • continuous
    trigger: Any suspected CO exposure (don't wait for COHb) (AACT 2023)
    Reduces COHb half-life from 5 hours to 60-90 min (AACT 2023)
  2. 2. hydroxocobalamin
    5 g IV (70 mg/kg peds) over 15 min • IV • single dose; can repeat once
    trigger: Fire victim + lactate >10 OR cardiac arrest OR refractory acidosis (AACT 2023)
    Empiric cyanide treatment in fire smoke inhalation (AACT 2023)
  3. 3. normal_saline_bolus
    rxcui 7407
    500-1000 mL • IV • PRN
    trigger: Hypotension or rhabdomyolysis (AACT 2023)
    Volume support (AACT 2023)

Auto-drafted A&P note

ed

Subjective

- Possible entry pathways: Smoke / fire / faulty heater / generator exposure (AACT 2023); Altered mental status with possible CO source (AACT 2023); Cluster headache/nausea in shared environment (winter, family) (AACT 2023).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Carbon monoxide poisoning** (tox.co-poisoning.core.v1).
Phenotype framing: Rule out hypoglycemia, stroke, opiate toxicity, sepsis, methemoglobinemia, alternative cause of cluster symptoms (AACT 2023)
Scope: Confirm CO exposure scenario; flag cyanide co-exposure in fire victims (AACT 2023)

No severity triggers fired against current inputs.

Plan

Regimen axis: **CO poisoning — oxygen elimination + HBO indication evaluation (AACT 2023)** — step "Step 1 — 100% normobaric O2 immediately".
1. oxygen_100_percent 100% via tight non-rebreather mask 15 L/min, OR ETT with FiO2 1.0 inhaled continuous until COHb <5% AND symptoms resolved (oxygen_therapy, first line) — COHb half-life: 5 hours room air → 60-90 min on 100% O2 → 20-30 min in HBO at 2.5-3 atm. NRB delivers ~70-90% FiO2; ETT with FiO2 1.0 is gold standard (AACT 2023)

Setting playbook (ed) — Confirm CO with CO-oximetry, immediately deliver 100% O2, evaluate HBO eligibility, screen for cyanide co-exposure in fire (AACT 2023)
2. oxygen_100_percent_NRB 100% via tight NRB mask 15 L/min inhaled continuous — Any suspected CO exposure (don't wait for COHb) (AACT 2023) (Reduces COHb half-life from 5 hours to 60-90 min (AACT 2023))
3. hydroxocobalamin 5 g IV (70 mg/kg peds) over 15 min IV single dose; can repeat once — Fire victim + lactate >10 OR cardiac arrest OR refractory acidosis (AACT 2023) (Empiric cyanide treatment in fire smoke inhalation (AACT 2023))
4. normal_saline_bolus 500-1000 mL IV PRN — Hypotension or rhabdomyolysis (AACT 2023) (Volume support (AACT 2023))

Non-pharmacologic actions:
- Remove from exposure source (unsafe rescue if not done — protect responders) (AACT 2023)
- Intubation if AMS / hypoxia / coma — increases FiO2 to 1.0 (AACT 2023)
- Continuous cardiac monitoring (AACT 2023)
- Notify HBO chamber early — transfer logistics often the rate-limiter (AACT 2023)
- Source remediation referral (CO detector education, faulty heater inspection) before discharge (AACT 2023)

AVOID / contraindication checks:
- No_methylene_blue_in_CO_only_methemoglobinemia (AACT 2023)
- HBO_relative_contraindications_pneumothorax_must_decompress_first (AACT 2023)
- Hydroxocobalamin_interferes_with_lab_assays_for_24h_red_urine_normal (AACT 2023)

Monitoring

Regimen monitoring:
- COHb serial q1-2h until under 5 (AACT 2023)
- continuous pulse oximetry NOTE falsely normal in CO (AACT 2023)
- CO-oximetry NOT pulse oximetry (AACT 2023)
- troponin serial q4-6h first 24h (AACT 2023)
- ECG continuous (AACT 2023)
- lactate q2h if concurrent cyanide suspected (AACT 2023)
- neurologic exam q1h initially (AACT 2023)
- fetal heart rate if pregnant (AACT 2023)

Setting (ed) monitoring:
- COHb q1-2h until <5% (AACT 2023)
- Troponin q6h × 24 h (AACT 2023)
- Continuous ECG (AACT 2023)
- Neurologic exam q1h (AACT 2023)
- Fetal heart rate if pregnant (AACT 2023)

Follow-up plan: Neurocognitive assessment 1–2 months for delayed neuropsychiatric syndrome; home CO detector education; source remediation; psych if intentional (AACT 2023)
- Close-out criterion: Discharge plan + education + neurocognitive follow-up booked

Monitoring phase: Serial COHb, neuro exam, telemetry, troponin trend, lactate clearance (AACT 2023)

Disposition

Current setting: ed — Confirm CO with CO-oximetry, immediately deliver 100% O2, evaluate HBO eligibility, screen for cyanide co-exposure in fire (AACT 2023)

Disposition criteria:
- Discharge home: COHb <5%, asymptomatic, no HBO criteria, source remediated, follow-up arranged for delayed neuropsychiatric syndrome screening (AACT 2023)
- Admit ward: persistent mild symptoms, comorbid cardiac concern, social barrier to remediation (AACT 2023)
- Admit ICU: any HBO criterion, any cardiac/neurologic end-organ involvement (AACT 2023)
- HBO chamber transfer: any HBO indication; arrange before COHb drops on NRB (kinetic argument) (AACT 2023)

Escalation triggers (move to higher acuity):
- COHb >25% (>15% pregnant) → HBO referral (AACT 2023)
- Any LOC during exposure → HBO referral (AACT 2023)
- Persistent neuro deficit after 4-6 h NRB → HBO referral (AACT 2023)
- Severe acidosis pH <7.2 → HBO + ICU (AACT 2023)
- ECG ischemia or troponin+ → HBO + cards consult + ICU (AACT 2023)
- Pregnancy with COHb >15-20% OR fetal distress → HBO + MFM consult (AACT 2023)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Fire / smoke inhalation + lactate >10 mmol/L unexplained (AACT 2023)
- [LIFE_THREATENING] Cardiac arrest in CO context (with or without ROSC) (AACT 2023)
- [SEVERE] COHb >25% (>15% in pregnancy) (AACT 2023)

Citations

- Pending — manifest is scaffold-level. Anchors: Weaver NEJM 2002 (HBO trial); UHMS HBO indications; ACEP CO clinical policy [PMID:12362006](https://pubmed.ncbi.nlm.nih.gov/12362006/)

Last reconciled with current guidelines: 2026-04-13.
References
  • Pending — manifest is scaffold-level. Anchors: Weaver NEJM 2002 (HBO trial); UHMS HBO indications; ACEP CO clinical policy — PMID:12362006