Carbon monoxide poisoning

Toxic effects of carbon monoxide

Medical condition

Carbon monoxide poisoning

Other names| Carbon monoxide intoxication, carbon monoxide toxicity, carbon monoxide overdose
Carbon monoxide
Specialty| Toxicology, emergency medicine
Symptoms| Headache, dizziness, weakness, vomiting, chest pain, confusion[1]
Complications| Loss of consciousness, arrhythmias, seizures[1][2]
Causes| Breathing in carbon monoxide[3]
Diagnostic method| Carboxyhemoglobin level:
3% (nonsmokers)
10% (smokers)[2]
Differential diagnosis| Cyanide toxicity, alcoholic ketoacidosis, aspirin poisoning, upper respiratory tract infection[2][4]
Prevention| Carbon monoxide detectors, venting of gas appliances, maintenance of exhaust systems[1]
Treatment| Supportive care, 100% oxygen, hyperbaric oxygen therapy[2]
Prognosis| Risk of death: 1–31%[2]
Frequency| >20,000 emergency visits for non-fire related cases per year (US)[1]
Deaths| >400 non-fire related a year (US)[1]

Carbon monoxide poisoning typically occurs from breathing in carbon monoxide (CO) at excessive levels.[3] Symptoms are often described as "flu-like" and commonly include headache, dizziness, weakness, vomiting, chest pain, and confusion.[1] Large exposures can result in loss of consciousness, arrhythmias, seizures, or death.[1][2] The classically described "cherry red skin" rarely occurs.[2] Long-term complications may include chronic fatigue, trouble with memory, and movement problems.[5]

CO is a colorless and odorless gas which is initially non-irritating.[5] It is produced during incomplete burning of organic matter.[5] This can occur from motor vehicles, heaters, or cooking equipment that run on carbon-based fuels.[1] Carbon monoxide primarily causes adverse effects by combining with hemoglobin to form carboxyhemoglobin (symbol COHb or HbCO) preventing the blood from carrying oxygen and expelling carbon dioxide as carbaminohemoglobin.[5] Additionally, many other hemoproteins such as myoglobin, Cytochrome P450, and mitochondrial cytochrome oxidase are affected, along with other metallic and non-metallic cellular targets.[2][6]

Diagnosis is typically based on a HbCO level of more than 3% among nonsmokers and more than 10% among smokers.[2] The biological threshold for carboxyhemoglobin tolerance is typically accepted to be 15% COHb, meaning toxicity is consistently observed at levels in excess of this concentration.[7] The FDA has previously set a threshold of 14% COHb in certain clinical trials evaluating the therapeutic potential of carbon monoxide.[8] In general, 30% COHb is considered severe carbon monoxide poisoning.[9] The highest reported non-fatal carboxyhemoglobin level was 73% COHb.[9]

Efforts to prevent poisoning include carbon monoxide detectors, proper venting of gas appliances, keeping chimneys clean, and keeping exhaust systems of vehicles in good repair.[1] Treatment of poisoning generally consists of giving 100% oxygen along with supportive care.[2][5] This procedure is often carried out until symptoms are absent and the HbCO level is less than 3%/10%.[2]

Carbon monoxide poisoning is relatively common, resulting in more than 20,000 emergency room visits a year in the United States.[1][10] It is the most common type of fatal poisoning in many countries.[11] In the United States, non-fire related cases result in more than 400 deaths a year.[1] Poisonings occur more often in the winter, particularly from the use of portable generators during power outages.[2][12] The toxic effects of CO have been known since ancient history.[13][9] The discovery that hemoglobin is affected by CO emerged with an investigation by James Watt and Thomas Beddoes into the therapeutic potential of hydrocarbonate in 1793, and later confirmed by Claude Bernard between 1846 and 1857.[9]

## Background

[edit]

Carbon monoxide is not toxic to all forms of life, and the toxicity is a classical dose-dependent example of hormesis. Small amounts of carbon monoxide are naturally produced through many enzymatic and non-enzymatic reactions across phylogenetic kingdoms where it can serve as an important neurotransmitter (subcategorized as a gasotransmitter) and a potential therapeutic agent.[14] In the case of prokaryotes, some bacteria produce, consume and respond to carbon monoxide whereas certain other microbes are susceptible to its toxicity.[6] Currently, there are no known adverse effects on photosynthesizing plants.[15]

The harmful effects of carbon monoxide are generally considered to be due to tightly binding with the prosthetic heme moiety of hemoproteins that results in interference with cellular operations, for example: carbon monoxide binds with hemoglobin to form carboxyhemoglobin which affects gas exchange and cellular respiration. Inhaling excessive concentrations of the gas can lead to hypoxic injury, nervous system damage, and even death.

As pioneered by Esther Killick,[9] different species and different people across diverse demographics may have different carbon monoxide tolerance levels.[16] The carbon monoxide tolerance level for any person is altered by several factors, including genetics (hemoglobin mutations), behavior such as activity level, rate of ventilation, a pre-existing cerebral or cardiovascular disease, cardiac output, anemia, sickle cell disease and other hematological disorders, geography and barometric pressure, and metabolic rate.[17][18][19][9]

### Physiology

[edit]

Main article: Gasotransmitters

Carbon monoxide is produced naturally by many physiologically relevant enzymatic and non-enzymatic reactions[6] best exemplified by heme oxygenase catalyzing the biotransformation of heme (an iron protoporphyrin) into biliverdin and eventually bilirubin.[20] Aside from physiological signaling, most carbon monoxide is stored as carboxyhemoglobin at non-toxic levels below 3% HbCO.[21]

#### Therapeutics

[edit]

Small amounts of CO are beneficial and enzymes exist that produce it at times of oxidative stress.[20] A variety of drugs are being developed to introduce small amounts of CO, these drugs are commonly called carbon monoxide-releasing molecules.[14][22] Historically, the therapeutic potential of factitious airs, notably carbon monoxide as hydrocarbonate, was investigated by Thomas Beddoes, James Watt, Tiberius Cavallo, James Lind, Humphry Davy, and others in many labs such as the Pneumatic Institution.[9]

## Signs and symptoms

[edit]

On average, exposures at 100 ppm or greater is dangerous to human health.[23] The WHO recommended levels of indoor CO exposure in 24 hours is 4 mg/m3.[24] Acute exposure should not exceed 10 mg/m3 in 8 hours, 35 mg/m3 in one hour and 100 mg/m3 in 15 minutes.[25]

Effects of carbon monoxide in relation to the concentration in parts per million in the air:[26][27] Concentration  | Symptoms

|

35 ppm (0.0035%), (0.035‰)  | Headache and dizziness within six to eight hours of constant exposure
100 ppm (0.01%), (0.1‰)  | Slight headache in two to three hours
200 ppm (0.02%), (0.2‰)  | Slight headache within two to three hours; loss of judgment
400 ppm (0.04%), (0.4‰)  | Frontal headache within one to two hours
800 ppm (0.08%), (0.8‰)  | Dizziness, nausea, and convulsions within 45 min; insensible within 2 hours
1,600 ppm (0.16%), (1.6‰)  | Headache, increased heart rate, dizziness, and nausea within 20 min; death in less than 2 hours
3,200 ppm (0.32%), (3.2‰)  | Headache, dizziness and nausea in five to ten minutes. Death within 30 minutes.
6,400 ppm (0.64%), (6.4‰)  | Headache and dizziness in one to two minutes. Convulsions, respiratory arrest, and death in less than 20 minutes.
12,800 ppm (1.28%), (12.8‰)  | Unconsciousness after 2–3 breaths. Death in less than three minutes.

