CME INDIA Case Presentation by Dr. R. K. Gupta, MD (Medicine), Yamuna Nagar, Haryana.

CME INDIA Case Study

ECG just after admission

How Presented?

  • 15 yrs. male presented in an unconscious state in the bath room while taking Bath
  • BP 100 /70
  • HR 125 /min
  • Spo2 85%
  • Deeply unconscious
  • B/L Pupils dilated & non reacting

ECG after 4 hrs

  • Patient fully conscious.
  • All Biochemical parameters normal, including electrolytes.

Can you guess what happened?

CME INDIA Discussion

Dr. D. P. Khaitan, Ahmedabad:

1st ECG shows:

  • Sinus Tachycardia
  • Global ST depression with ST elevation in aVR, -pointing towards subendocardial ischaemia (would be worth to mention here that in ischaemia culprit artery could not be localised)
  • QT interval is prolonged – QT interval is more than of half of the corresponding RR interval, see the precordial leads.
  • The amplitude of T wave, specially is less compared to smarter T on the ECG taken after the recovery – This is also the indicator of repolarization abnormality.
  • One remarkable point– The transition zone on 1st ECG is at V2 compared to 2nd ECG where this is at V4 – pointing towards unhealthy LV on first ECG wherein heathier LV on the second ECG.
  • There is no widening of QRS-T angle and no Poor R wave progression.

2nd ECG:

The gloomy picture of subendocardial ischaemia is kicked out – ECG tracing are within normal limits.

Two points are to be noted on this ECG:

  1. The smart T waves are smiling – see the precordial leads.
  2. QTc interval is within normal limits.

All these points indicate the smarter recovery with the institution of proper and quicker therapy.

Dr. Murali Mohan, Pulmonologist, Bengaluru:

  • Gas geyser- CO poisoning?

Dr. Prabhat Agarwal, Prof of Medicine, Agra:

  • My one relative had same episode almost 6-7 years ago.

Dr. Payal Prajapati, Surat:

  • Does patient was exposed to gas geyser in bathroom?
  • It can cause carbon monoxide poisoning due to incomplete burning of Gas.

Dr. Anand Malani, MD, Consultant Physician, Sangli, Maharashtra:

  • I would like to have ABG.
  • Look at Lactate and Carboxyhaemoglobin.
  • Mostly carbon Monoxide poisoning due to gas geyser.
  • ECG changes due to tissue hypoxia.
  • It’s usually a Sunday morning event especially in females or people with very long hair.
  • A leisurely hair wash.
  • Gas geyser inside the bathroom with no exhaust fan.
  • Many times, get treated as seizures and put on anti-epileptics.
  • ABG is diagnostic.
  • Need to look at co oximetry – Usually overlooked.
  • Oxygen saturation can be normal many times.

Dr. Bhavesh Shashikant Shah, Kapadwanj, Dist. Kheda, Gujarat:

  • I V Naloxone is useful in respiratory depression; I have treated 5 patients with O2 with oxygen concentrator.

Dr. Ashish Ranjan Jha, DM Card, Ranchi:

  • Now a days u will find similar kind of pt. found unconscious after Angithi burning in closed room lead to co poisoning.
  • Last yr. I found 65yr pt. unconscious with dynamic ECG change, CT Brain – lacunar infarct and Trop T-positive.

Dr. R. K. Gupta, Yamuna Nagar:

  • Yes, Gas Geyser installed in the bath room.
  • Father took bath first.
  • Immediately this patient went to take bath. The CO gas was full inside.
  • He inhaled full dose of CO.
  • Probably Ill ventilated.
  • I think only high flow Oxygen is treatment of choice.
  • Every year we get few patients in the winter season. We have been treating such patients every in winters for the last about 10-12 years.

Dr. Abhay, Bilaspur:

  • Gas geyser syndrome is also a known cause for early onset parkinsonism, it also triggers epilepsy in adults. MRI is a useful diagnostic tool. My own son had it once, since then I am advising everyone including my Pts to remove gas geyser.

Dr. Prakash Wali, Kolhapur:

  • CO poisoning due to gas geyser in bathroom.

Dr. Ajay Mandal, WB:

  • Sudden loss of consciousness in the bathroom can be due to a number of causes like seizure, head injury, stroke involving subarachnoid haemorrhage, cardiac events, syncopal episodes to various poisonings and toxin exposures, in this era new possible cause-carbon monoxide poisoning.
  • In this situation loss of consciousness probably be associated with the exposure to toxic gases, predominantly carbon monoxide, released during the combustion of LPG in these gas geysers.

