If smoke inhalation, good pulmonary toilet is very important
NEVER use steroids in smoke inhalation injury; intubate early if concern for obstructing edema
O2 100% by NRB or ETT
Provide O2 until COhemoglobin value <10%
Early PEEP prevents progressive atelectasis and improves O2 diffusion
In general, COhemoglobin levels fall rapidly to < 10% within 30 min of 100% O2
Maintain 100% O2 for additional 2-3 hrs after < 10%, since anaerobic Cometabolism is occuring due to cytochrome oxidase poisoning
Anaerobic metabolism universally seen with COhemoglobin > 40%
Monitor for return of aerobic metabolism with normal serum bicarbonate levels
Consider other combustion products such as Cyanide
Provide O2 until COhemoglobin value <10%
Early PEEP prevents progressive atelectasis and improves O2 diffusion
In general, COhemoglobin levels fall rapidly to < 10% within 30 min of 100% O2
Maintain 100% O2 for additional 2-3 hrs after < 10%, since anaerobic Cometabolism is occuring due to cytochrome oxidase poisoning
Anaerobic metabolism universally seen with COhemoglobin > 40%
Monitor for return of aerobic metabolism with normal serum bicarbonate levels
Anaerobic metabolism universally seen with COhemoglobin > 40%
Monitor for return of aerobic metabolism with normal serum bicarbonate levels
Decision to initiate HBO should be made in consultation with a hyperbaric specialist
There is controversy regarding benefit
Three HBO treatments within 24hrs shown to reduce risk of cognitive sequelae 6 weeks and 12 months after CO poisoning
However, another study showed no benefit and suggested worse outcomes in HBO therapy
Patient must be stable prior to transport since response to acute medical conditions while undergoing hyperbaric therapy in a chamber is difficult.
Indications (generally accepted guidelines): 
Syncope
Confusion/altered mental status
Seizure
Coma
Focal neuro deficit
Pregnancy with Cohemoglobin level >15%
Fetal Hb tends to bind more CO
Blood level >25%
Acute myocardial ischemia
Prolonged CO exposure with minor clinical findings (“soaking”)
Three HBO treatments within 24hrs shown to reduce risk of cognitive sequelae 6 weeks and 12 months after CO poisoning
However, another study showed no benefit and suggested worse outcomes in HBO therapy
Syncope
Confusion/altered mental status
Seizure
Coma
Focal neuro deficit
Pregnancy with Cohemoglobin level >15%
Fetal Hb tends to bind more CO
Blood level >25%
Acute myocardial ischemia
Prolonged CO exposure with minor clinical findings (“soaking”)
Fetal Hb tends to bind more CO
Carbon monoxide toxicity
A "great mimicker" due to the presentation of poisoning being diverse and nonspecific
Oxygen toxicity
Viral syndrome
Chlorate toxicity
Depression
Smoke inhalation injury
Chronic fatigue syndrome