### Acute poisoning

[edit]

CO toxicity symptoms

The main manifestations of carbon monoxide poisoning develop in the organ systems most dependent on oxygen use, the central nervous system and the heart.[28] The initial symptoms of acute carbon monoxide poisoning include headache, nausea, malaise, and fatigue.[29] These symptoms are often mistaken for a virus such as influenza or other illnesses such as food poisoning or gastroenteritis.[21] Headache is the most common symptom of acute carbon monoxide poisoning; it is often described as dull, frontal, and continuous.[30] Increasing exposure produces cardiac abnormalities including fast heart rate, low blood pressure, and cardiac arrhythmia;[31][32] central nervous system symptoms include delirium, hallucinations, dizziness, unsteady gait, confusion, seizures, central nervous system depression, unconsciousness, respiratory arrest, and death.[33][34] Less common symptoms of acute carbon monoxide poisoning include myocardial ischemia, atrial fibrillation, pneumonia, pulmonary edema, high blood sugar, lactic acidosis, muscle necrosis, acute kidney failure, skin lesions, and visual and auditory problems.[31][35][36][37] Carbon monoxide exposure may lead to a significantly shorter life span due to heart damage.[38]

One of the major concerns following acute carbon monoxide poisoning is the severe delayed neurological manifestations that may occur. Problems may include difficulty with higher intellectual functions, short-term memory loss, dementia, amnesia, psychosis, irritability, a strange gait, speech disturbances, Parkinson's disease-like syndromes, cortical blindness, and a depressed mood.[21][39] Depression may occur in those who did not have pre-existing depression.[40] These delayed neurological sequelae may occur in up to 50% of poisoned people after 2 to 40 days.[21] It is difficult to predict who will develop delayed sequelae; however, advanced age, loss of consciousness while poisoned, and initial neurological abnormalities may increase the chance of developing delayed symptoms.[41]

### Chronic poisoning

[edit]

Chronic exposure to relatively low levels of carbon monoxide may cause persistent headaches, lightheadedness, depression, confusion, memory loss, nausea, hearing disorders and vomiting.[42][43] It is unknown whether low-level chronic exposure may cause permanent neurological damage.[21] Typically, upon removal from exposure to carbon monoxide, symptoms usually resolve themselves, unless there has been an episode of severe acute poisoning.[42] However, one case noted permanent memory loss and learning problems after a three-year exposure to relatively low levels of carbon monoxide from a faulty furnace.[44]

Chronic exposure may worsen cardiovascular symptoms in some people.[42] Chronic carbon monoxide exposure might increase the risk of developing atherosclerosis.[45][46] Long-term exposures to carbon monoxide present the greatest risk to persons with coronary heart disease and in females who are pregnant.[47]

In experimental animals, carbon monoxide appears to worsen noise-induced hearing loss at noise exposure conditions that would have limited effects on hearing otherwise.[48] In humans, hearing loss has been reported following carbon monoxide poisoning.[43] Unlike the findings in animal studies, noise exposure was not a necessary factor for the auditory problems to occur.

### Fatal poisoning

[edit]

One classic sign of carbon monoxide poisoning is more often seen in the dead rather than the living – people have been described as looking red-cheeked and healthy. However, since this "cherry-red" appearance is more common in the dead, it is not considered a useful diagnostic sign in clinical medicine. In autopsy examinations, the appearance of carbon monoxide poisoning is notable because unembalmed dead persons are normally bluish and pale, whereas dead carbon-monoxide poisoned people may appear unusually lifelike in coloration.[49][50][51] The colorant effect of carbon monoxide in such postmortem circumstances is thus analogous to its use as a red colorant in the commercial meat-packing industry.

## Epidemiology

[edit]

The true number of cases of carbon monoxide poisoning is unknown, since many non-lethal exposures go undetected.[29][52] From the available data, carbon monoxide poisoning is the most common cause of injury and death due to poisoning worldwide.[53] Poisoning is typically more common during the winter months.[28][54][55][56] This is due to increased domestic use of gas furnaces, gas or kerosene space heaters, and kitchen stoves during the winter months, which if faulty and/or used without adequate ventilation, may produce excessive carbon monoxide.[28][57] Carbon monoxide detection and poisoning also increases during power outages, when electric heating and cooking appliances become inoperative and residents may temporarily resort to fuel-burning space heaters, stoves, and grills (some of which are safe only for outdoor use but nonetheless are errantly burned indoors).[58][59][60]

It has been estimated that more than 40,000 people per year seek medical attention for carbon monoxide poisoning in the United States.[61] 95% of carbon monoxide poisoning deaths in Australia are due to gas space heaters.[62][63] In many industrialized countries, carbon monoxide is the cause of more than 50% of fatal poisonings.[11] In the United States, approximately 200 people die each year from carbon monoxide poisoning associated with home fuel-burning heating equipment.[64] Carbon monoxide poisoning contributes to the approximately 5,613 smoke inhalation deaths each year in the United States.[65] The CDC reports, "Each year, more than 500 Americans die from unintentional carbon monoxide poisoning, and more than 2,000 commit suicide by intentionally poisoning themselves."[66] For the 10-year period from 1979 to 1988, 56,133 deaths from carbon monoxide poisoning occurred in the United States, with 25,889 of those being suicides, leaving 30,244 unintentional deaths.[65] A report from New Zealand showed that 206 people died from carbon monoxide poisoning in the years of 2001 and 2002. In total carbon monoxide poisoning was responsible for 43.9% of deaths by poisoning in that country.[67] In South Korea, 1,950 people had been poisoned by carbon monoxide with 254 deaths from 2001 through 2003.[68] A report from Jerusalem showed 3.53 per 100,000 people were poisoned annually from 2001 through 2006.[69] In Hubei, China, 218 deaths from poisoning were reported over a 10-year period with 16.5% being from carbon monoxide exposure.[70]

### Causes

[edit]

Concentration  | Source

|

0.1 ppm  | Natural atmosphere level (MOPITT)[71]
0.5 to 5 ppm  | Average level in homes[72]
5 to 15 ppm  | Near properly adjusted gas stoves in homes[72]
100 to 200 ppm  | Exhaust from automobiles in the Mexico City central area[73]
5,000 ppm  | Exhaust from a home wood fire[74]
7,000 ppm  | Undiluted warm car exhaust without a catalytic converter[74]
30,000 ppm  | Afterdamp following an explosion in a coal mine[75]

