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Mass Casualty Triage in the Case of Carbon Monoxide Poisoning: Lessons Learned

  • Mathieu Pasquier (a1), Fabrice Dami (a1), Pierre-Nicolas Carron (a1), Bertrand Yersin (a1), Rodrigue Pignel (a2) and Olivier Hugli (a1)...


Carbon monoxide (CO) can cause mass intoxication, but no standard triage algorithm specifically addresses CO poisoning. The roles of some recent diagnostic tools in triage as well as treatment with hyperbaric oxygen are controversial. We describe a mass casualty case of CO poisoning involving 77 patients, with a focus on the triage and treatment options decided on-site. The reasons for choosing these options are reviewed, and the pitfalls that occurred and the lessons learned from this major incident are described. We discuss the potential to improve the management of such an event and strategies to accomplish this, including simplifying triage and administering oxygen to all exposed persons for 6 h. (Disaster Med Public Health Preparedness. 2018; 12: 373–378)


Corresponding author

Correspondence and reprint requests to Mathieu Pasquier, MD, Emergency Service, University Hospital Centre, BH 09, CHUV, 1011 Lausanne, Switzerland (email:


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1. Valerio, A, Verzè, M, Marchiori, F, et al. Managing a mass CO poisoning: critical issues and solutions from the field to the hyperbaric chamber. Disaster Med Public Health Prep. 2017;11(2):251-255. doi: 10.1017/dmp.2016.
2. Mortelmans, LJ, Populaire, J, Desruelles, D, et al. Mass carbon monoxide poisoning at an ice-hockey game: initial approach and long-term follow-up. Eur J Emerg Med. 2013;20(6):408-412.
3. McGuffie, C, Wyatt, JP, Kerr, GW, et al. Mass carbon monoxide poisoning. J Accid Emerg Med. 2000;17(1):38-39.
4. Klasner, AE, Smith, SR, Thompson, MW, Scalzo, AJ. Carbon monoxide mass exposure in a pediatric population. Acad Emerg Med. 1998;5(10):992-996.
5. Carbon monoxide poisoning at an indoor ice arena and bingo hall--Seattle, 1996. From the Centers for Disease Control and Prevention. JAMA. 1996;275(19):1468-1469.
6. Ely, EW, Moorehead, B, Haponik, EF. Warehouse workers’ headache: emergency evaluation and management of 30 patients with carbon monoxide poisoning. Am J Med. 1995;98(2):145-155.
7. Paulozzi, LJ, Satink, F, Spengler, RF. A carbon monoxide mass poisoning in an ice arena in Vermont. Am J Public Health. 1991;81(2):222.
8. Burney, RE, Wu, SC, Nemiroff, MJ. Mass carbon monoxide poisoning: clinical effects and results of treatment in 184 victims. Ann Emerg Med. 1982;11(8):394-399.
9. Cone, DC, Koenig, KL. Mass casualty triage in the chemical, biological, radiological, or nuclear environment. Eur J Emerg Med. 2005;12(6):287-302.
10. Buckley, NA, Juurlink, DN, Isbister, G, et al. Hyperbaric oxygen for carbon monoxide poisoning. Cochrane Database Syst Rev. 2011;4:CD002041.
11. Carron, PN, Reigner, P, Vallotton, L, et al. Implementation of a medical command and control team in Switzerland. Disasters. 2014;38(2):434-450.
12. Hampson, NB, Dunn, SL. UHMCS/CDC CO poisoning surveillance group. Symptoms of carbon monoxide poisoning do not correlate with the initial carboxyhemoglobin level. Undersea Hyperb Med. 2012;39:657-665.
13. Hampson, NB, Piantadosi, CA, Thom, SR, et al. Practice recommendations in the diagnosis, management, and prevention of carbon monoxide poisoning. Am J Respir Crit Care Med. 2012;186(11):1095-1101.
14. Roth, D, Bayer, A, Schrattenbacher, G, et al. Exposure to carbon monoxide for patients and providers in an urban emergency medical service. Prehosp Emerg Care. 2013;17(3):354-360.
15. Risavi, BL, Wadas, RJ Jr, Thomas, C, et al. A novel method for continuous environmental surveillance for carbon monoxide exposure to protect emergency medical service providers and patients. J Emerg Med. 2013;44(3):637-640.
16. Hampson, NB. Noninvasive pulse CO-oximetry expedites evaluation and management of patients with carbon monoxide poisoning. Am J Emerg Med. 2012;30(9):2021-2024.
17. Nilson, D, Partridge, R, Suner, S, et al. Non-invasive carboxyhemoglobin monitoring: screening emergency medical services patients for carbon monoxide exposure. Prehosp Disaster Med. 2010;25(03):253-256.
18. Henz, S, Maeder, M. Prospective study of accidental carbon monoxide poisoning in 38 Swiss soldiers. Swiss Med Wkly. 2005;135:398-408.
19. Hampson, NB, Hauff, NM. Carboxyhemoglobin levels in carbon monoxide poisoning: do they correlate with the clinical picture? Am J Emerg Med. 2008;26(6):665-669.
20. Wolf, SJ, Maloney, GE, Shih, RD, et al; American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on Carbon Monoxide Poisoning. Wolf, SJ, Maloney, GE, Shih, RD, Shy, BD, Brown, MD. 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(1):98-107.e6.
21. Weaver, LK. Clinical practice. Carbon monoxide poisoning. N Engl J Med. 2009;360(12):1217-1225.
22. Roth, D, Herkner, H, Schreiber, W, et al. Accuracy of noninvasive multiwave pulse oximetry compared with carboxyhemoglobin from blood gas analysis in unselected emergency department patients. Ann Emerg Med. 2011;58(1):74-79.
23. Suner, S, Partridge, R, Sucov, A, et al. Non-invasive pulse CO-oximetry screening in the emergency department identifies occult carbon monoxide toxicity. J Emerg Med. 2008;34(4):441-450.
24. Sebbane, M, Claret, PG, Mercier, G, et al. Emergency department management of suspected carbon monoxide poisoning: role of pulse CO-oximetry. Respir Care. 2013;58(10):1614-1620.
25. Touger, M, Birnbaum, A, Wang, J, et al. Performance of the RAD-57 pulse CO-oximeter compared with standard laboratory carboxyhemoglobin measurement. Ann Emerg Med. 2010;56(4):382-388.
26. Bledsoe, BE, Nowicki, K, Creel, JH Jr, et al. Use of pulse co-oximetry as a screening and monitoring tool in mass carbon monoxide poisoning. Prehosp Emerg Care. 2010;14(1):131-133.
27. Lapostolle, F, Raynaud, PJ, Le Toumelin, P, et al. Measurement of carbon monoxide in expired breath in prehospital management of carbon monoxide intoxication [in French]. Ann Fr Anesth Reanim. 2001;20:10-15.
28. Clarke, SF, Stephens, C, Farhan, M, et al. Multiple patients with carbon monoxide toxicity from water-pipe smoking. Prehosp Disaster Med. 2012;27(06):612-614.
29. Rose, JJ, Wang, L, Xu, Q, et al. Carbon monoxide poisoning: pathogenesis, management and future directions of therapy [published online October 18, 2016]. Am J Respir Crit Care Med. doi:


Mass Casualty Triage in the Case of Carbon Monoxide Poisoning: Lessons Learned

  • Mathieu Pasquier (a1), Fabrice Dami (a1), Pierre-Nicolas Carron (a1), Bertrand Yersin (a1), Rodrigue Pignel (a2) and Olivier Hugli (a1)...


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