The question was:

No need for words.

The answer is:

A 50 year-old woman presented in coma following removal from a house fire. She was intubated at the scene and transported via helicopter to our facility. Admission carboxyhemoglobin concentration was 15.7%. A head CT obtained in the emergency center showed bilateral hypodensities in the globus pallidus. These lesions have been regarded as a pathological hallmark of CO poisoning, but they have been seen in non-CO hypoxic/ischemic injury as well.

Figure 1

Figure 1: Head CT showing bilateral hypodensities in the globus pallidus

The patient underwent emergent hyperbaric oxygen therapy without a change in her neurological condition. She was admitted to the ICU and a bronchoscopy was performed and demonstrated excessive amounts of soot throughout all airways examined. Some erythema was noted as well. See chest x-ray and photograph below. Despite aggressive positive pressure ventilation she expired the day following admission from progressive hypoxemia.

Figure 2

Figure 2: Chest X-Ray

Figure 3

Figure 3: Trachea in endoscopy

Figure 4

Figure 4: Carina in endoscopy

Figure 5

Figure 5: Small airways in endoscopy

Suggested Literature:

Tomson LF, et al. Management of the moribund carbon monoxide victim. Archives of Emergency

Medicine 1992;9:208-213.

Starkstein SE, et al. Psychic Akinesia following bilateral pallidal lesions. International Journal of

Psychiatry in Medicine. 1989;19:155-164.

Please e-mail any comments to : jnates@anes1.med.uth.tmc.edu