Carbon monoxide is a product of combustion of organic matter under conditions of restricted oxygen supply, which prevents complete oxidation to carbon dioxide (CO2). Sources of carbon monoxide include cigarette smoke, house fires, faulty furnaces, heaters, wood-burning stoves,[76] internal combustion vehicle exhaust, electrical generators, propane-fueled equipment such as portable stoves, and gasoline-powered tools such as leaf blowers, lawn mowers, high-pressure washers, concrete cutting saws, power trowels, and welders.[21][42][77][78][79][80][81] Exposure typically occurs when equipment is used in buildings or semi-enclosed spaces.[21]

Riding in the back of pickup trucks has led to poisoning in children.[82] Idling automobiles with the exhaust pipe blocked by snow has led to the poisoning of car occupants.[83] Any perforation between the exhaust manifold and shroud can result in exhaust gases reaching the cabin. Generators and propulsion engines on boats, especially houseboats, has resulted in fatal carbon monoxide exposures.[84][85]

Poisoning may also occur following the use of a self-contained underwater breathing apparatus (SCUBA) due to faulty diving air compressors.[86]

In caves carbon monoxide can build up in enclosed chambers due to the presence of decomposing organic matter.[87] In coal mines incomplete combustion may occur during explosions resulting in the production of afterdamp. The gas is up to 3% CO and may be fatal after just a single breath.[75] Following an explosion in a colliery, adjacent interconnected mines may become dangerous due to the afterdamp leaking from mine to mine. Such an incident followed the Trimdon Grange explosion which killed men in the Kelloe mine.[88]

Another source of poisoning is exposure to the organic solvent dichloromethane, also known as methylene chloride, found in some paint strippers,[89] as the metabolism of dichloromethane produces carbon monoxide.[90][91][52] In November 2019, an EPA ban on dichloromethane in paint strippers for consumer use took effect in the United States.[92]

### Prevention

[edit]

Carbon monoxide detector connected to a North American power outlet

#### Detectors

[edit]

A carbon monoxide monitor clipped to the uniform of a paramedic

Prevention remains a vital public health issue, requiring public education on the safe operation of appliances, heaters, fireplaces, and internal-combustion engines, as well as increased emphasis on the installation of carbon monoxide detectors.[54] Carbon monoxide is tasteless, odourless, and colourless, and therefore can not be detected by visual cues or smell.[93]

The United States Consumer Product Safety Commission has stated, "carbon monoxide detectors are as important to home safety as smoke detectors are," and recommends each home have at least one carbon monoxide detector, and preferably one on each level of the building.[64] These devices, which are relatively inexpensive[94] and widely available, are either battery- or AC-powered, with or without battery backup.[95] In buildings, carbon monoxide detectors are usually installed around heaters and other equipment. If a relatively high level of carbon monoxide is detected, the device sounds an alarm, giving people the chance to evacuate and ventilate the building.[94][96] Unlike smoke detectors, carbon monoxide detectors do not need to be placed near ceiling level.

The use of carbon monoxide detectors has been standardized in many areas. In the US, NFPA 720–2009,[97] the carbon monoxide detector guidelines published by the National Fire Protection Association, mandates the placement of carbon monoxide detectors/alarms on every level of the residence, including the basement, in addition to outside sleeping areas. In new homes, AC-powered detectors must have battery backup and be interconnected to ensure early warning of occupants at all levels.[97] NFPA 720-2009 is the first national carbon monoxide standard to address devices in non-residential buildings. These guidelines, which now pertain to schools, healthcare centers, nursing homes, and other non-residential buildings, include three main points:[97]

1\. A secondary power supply (battery backup) must operate all carbon monoxide notification appliances for at least 12 hours,
2\. Detectors must be on the ceiling in the same room as permanently installed fuel-burning appliances, and
3\. Detectors must be located on every habitable level and in every HVAC zone of the building.

Gas organizations will often recommend getting gas appliances serviced at least once a year.[98]

#### Legal requirements

[edit]

The NFPA standard is not necessarily enforced by law. As of April 2006, the US state of Massachusetts requires detectors to be present in all residences with potential CO sources, regardless of building age and whether they are owner-occupied or rented.[99] This is enforced by municipal inspectors and was inspired by the death of 7-year-old Nicole Garofalo in 2005 due to snow blocking a home heating vent.[100] Other jurisdictions may have no requirement or only mandate detectors for new construction or at time of sale.

#### World Health Organization recommendations

[edit]

The following guideline values (ppm values rounded) and periods of time-weighted average exposures have been determined in such a way that the carboxyhemoglobin (COHb) level of 2.5% is not exceeded, even when a normal subject engages in light or moderate exercise:

* 100 mg/m3 (87 ppm) for 15 min
* 60 mg/m3 (52 ppm) for 30 min
* 30 mg/m3 (26 ppm) for 1 h
* 10 mg/m3 (9 ppm) for 8 h
* 7 mg/m3 (6 ppm) for 24 h (for indoor air quality, so as not to exceed 2% COHb for chronic exposure)[25]

## Diagnosis

[edit]

Finger tip carboxyhemoglobin saturation monitor (SpCO%). Note: This is not the same as a pulse oximeter (SpO2%), although some models (such as this one) do measure both the oxygen and carbon monoxide saturation. Breath CO monitor displaying carbon monoxide concentration of an exhaled breath sample (in ppm) with its corresponding percent concentration of carboxyhemoglobin. When dealing with CO, time is critical. In the blood stream carbon Monoxide has an affinity with hemoglobin some 200 times greater than oxygen.

As many symptoms of carbon monoxide poisoning also occur with many other types of poisonings and infections (such as the flu), the diagnosis is often difficult.[52][101] A history of potential carbon monoxide exposure, such as being exposed to a residential fire, may suggest poisoning, but the diagnosis is confirmed by measuring the levels of carbon monoxide in the blood. This can be determined by measuring the amount of carboxyhemoglobin compared to the amount of hemoglobin in the blood.[21]

The ratio of carboxyhemoglobin to hemoglobin molecules in an average person may be up to 5%, although cigarette smokers who smoke two packs per day may have levels up to 9%.[102] In symptomatic poisoned people they are often in the 10–30% range, while persons who die may have postmortem blood levels of 30–90%.[103][104]

As people may continue to experience significant symptoms of CO poisoning long after their blood carboxyhemoglobin concentration has returned to normal, presenting to examination with a normal carboxyhemoglobin level (which may happen in late states of poisoning) does not rule out poisoning.[105]

### Measuring

[edit]

Carbon monoxide may be quantitated in blood using spectrophotometric methods or chromatographic techniques in order to confirm a diagnosis of poisoning in a person or to assist in the forensic investigation of a case of fatal exposure.

