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Misdiagnosis Not your basic acute sinusitis

Misdiagnosis Not your basic acute sinusitis. Mary Thomason March 8, 2006. No Financial Disclosures. Case Presentation. 55 yo female with PMH significant for presumed acute sinusitis in March/April of 2005 requiring 6 weeks of antibiotics who presented with HA and nasal congestion.

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Misdiagnosis Not your basic acute sinusitis

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  1. MisdiagnosisNot your basic acute sinusitis Mary Thomason March 8, 2006

  2. No Financial Disclosures

  3. Case Presentation • 55 yo female with PMH significant for presumed acute sinusitis in March/April of 2005 requiring 6 weeks of antibiotics who presented with HA and nasal congestion. • 12/2/05 at urgent care dx: Acute Sinusitis tx: 2 Z-Paks • 12/6/05 in clinic cc: headache dx:? tx: complete antibiotics and follow up in one week

  4. Case Presentation • 12/16/05 clinic followup cc: headache and nasal congestion dx: persistent URI symptoms tx: nasal steroids and sinus CT scan • 12/19/05 radiology CT scan negative for acute sinusitis or congestion

  5. Case Presentation • 12/30/05 clinic follow up • Dx: Carbon Monoxide (CO) Poisoning

  6. Objectives • Recognize symptoms of CO exposure • Diagnosis of CO exposure • Treatment of CO exposure • Prevention of CO exposure

  7. Physiology • CO diffuses rapidly over the alveolar membrane • Binds reversibly with 200-fold affinity to Hgb • Shifts the oxyhemoglobin dissociation curve

  8. Statistics • Leading cause of accidental poisoning death in the US • Estimated 15,000 treated annually in ED • Approximate 500 deaths annually JAMA vol. 293, no. 10, 3/9/05, 1183-86

  9. CO Sources • Furnaces • Generators • Gas heaters • Motor vehicles (cars, trucks, tractors, boats) • Fires

  10. Exposures • Majority of CO exposures occur in the fall and winter months • 64.3% occur in the home • 18.5% due to faulty furnaces • 9% motor vehicles JAMA vol. 293, no. 10, 3/9/05, 1183-86

  11. CO Exposure After Katrina • 51 cases reported by HBO2 facilities of AL, LA, MS • 46 nonfatal, 5 deaths • The source for all but one of the non-fatal cases was exhaust from a portable generator. MMWR vol. 54, no. 39, 10/7/05, 996-998

  12. Symptoms of Mild Poisoning • Throbbing temporal or frontal HA • Fatigue • Weakness • Lightheadedness • Nausea/Vomiting • Shortness of Breath

  13. Symptoms of Moderate Poisoning • Severe HA • Tachycardia/Tachypnea • Flushing, perspiration • Diminished manual dexterity/prolonged reaction time • Impaired judgment/confusion • Vision changes (darkened, blurred) • Tinnitus

  14. Symptoms of Severe Poisoning • Syncope • Seizures • MI • Dysrhythmias • Respiratory failure/ pulmonary edema • Coma • Death

  15. Delayed Effects • Depression • Dementia/Memory Loss • Psychosis • Peripheral neuropathy • Parkinsonism • Visual impairment • Chorea

  16. Diagnosis of CO poisoning • Have a high clinical suspicion • Determine the COHb level when the pt is first seen and repeat q2-4 hours until pt is asymptomatic or the value is normal. • If symptomatic or COHb greater than 20% monitor with ECG, lytes, CK, UA, ABG to evaluate for sequella Poisindex (accessed feb 2006)

  17. Range of Toxicity • Normal COHb is 1-3% • Cigarette smokers increase their levels by 5% per pack per day (may tolerate up to 10%) • Toxic affects appear at 15-20% • COHb levels above 25% are considered severe • Toxicity however is determined symptomatically (cardiovascular and mental status) NEJM vol. 347, no. 14, 10/3/02, 1054-55

  18. When to Hospitalize • Neurologic signs • Abnormal ECG • Metabolic Acidosis

  19. Treatment • Decontamination –move to fresh air • Administer 100% oxygen (x 6 hours) • Consider hyperbaric oxygen for severely poisoned (coma, seizures, MI) and pregnant patients at 3 atmospheres absolute. NEJM vol. 347, no. 14, 10/3/02, 1057-67

  20. Guideline to prevent CO exposure • Service heating system/water heater yearly • Install a battery-operated CO detector and check the batteries twice yearly • Do not use charcoal grill or camp stove inside the home, garage, or near a window • Do not run vehicle inside garage • Do no use stove or fire place that isn’t vented • Do not heat your home with a gas oven JAMA vol. 293, no. 10, 3/9/05, 1183-86

  21. Summary • Leading cause of accidental poisoning death in the US • Mild symptoms are similar to a viral illness, therefore a high index of suspicion is required • CO poisoning is diagnosed symptomatically, but CO level testing can be helpful • The mainstay of treatment is oxygen therapy • Prevention is the key

  22. Questions?

  23. References • Poisindex • NEJM vol. 347, no. 14, 10/3/02, 1054-55 • NEJM vol. 347, no. 14, 10/3/02, 1057-67 • MMWR vol. 54, no. 39, 10/7/05, 996-998 • JAMA vol. 293, no. 10, 3/9/05, 1183-86 • JAMA vol. 295, no. 4, 1/25/06, 398-402 • American Journal of Emergency Medicine, Vol. 23, 3/23/05, 838-841

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