Dr. N. K. Singh:

  • Gasoline heaters require an intake source of fresh air, and exhaust combusted gasses. Due to the toxicity of the latter – carbon monoxide in particular – it is crucial to prevent spent gasses from entering a vehicle’s interior.
  • Other combustion by-products include soot, sulphur dioxide, carbon dioxide, and some carbon monoxide.
  • The gas geyser depletes the oxygen available in the closed space and starts giving out CO which gets inside the body and causes poisoning which can further cause brains damage, cardiac arrest and multiple organ failure.

Final Diagnosis

  • Gas Geyser Poisoning (Most likely due to CO).
  • Treated with high flow Oxygen.
  • After 2 hrs Oxygen saturation 98% and Patient became fully conscious and discharged in the evening.
  • The diagnosis was so clear that when patient came deeply Unconscious, author just started Oxygen High Flow without any delay.
  • Simple Routine Biochemistry was done which was normal.
  • Author did not ask for ABG.

CME INDIA Learning Points

  • Carbon monoxide (CO) is a colorless, odorless gas produced through the incomplete combustion of carbon-containing fossil fuels. Despite lacking irritative qualities, CO poisoning stands as a significant global concern for unintentional poisonings. In winter, incidents of accidental CO poisoning are often linked to the incomplete combustion of coal.
  • This report highlights the case of a young patient who suffered hypoxic brain injury due to CO poisoning while using a gas geyser in the bathroom.
  • The diagnosis of CO poisoning was established through a comprehensive assessment, including the patient’s history and vital signs, as patients improved fast, no blood gas analysis, and MRI scan done. The patient exhibited positive recovery outcomes following high-flow normobaric oxygen therapy.
  • This case emphasizes the importance of maintaining a high index of suspicion for CO toxicity, especially in scenarios involving the use of gas geysers. Early recognition of symptoms by emergency physicians, coupled with thorough history-taking, plays a crucial role in achieving a clinical diagnosis of CO poisoning. Such timely interventions are pivotal for effective management and the prevention of adverse outcomes associated with CO exposure.
  • Liquefied Petroleum Gas (LPG) geysers are widely employed in India to heat water, especially in areas facing persistent electrical supply issues. While this simple and cost-effective device is a daily essential in many Indian households, its use may be associated with potentially disabling neurological events.
  • The sudden loss of consciousness in a bathroom can stem from various causes, including seizures, head injuries, strokes, cardiac events, syncopal episodes, as well as exposure to different poisons and toxins.
  • Experiencing such an episode is profoundly distressing and may lead to long-lasting or even life-threatening consequences. The widespread use of LPG geysers underscores the importance of awareness and precautions to mitigate the risks associated with their usage.

Why is it used?

  • Gas geysers have gained popularity as a cost-effective and user-friendly method for heating water in homes, particularly in India. Operating on liquid petroleum gas, the combustion process produces carbon monoxide (CO), hydrocarbons, and nitrogen oxides.
  • Notably, CO has an affinity for hemoglobin that is 200-250 times greater than that of oxygen. Elevated concentrations of CO can lead to fatal outcomes by forming carboxyhemoglobin (COHb), which impairs the blood’s capacity to carry oxygen. Normal COHb levels are below 5% in smokers and less than 2% in non-smokers, with heavy smokers potentially reaching levels as high as 10-15%.
  • Accidental CO poisoning in India, particularly during the winter season, has been reported, often linked to incomplete combustion of coal. CO poisoning can manifest with symptoms resembling common ailments, potentially leading to overlooked cases and fatalities. It is reported as the most frequent cause of fatal poisoning, with an incidence rate of 31%.
  •  Instances of surviving CO intoxication from gas geysers in India are relatively scarce.
  • Symptoms in patients can range from headaches, nausea, dizziness, and confusion at COHb levels of 10-30%, progressing to unconsciousness at levels of 30-50%. Levels exceeding 50% may result in death. CO poisoning is associated with serious complications such as myocardial infarction, life-threatening dysrhythmias, and cardiac arrest.
  • The acute mortality in CO poisoning is often attributed to ventricular dysrhythmias, likely induced by accompanying hypoxia. It underscores the importance of recognizing and addressing the potential dangers associated with gas geysers to prevent severe health consequences.
  • The Gas Geyser Syndrome has been observed in individuals spending extended periods in inadequately ventilated bathrooms, stemming from carbon monoxide poisoning due to emissions from gas geysers installed in these spaces.

Why oxygen depletes?

  • The installation of gas geysers, specifically LPG geysers, in bathrooms coupled with insufficient ventilation leads to oxygen depletion. Consequently, carbon monoxide is produced instead of carbon dioxide, resulting in hypoxia, seizures, and unconsciousness.
  • To mitigate the risks, experts recommend turning off the gas heater before entering a bath and ensuring proper ventilation in the bathroom.