A CO-oximeter can be used to determine carboxyhemoglobin levels.[106][107] Pulse CO-oximeters estimate carboxyhemoglobin with a non-invasive finger clip similar to a pulse oximeter.[108] These devices function by passing various wavelengths of light through the fingertip and measuring the light absorption of the different types of hemoglobin in the capillaries.[109] The use of a regular pulse oximeter is not effective in the diagnosis of carbon monoxide poisoning[110] as these devices may be unable to distinguish carboxyhemoglobin from oxyhemoglobin.[111] Breath CO monitoring offers an alternative to pulse CO-oximetry. Carboxyhemoglobin levels have been shown to have a strong correlation with breath CO concentration.[112][113] However, many of these devices require the user to inhale deeply and hold their breath to allow the CO in the blood to escape into the lung before the measurement can be made. As this is not possible in people who are unresponsive, these devices may not appropriate for use in on-scene emergency care detection of CO poisoning.

### Differential diagnosis

[edit]

There are many conditions to be considered in the differential diagnosis of carbon monoxide poisoning.[28][34] The earliest symptoms, especially from low level exposures, are often non-specific and readily confused with other illnesses, typically flu-like viral syndromes, depression, chronic fatigue syndrome, chest pain, and migraine or other headaches.[114] Carbon monoxide has been called a "great mimicker" due to the presentation of poisoning being diverse and nonspecific.[28] Other conditions included in the differential diagnosis include acute respiratory distress syndrome, altitude sickness, lactic acidosis, diabetic ketoacidosis, meningitis, methemoglobinemia, or opioid or toxic alcohol poisoning.[34]

## Treatment

[edit]

Time to remove 50% carboxyhemoglobin[115] Oxygen pressure О2 | Time

|

21% oxygen at normal atmospheric pressure (fresh air)  | 5 hours 20 min
100% oxygen at normal atmospheric pressure (non-rebreather oxygen mask)  | 1 hours 20 min
100% hyperbaric oxygen (3 atmospheres absolute)  | 23 min

Initial treatment for carbon monoxide poisoning is to immediately remove the person from the exposure without endangering further people. Those who are unconscious may require CPR on site.[49] Administering oxygen via non-rebreather mask shortens the half-life of carbon monoxide from 320 minutes, when breathing normal air, to only 80 minutes.[33] Oxygen hastens the dissociation of carbon monoxide from carboxyhemoglobin, thus turning it back into hemoglobin.[16][116] Due to the possible severe effects in the baby, pregnant women are treated with oxygen for longer periods of time than non-pregnant people.[117]

### Hyperbaric oxygen

[edit]

A person within a hyperbaric oxygen chamber

Hyperbaric oxygen is also used in the treatment of carbon monoxide poisoning, as it may hasten dissociation of CO from carboxyhemoglobin[16] and cytochrome oxidase[118] to a greater extent than normal oxygen. Hyperbaric oxygen at three times atmospheric pressure reduces the half life of carbon monoxide to 23 minutes, compared to 80 minutes for oxygen at regular atmospheric pressure.[16] It may also enhance oxygen transport to the tissues by plasma, partially bypassing the normal transfer through hemoglobin.[116] However, it is controversial whether hyperbaric oxygen actually offers any extra benefits over normal high flow oxygen, in terms of increased survival or improved long-term outcomes.[119][120][121][122][123][124] There have been randomized controlled trials in which the two treatment options have been compared;[125][126][127][128][129][130] of the six performed, four found hyperbaric oxygen improved outcome and two found no benefit for hyperbaric oxygen.[119] Some of these trials have been criticized for apparent flaws in their implementation.[131][132][133][134] A review of all the literature concluded that the role of hyperbaric oxygen is unclear and the available evidence neither confirms nor denies a medically meaningful benefit. The authors suggested a large, well designed, externally audited, multicentre trial to compare normal oxygen with hyperbaric oxygen.[119] While hyperbaric oxygen therapy is used for severe poisonings, the benefit over standard oxygen delivery is unclear.[2][120]

### Other

[edit]

Further treatment for other complications such as seizure, hypotension, cardiac abnormalities, pulmonary edema, and acidosis may be required. Hypotension requires treatment with intravenous fluids; vasopressors may be required to treat myocardial depression.[135] Cardiac dysrhythmias are treated with standard advanced cardiac life support protocols.[21] If severe, metabolic acidosis is treated with sodium bicarbonate. Treatment with sodium bicarbonate is controversial as acidosis may increase tissue oxygen availability.[136] Treatment of acidosis may only need to consist of oxygen therapy.[21][34] The delayed development of neuropsychiatric impairment is one of the most serious complications of carbon monoxide poisoning. Brain damage is confirmed following MRI or CAT scans.[29][137][138] Extensive follow up and supportive treatment is often required for delayed neurological damage.[33] Outcomes are often difficult to predict following poisoning,[139] especially people who have symptoms of cardiac arrest, coma, metabolic acidosis, or have high carboxyhemoglobin levels.[34] One study reported that approximately 30% of people with severe carbon monoxide poisoning will have a fatal outcome.[52] It has been reported that electroconvulsive therapy (ECT) may increase the likelihood of delayed neuropsychiatric sequelae (DNS) after carbon monoxide (CO) poisoning.[140] A device that also provides some carbon dioxide to stimulate faster breathing (sold under the brand name ClearMate) may also be used.[141]

## Pathophysiology

[edit]

The precise mechanisms by which the effects of carbon monoxide are induced upon bodily systems are complex and not yet fully understood.[29] Known mechanisms include carbon monoxide binding to hemoglobin, myoglobin and mitochondrial cytochrome c oxidase and restricting oxygen supply, and carbon monoxide causing brain lipid peroxidation.[33][49][142]

### Hemoglobin

[edit]

Main article: Carboxyhemoglobin

Carbon monoxide has a higher diffusion coefficient compared to oxygen, and the main enzyme in the human body that produces carbon monoxide is heme oxygenase, which is located in nearly all cells and platelets.[6] Most endogenously produced CO is stored bound to hemoglobin as carboxyhemoglobin. The simplistic understanding for the mechanism of carbon monoxide toxicity is based on excess carboxyhemoglobin decreasing the oxygen-delivery capacity of the blood to tissues throughout the body. In humans, the affinity between hemoglobin and carbon monoxide is approximately 240 times stronger than the affinity between hemoglobin and oxygen.[49][143][144] However, certain mutations such as the Hb-Kirklareli mutation has a relative 80,000 times greater affinity for carbon monoxide than oxygen resulting in systemic carboxyhemoglobin reaching a sustained level of 16% COHb.[9]

