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Emergency / Toxicology · Ward Pathways · Locked — free with a referral
By Dr Javed Akhtar · Last reviewed 2 October 2026
Presentation Family found drowsy in a closed room with a coal brazier (angithi) overnight; headache, vomiting; GCS 13; SpO₂ reads 99%; COHb 32%
Red flags Loss of consciousness Chest pain/ECG change Pregnancy Lactate >8 (cyanide) Differential diagnosis Cyanide poisoning Viral illness (whole family "flu") Alcohol/drug intoxication Hypoglycaemia When to admit, call ICU or discharge Admit: Symptomatic, COHb >10–15%, cardiac or neuro involvement, pregnancyICU: Coma, seizures, cardiac injury, severe acidosisIntubate: GCS ≤8, airway burnsKey points India: winter braziers (angithi), generators and gas geysers in closed bathrooms are common sources. Delayed neurological sequelae occur in up to 40% of significant exposures. Fetal haemoglobin binds CO avidly — treat pregnant patients longer. Never Trust a normal SpO₂ in CO poisoning Send the patient back to an unventilated room with the brazier or generator Forget cyanide in fire victims Stop O₂ early because the patient looks better Common mistakes Pulse oximetry trust Missing cardiac injury Short O₂ course Not checking other household members Disposition and follow-up Ward on 100% O₂; ICU for coma or cardiac injury; neuro follow-up.
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