Twenty-six cases of predominantly three distinct prototypes (Ref-5)

The three distinct prototypes noted:

  1. Seizure like episodes seen in 11 patients,
  2. Carbon monoxide intoxication in 13 patients with near cardiac arrest in 4, and
  3. A precipitating factor for epilepsy as seen in 2 cases.

CME INDIA Tail-Piece

Gas geysers come in three main types based on the type of flue (vent) system used:

  1. Room Sealed (Balanced Flue):
    • This type is the preferred choice for new installations.
    • It utilizes a balanced flue system where fresh air for combustion and combustion products are taken from and discharged directly to the outside air.
    • This design prevents the contamination of room air.
  2. External Flue:
    • The external flue system involves the venting of combustion products to the external environment.
  3. Flueless:
    • Flueless gas water heaters are considered potentially hazardous, especially when used to supply hot water to a bath or shower.
    • In this type, the products of combustion, including carbon monoxide (CO), discharge directly into the room, and there is a risk of dangerous levels building up.
    • In some regions like Hong Kong, flueless gas water heaters are now considered obsolete, and regulations may mandate warning labels even for flueless gas water heaters used for kitchen sinks.
    • The United Kingdom’s gas safety regulations have specific ventilation criteria for flueless gas appliances.
    • Canada recommends against the use of flueless gas appliances due to potential serious health and safety risks to occupants.

Gas installation Manual Rules

Do not operate this appliance before reading the instruction (user guide) booklet.
Do not place articles on or against this appliance.
Do not store chemicals or flammable materials, or spray aerosols near this appliance.
Do not operate with panels, covers or guards removed from this appliance.
Do not operate in a bathroom or bedroom.
Do not operate in an unventilated room.
Do not operate in a room with volume less than (a value dependent on heater capacity).
Emissions from this space heater may affect persons susceptible to respiratory problems.

Quick Take-Aways

Why the increasing domestic use of gas geysers for hot water supply in bathrooms and kitchens?

  • It is attributed to their cost-effective initial installation and independence from electricity. However, the use of LPG gas geysers can pose serious hazards and, in some cases, fatal consequences if not installed and operated under recommended conditions.
  • Incomplete combustion of LPG, often resulting from insufficient ventilation, leads to the accumulation of potentially harmful gases, primarily carbon monoxide and nitrous oxide. Acute carbon monoxide poisoning is characterized by clinical features such as headaches, dizziness, and confusion. Prolonged exposure to elevated levels of carbon monoxide can escalate to more severe outcomes, including coma or seizures.
  • This underscores the critical importance of proper installation and ventilation to mitigate the risks associated with gas geyser usage, emphasizing the need for user awareness and adherence to safety guidelines.

References:

  1. Mohankumar TS, Kanchan T, Pinakini KS, Menezes RG, Singh M, Sirohi P, Anwar N. Gas geyser–a cause of fatal domestic carbon monoxide poisoning. J Forensic Leg Med. 2012 Nov;19(8):490-3. doi: 10.1016/j.jflm.2012.02.025. Epub 2012 Mar 8. PMID: 23084315.
  2. Jaiswal S, Batra A, Verma A, Haldar M, Sheikh WR. Carbon Monoxide Poisoning Secondary to Gas Geyser. Indian J Case Reports. 2019;5(5):423-425
  3. Sharma S, Gupta R, Paul BS, Puri S, Garg S. Accidental carbon monoxide poisoning in our homes. Indian J Crit Care Med. 2009; 13:169-70.
  4. Wolf SJ, Maloney GE, Shih RD, et al. Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department with Acute Carbon Monoxide Poisoning. Ann Emerg Med. 2017;69:98-107.
  5. Correia P, Agrawal C, Ranjan R. Gas geyser syndrome: An important preventable cause of disabling neurological events. Ann Indian Acad Neurol. 2013 Apr;16(2):245-8. doi: 10.4103/0972-2327.112482. PMID: 23956574; PMCID: PMC3724084.
  6. 8. DNR (Department of Natural Resources Canada) Office of energy efficiency.  Availablefrom: http://oee.nrcan.gc.ca/english/r2000_standard_mechsys.cfm? PrintView=N&Text=N .
  7. Know more about gas safety. Domestic Gas Appliance Safety. [Available from: www.ab.ust.hk/hseo/pdf/gass.PDF .
  8. The health effects of unflued gas heater use in Australia.  Available from: www.health.gov.au:en health. (PDF 583kb)


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