Hemoglobin is a tetramer with four prosthetic heme groups to serve as oxygen binding sites. The average red blood cell contains 250 million hemoglobin molecules, therefore 1 billion heme sites capable of binding gas.[6] The binding of carbon monoxide at any one of these sites increases the oxygen affinity of the remaining three sites, which causes the hemoglobin molecule to retain oxygen that would otherwise be delivered to the tissue; therefore carbon monoxide binding at any site may be as dangerous as carbon monoxide binding to all sites.[142] Delivery of oxygen is largely driven by the Bohr effect and Haldane effect. To provide a simplified synopsis of the molecular mechanism of systemic gas exchange in layman's terms, upon inhalation of air it was widely thought oxygen binding to any of the heme sites triggers a conformational change in the globin/protein unit of hemoglobin which then enables the binding of additional oxygen to each of the other vacant heme sites. Upon arrival to the cell/tissues, oxygen release into the tissue is driven by "acidification" of the local pH (meaning a relatively higher concentration of 'acidic' protons/hydrogen ions) caused by an increase in the biotransformation of carbon dioxide waste into carbonic acid via carbonic anhydrase. In other words, oxygenated arterial blood arrives at cells in the "hemoglobin R-state" which has deprotonated/unionized amino acid residues (regarding nitrogen/amines) due to the less-acidic arterial pH environment (arterial blood averages pH 7.407 whereas venous blood is slightly more acidic at pH 7.371). The "T-state" of hemoglobin is deoxygenated in venous blood partially due to protonation/ionization caused by the acidic environment hence causing a conformation unsuited for oxygen-binding (in other words, oxygen is 'ejected' upon arrival to the cell because acid "attacks" the amines of hemoglobin causing ionization/protonation of the amine residues resulting in a conformation change unsuited for retaining oxygen). Furthermore, the mechanism for formation of carbaminohemoglobin generates additional 'acidic' hydrogen ions that may further stabilize the protonated/ionized deoxygenated hemoglobin. Upon return of venous blood into the lung and subsequent exhalation of carbon dioxide, the blood is "de-acidified" (see also: hyperventilation) allowing for the deprotonation/unionization of hemoglobin to then re-enable oxygen-binding as part of the transition to arterial blood (note this process is complex due to involvement of chemoreceptors and other physiological functionalities). Carbon monoxide is not 'ejected' due to acid, therefore carbon monoxide poisoning disturbs this physiological process hence the venous blood of poisoning patients is bright red akin to arterial blood since the carbonyl/carbon monoxide is retained. Hemoglobin is dark in deoxygenated venous blood, but it has a bright red color when carrying blood in oxygenated arterial blood and when converted into carboxyhemoglobin in both arterial and venous blood, so poisoned cadavers and even commercial meats treated with carbon monoxide acquire an unnatural lively reddish hue.[145]

At toxic concentrations, carbon monoxide as carboxyhemoglobin significantly interferes with respiration and gas exchange by simultaneously inhibiting acquisition and delivery of oxygen to cells and preventing formation of carbaminohemoglobin which accounts for approximately 30% of carbon dioxide exportation. Therefore, a patient with carbon monoxide poisoning may experience severe hypoxia[21] and acidosis (potentially both respiratory acidosis and metabolic acidosis) in addition to the toxicities of excess carbon monoxide inhibiting numerous hemoproteins, metallic and non-metallic targets which affect cellular machinery.

### Myoglobin

[edit]

Carbon monoxide also binds to the hemeprotein myoglobin. It has a high affinity for myoglobin, about 60 times greater than that of oxygen.[21] Carbon monoxide bound to myoglobin may impair its ability to utilize oxygen.[49] This causes reduced cardiac output and hypotension, which may result in brain ischemia.[21] A delayed return of symptoms have been reported. This results following a recurrence of increased carboxyhemoglobin levels; this effect may be due to a late release of carbon monoxide from myoglobin, which subsequently binds to hemoglobin.[11]

### Cytochrome oxidase

[edit]

Another mechanism involves effects on the mitochondrial respiratory enzyme chain that is responsible for effective tissue utilization of oxygen. Carbon monoxide binds to cytochrome oxidase with less affinity than oxygen, so it is possible that it requires significant intracellular hypoxia before binding.[146] This binding interferes with aerobic metabolism and efficient adenosine triphosphate synthesis. Cells respond by switching to anaerobic metabolism, causing anoxia, lactic acidosis, and eventual cell death.[147] The rate of dissociation between carbon monoxide and cytochrome oxidase is slow, causing a relatively prolonged impairment of oxidative metabolism.[29]

### Central nervous system effects

[edit]

The mechanism that is thought to have a significant influence on delayed effects involves formed blood cells and chemical mediators, which cause brain lipid peroxidation (degradation of unsaturated fatty acids). Carbon monoxide causes endothelial cell and platelet release of nitric oxide, and the formation of oxygen free radicals including peroxynitrite.[29] In the brain this causes further mitochondrial dysfunction, capillary leakage, leukocyte sequestration, and apoptosis.[148] The result of these effects is lipid peroxidation, which causes delayed reversible demyelination of white matter in the central nervous system known as Grinker myelinopathy, which can lead to edema and necrosis within the brain.[142] This brain damage occurs mainly during the recovery period. This may result in cognitive defects, especially affecting memory and learning, and movement disorders. These disorders are typically related to damage to the cerebral white matter and basal ganglia.[148][149] Hallmark pathological changes following poisoning are bilateral necrosis of the white matter, globus pallidus, cerebellum, hippocampus and the cerebral cortex.[23][21][150]

### Pregnancy

[edit]

Carbon monoxide poisoning in pregnant women may cause severe adverse fetal effects. Poisoning causes fetal tissue hypoxia by decreasing the release of maternal oxygen to the fetus. Carbon monoxide also crosses the placenta and combines with fetal hemoglobin, causing more direct fetal tissue hypoxia. Additionally, fetal hemoglobin has a 10 to 15% higher affinity for carbon monoxide than adult hemoglobin, causing more severe poisoning in the fetus than in the adult.[11] Elimination of carbon monoxide is slower in the fetus, leading to an accumulation of the toxic chemical.[151] The level of fetal morbidity and mortality in acute carbon monoxide poisoning is significant, so despite mild maternal poisoning or following maternal recovery, severe fetal poisoning or death may still occur.[152]

## History

[edit]

Humans have maintained a complex relationship with carbon monoxide since first learning to control fire circa 800,000 BC. Primitive cavemen probably discovered the toxicity of carbon monoxide upon introducing fire into their dwellings. The early development of metallurgy and smelting technologies emerging circa 6,000 BC through the Bronze Age likewise plagued humankind with carbon monoxide exposure. Apart from the toxicity of carbon monoxide, indigenous Native Americans may have experienced the neuroactive properties of carbon monoxide through shamanistic fireside rituals.[9]

Early civilizations developed mythological tales to explain the origin of fire, such as Vulcan, Pkharmat, and Prometheus from Greek mythology who shared fire with humans. Aristotle (384–322 BC) first recorded that burning coals produced toxic fumes. Greek physician Galen (129–199 AD) speculated that there was a change in the composition of the air that caused harm when inhaled, and symptoms of CO poisoning appeared in Cassius Iatrosophista's Quaestiones Medicae et Problemata Naturalia circa 130 AD.[9] Julian the Apostate, Caelius Aurelianus, and several others similarly documented early knowledge of the toxicity symptoms of carbon monoxide poisoning as caused by coal fumes in the ancient era.[9]

Documented cases by Livy and Cicero allude to carbon monoxide being used as a method of suicide in ancient Rome.[9][153] Emperor Lucius Verus used smoke to execute prisoners.[9] Many deaths have been linked to carbon monoxide poisoning including Emperor Jovian, Empress Fausta, and Seneca.[9] The most high-profile death by carbon monoxide poisoning may possibly have been Cleopatra[9] or Edgar Allan Poe.[154]

In the fifteenth century, coal miners believed sudden death was caused by evil spirits; carbon monoxide poisoning has been linked to supernatural and paranormal experiences, witchcraft, etc. throughout the following centuries[9] including in the modern present day exemplified by Carrie Poppy's investigations.[155]

Georg Ernst Stahl mentioned carbonarii halitus in 1697 in reference to toxic vapors thought to be carbon monoxide. Friedrich Hoffmann conducted the first modern scientific investigation into carbon monoxide poisoning from coal in 1716, notably rejecting villagers attributing death to demonic superstition. Herman Boerhaave conducted the first scientific experiments on the effect of carbon monoxide (coal fumes) on animals in the 1730s.[9] Joseph Priestley is credited with first synthesizing carbon monoxide in 1772 which he had called heavy inflammable air, and Carl Wilhelm Scheele isolated carbon monoxide from coal in 1773 suggesting it to be the toxic entity.[9]

The dose-dependent risk of carbon monoxide poisoning as hydrocarbonate was investigated in the late 1790s by Thomas Beddoes, James Watt, Tiberius Cavallo, James Lind, Humphry Davy, and many others in the context of inhalation of factitious airs, much of which occurred at the Pneumatic Institution.[9]

William Cruickshank discovered carbon monoxide as a molecule containing one carbon and one oxygen atom in 1800, thereby initiating the modern era of research exclusively focused on carbon monoxide. The mechanism for toxicity was first suggested by James Watt in 1793, followed by Adrien Chenot in 1854 and finally demonstrated by Claude Bernard after 1846 as published in 1857 and also independently published by Felix Hoppe-Seyler in the same year.[9]

The first controlled clinical trial studying the toxicity of carbon monoxide occurred in 1973.[9]

### Historical detection

[edit]

Carbon monoxide poisoning has plagued coal miners for many centuries. In the context of mining, carbon monoxide is widely known as whitedamp. John Scott Haldane identified carbon monoxide as the lethal constituent of afterdamp, the gas created by combustion, after examining many bodies of miners killed in pit explosions.[9] By 1911, Haldane introduced the use of small animals for miners to detect dangerous levels of carbon monoxide underground, either white mice or canaries which have little tolerance for carbon monoxide thereby offering an early warning, i.e. canary in a coal mine.[9] The canary in British pits was replaced in 1986 by the electronic gas detector.

The first qualitative analytical method to detect carboxyhemoglobin emerged in 1858 with a colorimetric method developed by Felix Hoppe-Seyler, and the first quantitative analysis method emerged in 1880 with Josef von Fodor.[9]

### Historical treatment

[edit]

The use of oxygen emerged with anecdotal reports such as Humphry Davy having been treated with oxygen in 1799 upon inhaling three quarts of hydrocarbonate (water gas).[9] Samuel Witter developed an oxygen inhalation protocol in response to carbon monoxide poisoning in 1814.[9] Similarly, an oxygen inhalation protocol was recommend for malaria (literally translated to "bad air") in 1830 based on malaria symptoms aligning with carbon monoxide poisoning.[9] Other oxygen protocols emerged in the late 1800s.[10] The use of hyperbaric oxygen in rats following poisoning was studied by Haldane in 1895 while its use in humans began in the 1960s.[153]

### Incidents

[edit]

See also the categories Deaths from carbon monoxide poisoning and Deaths by smoke inhalation

See also: Charcoal-burning suicide

The worst accidental mass poisoning from carbon monoxide was the Balvano train disaster which occurred on 3 March 1944 in Italy, when a freight train with many illegal passengers stalled in a tunnel, leading to the death of over 500 people.[156]

Over 50 people are suspected to have died from smoke inhalation as a result of the Branch Davidian Massacre during the Waco siege in 1993.[157]

### Weaponization

[edit]

Main article: Gas chamber

In ancient history, Hannibal executed Roman prisoners with coal fumes during the Second Punic War.[9]

The extermination of stray dogs by a carbon monoxide gas chamber was described in 1874.[9] In 1884, an article appeared in Scientific American describing the use of a carbon monoxide gas chamber for slaughterhouse operations as well as euthanizing a variety of animals.[158]

As part of the Holocaust during World War II, the Nazis used gas vans at Chelmno extermination camp and elsewhere to murder an estimated 700,000 or more people by carbon monoxide poisoning. This method was also used in the gas chambers of several death camps such as Treblinka, Sobibor, and Belzec. Gassing with carbon monoxide started in Action T4. The gas was supplied by IG Farben in pressurized cylinders and fed by tubes into the gas chambers built at various mental hospitals, such as Hartheim Euthanasia Centre. Exhaust fumes from tank engines, for example, were used to supply the gas to the chambers.[159]

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[edit]

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98. ^ "Gas Safety in the Home". UK Gas Safe Register. Archived from the original on 2013-05-02. Retrieved 2013-05-27.
99. ^ "MGL Ch. 148 §28F1/2 – Nicole's Law, effective March 31, 2006". malegislature.gov. Archived from the original on December 30, 2012.
100. ^ "Massachusetts Law About Carbon Monoxide Detectors". Trial Court Law Libraries. Commonwealth of Massachusetts. Archived from the original on 2013-03-05. Retrieved 2013-02-22.
101. ^ Bennetto L, Powter L, Scolding NJ (April 2008). "Accidental carbon monoxide poisoning presenting without a history of exposure: a case report". Journal of Medical Case Reports. 2 (1): 118. doi:10.1186/1752-1947-2-118. PMC 2390579. PMID 18430228.
102. ^ Ford MD, Delaney KA, Ling LJ, Erickson T, eds. (2001). Clinical Toxicology. WB Saunders Company. p. 1046\. ISBN 978-0721654850.
103. ^ Sato, Keizo; Tamaki, Keiji; Hattori, Hideki; Moore, Christine Mary; Tsutsumi, Hajime; Okajima, Hiroshi; Katsumata, Yoshinao (November 1990). "Determination of total hemoglobin in forensic blood samples with special reference to carboxyhemoglobin analysis". Forensic Science International. 48 (1): 89–96. doi:10.1016/0379-0738(90)90275-4. PMID 2279722.
104. ^ R. Baselt, Disposition of Toxic Drugs and Chemicals in Man, 8th edition, Biomedical Publications, Foster City, CA, 2008, pp. 237–41.
105. ^ Keleş A, Demircan A, Kurtoğlu G (June 2008). "Carbon monoxide poisoning: how many patients do we miss?". European Journal of Emergency Medicine. 15 (3): 154–7. doi:10.1097/MEJ.0b013e3282efd519. PMID 18460956. S2CID 20998393.
106. ^ Rodkey FL, Hill TA, Pitts LL, Robertson RF (August 1979). "Spectrophotometric measurement of carboxyhemoglobin and methemoglobin in blood". Clinical Chemistry. 25 (8): 1388–93. doi:10.1093/clinchem/25.8.1388. PMID 455674.
107. ^ Rees PJ, Chilvers C, Clark TJ (January 1980). "Evaluation of methods used to estimate inhaled dose of carbon monoxide". Thorax. 35 (1): 47–51. doi:10.1136/thx.35.1.47. PMC 471219. PMID 7361284.
108. ^ Coulange M, Barthelemy A, Hug F, Thierry AL, De Haro L (March 2008). "Reliability of new pulse CO-oximeter in victims of carbon monoxide poisoning". Undersea & Hyperbaric Medicine. 35 (2): 107–11. PMID 18500075.
109. ^ Maisel WH, Lewis RJ (October 2010). "Noninvasive measurement of carboxyhemoglobin: how accurate is accurate enough?". Annals of Emergency Medicine. 56 (4): 389–91. doi:10.1016/j.annemergmed.2010.05.025. PMID 20646785.
110. ^ Vegfors M, Lennmarken C (May 1991). "Carboxyhaemoglobinaemia and pulse oximetry". British Journal of Anaesthesia. 66 (5): 625–6. doi:10.1093/bja/66.5.625. PMID 2031826.
111. ^ Barker SJ, Tremper KK (May 1987). "The effect of carbon monoxide inhalation on pulse oximetry and transcutaneous PO2". Anesthesiology. 66 (5): 677–9. doi:10.1097/00000542-198705000-00014. PMID 3578881.
112. ^ Jarvis MJ, Belcher M, Vesey C, Hutchison DC (November 1986). "Low cost carbon monoxide monitors in smoking assessment". Thorax. 41 (11): 886–7. doi:10.1136/thx.41.11.886. PMC 460516. PMID 3824275.
113. ^ Wald NJ, Idle M, Boreham J, Bailey A (May 1981). "Carbon monoxide in breath in relation to smoking and carboxyhaemoglobin levels". Thorax. 36 (5): 366–9. doi:10.1136/thx.36.5.366. PMC 471511. PMID 7314006.
114. ^ Ilano AL, Raffin TA (January 1990). "Management of carbon monoxide poisoning". Chest. 97 (1): 165–9. doi:10.1378/chest.97.1.165. PMID 2403894.
115. ^ Mathieu D (2006). Handbook on Hyperbaric Medicine (Online-Ausg. ed.). [New York]: Springer. ISBN 978-1402043765.
116. ^ a b Olson KR (1984). "Carbon monoxide poisoning: mechanisms, presentation, and controversies in management". The Journal of Emergency Medicine. 1 (3): 233–43. doi:10.1016/0736-4679(84)90078-7. PMID 6491241.
117. ^ Margulies JL (November 1986). "Acute carbon monoxide poisoning during pregnancy". The American Journal of Emergency Medicine. 4 (6): 516–9. doi:10.1016/S0735-6757(86)80008-0. PMID 3778597.
118. ^ Brown DB, Mueller GL, Golich FC (November 1992). "Hyperbaric oxygen treatment for carbon monoxide poisoning in pregnancy: a case report". Aviation, Space, and Environmental Medicine. 63 (11): 1011–4. PMID 1445151.
119. ^ a b c Buckley NA, Isbister GK, Stokes B, Juurlink DN (2005). "Hyperbaric oxygen for carbon monoxide poisoning : a systematic review and critical analysis of the evidence". Toxicological Reviews. 24 (2): 75–92. doi:10.2165/00139709-200524020-00002. hdl:1959.13/936317. PMID 16180928. S2CID 30011914.
120. ^ a b Buckley NA, Juurlink DN, Isbister G, Bennett MH, Lavonas EJ (April 2011). "Hyperbaric oxygen for carbon monoxide poisoning". The Cochrane Database of Systematic Reviews. 2011 (4): CD002041. doi:10.1002/14651858.CD002041.pub3. PMC 7066484. PMID 21491385.
121. ^ Henry JA (2005). "Hyperbaric therapy for carbon monoxide poisoning : to treat or not to treat, that is the question". Toxicological Reviews. 24 (3): 149–50, discussion 159–60. doi:10.2165/00139709-200524030-00002. PMID 16390211. S2CID 70992548.
122. ^ Olson KR (2005). "Hyperbaric oxygen or normobaric oxygen?". Toxicological Reviews. 24 (3): 151, discussion 159–60. doi:10.2165/00139709-200524030-00003. PMID 16390212. S2CID 41578807.
123. ^ Seger D (2005). "The myth". Toxicological Reviews. 24 (3): 155–6, discussion 159–60. doi:10.2165/00139709-200524030-00005. PMID 16390214. S2CID 40639134.
124. ^ Thom SR (2005). "Hyperbaric oxygen therapy for carbon monoxide poisoning : is it time to end the debates?". Toxicological Reviews. 24 (3): 157–8, discussion 159–60. doi:10.2165/00139709-200524030-00006. PMID 16390215. S2CID 71227659.
125. ^ Scheinkestel CD, Bailey M, Myles PS, Jones K, Cooper DJ, Millar IL, Tuxen DV (March 1999). "Hyperbaric or normobaric oxygen for acute carbon monoxide poisoning: a randomised controlled clinical trial". The Medical Journal of Australia. 170 (5): 203–10. doi:10.5694/j.1326-5377.1999.tb140318.x. PMID 10092916.
126. ^ Thom SR, Taber RL, Mendiguren II, Clark JM, Hardy KR, Fisher AB (April 1995). "Delayed neuropsychologic sequelae after carbon monoxide poisoning: prevention by treatment with hyperbaric oxygen". Annals of Emergency Medicine. 25 (4): 474–80. doi:10.1016/S0196-0644(95)70261-X. PMID 7710151.
127. ^ Raphael JC, Elkharrat D, Jars-Guincestre MC, Chastang C, Chasles V, Vercken JB, Gajdos P (August 1989). "Trial of normobaric and hyperbaric oxygen for acute carbon monoxide intoxication". Lancet. 2 (8660): 414–9. doi:10.1016/S0140-6736(89)90592-8. PMID 2569600. S2CID 26710636.
128. ^ Ducassé JL, Celsis P, Marc-Vergnes JP (March 1995). "Non-comatose patients with acute carbon monoxide poisoning: hyperbaric or normobaric oxygenation?". Undersea & Hyperbaric Medicine. 22 (1): 9–15. PMID 7742714. Archived from the original on 2011-08-11. Retrieved 2007-10-05.`{{cite journal}}`: CS1 maint: unfit URL (link)
129. ^ Mathieu D, Mathieu-Nolf M, Durak C, Wattel F, Tempe JP, Bouachour G, Sainty JM (1996). "Randomized prospective study comparing the effect of HBO vs 12 hours NBO in non-comatose CO-poisoned patients: results of the preliminary analysis". Undersea & Hyperbaric Medicine. 23: 7. Archived from the original on 2011-07-02. Retrieved 2008-05-16.`{{cite journal}}`: CS1 maint: unfit URL (link)
130. ^ Weaver LK, Hopkins RO, Chan KJ, Churchill S, Elliott CG, Clemmer TP, et al. (October 2002). "Hyperbaric oxygen for acute carbon monoxide poisoning". The New England Journal of Medicine. 347 (14): 1057–67. doi:10.1056/NEJMoa013121. PMID 12362006.
131. ^ Gorman DF (June 1999). "Hyperbaric or normobaric oxygen for acute carbon monoxide poisoning: a randomised controlled clinical trial. Unfortunate methodological flaws". The Medical Journal of Australia. 170 (11): 563, author reply 564–5. doi:10.5694/j.1326-5377.1999.tb127887.x. PMID 10397050. S2CID 28464628.
132. ^ Scheinkestel CD, Jones K, Myles PS, Cooper DJ, Millar IL, Tuxen DV (April 2004). "Where to now with carbon monoxide poisoning?". Emergency Medicine Australasia. 16 (2): 151–4. doi:10.1111/j.1742-6723.2004.00567.x. PMID 15239731.
133. ^ Isbister GK, McGettigan P, Harris I (February 2003). "Hyperbaric oxygen for acute carbon monoxide poisoning". The New England Journal of Medicine. 348 (6): 557–60, author reply 557–60. doi:10.1056/NEJM200302063480615. PMID 12572577.
134. ^ Buckley NA, Juurlink DN (June 2013). "Carbon monoxide treatment guidelines must acknowledge the limitations of the existing evidence". American Journal of Respiratory and Critical Care Medicine. 187 (12): 1390. doi:10.1164/rccm.201212-2262LE. PMID 23767905.
135. ^ Tomaszewski C (January 1999). "Carbon monoxide poisoning. Early awareness and intervention can save lives". Postgraduate Medicine. 105 (1): 39–40, 43–8, 50. doi:10.3810/pgm.1999.01.496. PMID 9924492.
136. ^ Peirce EC (1986). "Treating acidemia in carbon monoxide poisoning may be dangerous". Journal of Hyperbaric Medicine. 1 (2): 87–97. Archived from the original on 2011-07-03. Retrieved 2009-10-29.`{{cite journal}}`: CS1 maint: unfit URL (link)
137. ^ Devine SA, Kirkley SM, Palumbo CL, White RF (October 2002). "MRI and neuropsychological correlates of carbon monoxide exposure: a case report". Environmental Health Perspectives. 110 (10): 1051–5. doi:10.1289/ehp.021101051. PMC 1241033. PMID 12361932.
138. ^ O'Donnell P, Buxton PJ, Pitkin A, Jarvis LJ (April 2000). "The magnetic resonance imaging appearances of the brain in acute carbon monoxide poisoning". Clinical Radiology. 55 (4): 273–80. doi:10.1053/crad.1999.0369. PMID 10767186.
139. ^ Seger D, Welch L (August 1994). "Carbon monoxide controversies: neuropsychologic testing, mechanism of toxicity, and hyperbaric oxygen". Annals of Emergency Medicine. 24 (2): 242–8. doi:10.1016/S0196-0644(94)70136-9. PMID 8037390.
140. ^ Chiang CL, Tseng MC (27 September 2011). "Safe use of electroconvulsive therapy in a highly suicidal survivor of carbon monoxide poisoning". General Hospital Psychiatry. 34 (1): 103.e1–3. doi:10.1016/j.genhosppsych.2011.08.017. PMID 21958445.
141. ^ "Press Announcements - FDA allows marketing of new device to help treat carbon monoxide poisoning". www.fda.gov. Retrieved 21 March 2019.
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## External links

[edit]

* Centers for Disease Control and Prevention (CDC) – Carbon Monoxide – NIOSH Workplace Safety and Health Topic
* International Programme on Chemical Safety (1999). Carbon Monoxide, Environmental Health Criteria 213, Geneva: WHO

Classification|

* ICD-10: T58
* ICD-9-CM: 986
* MeSH: D002249

|

External resources|

* eMedicine: article/819987
* Patient UK: Carbon monoxide poisoning

* v
* t
* e

* Poisoning
* Toxicity
* Overdose

* Poison
* History

Inorganic|

| Metals|

| Toxic metals|

* Beryllium
* Cadmium
* Lead
* Mercury
* Nickel
* Thallium
* Tin

|

Dietary minerals|

* Chromium
* Cobalt
* Copper
* Iron
* Manganese
* Zinc

Other non-toxic metals|

* Silver1

Metalloids|

* Arsenic

Nonmetals|

* Sulfuric acid
* Selenium
* Chlorine
* Fluoride

Organic|

| Phosphorus|

* Pesticides
* Aluminium phosphide
* Organophosphates

|

Nitrogen|

* Cyanide
* Nicotine
* Nitrogen dioxide poisoning

CHO|

* alcohol
* Ethanol
* Ethylene glycol
* Methanol
* Carbon monoxide
* Oxygen
* Toluene

Pharmaceutical|

| Drug overdoses|

| Nervous|

* Alcohol
* Anticholinesterase
* Aspirin
* Barbiturates
* Benzodiazepines
* Cocaine
* Lithium
* Opioids
* Paracetamol
* Serotonergic substances
* Tricyclic antidepressants

|

Cardiovascular|

* Digoxin
* Dipyridamole

Vitamin poisoning|

* Vitamin A
* Vitamin D
* Vitamin E
* Megavitamin-B6 syndrome

Biological2|

| Fish / Seafood|

* Ciguatera
* Haff disease
* Ichthyoallyeinotoxism
* Scombroid
* Shellfish poisoning
* Amnesic
* Diarrhetic
* Neurotoxic
* Paralytic

|

Other vertebrates|

* Amphibian
* Batrachotoxin
* Bombesin
* Bufotenin
* Physalaemin
* Birds
* Coturnism
* Mammal
* Snakes / Snake venom
* Alpha-Bungarotoxin
* Ancrod
* Batroxobin

Arthropods|

* Arthropod bites and stings
* Bee sting / Bee venom
* Apamin
* Melittin
* Scorpion venom
* Charybdotoxin
* spider venom
* Latrotoxin / Latrodectism
* Loxoscelism
* Tick paralysis

Plants / Fungi|

* Cinchonism
* Ergotism
* Fish toxins
* Lathyrism
* Locoism
* Mushroom
* Strychnine

Related topics|

* Bite and Stinger
* plant
* Cnidocyte
* Venomous animals
* Poisonous animals
* Deadly fungus
* Mycotoxicology

Miscellaneous|

* Antibiotic
* EPA list of hazard
* Lists of poisonings
* List of types of poison
* Pollution

1Silver is generally non-toxic metal, but in large doses it can lead to argyria, which is rare.
2 including venoms, toxins, foodborne illnesses.

* Category
* Commons
* WikiProject

* v
* t
* e

Underwater diving

* Diving activities
* Diving modes
* Atmospheric pressure diving
* Freediving
* Saturation diving
* Scuba diving
* Snorkeling
* Surface oriented diving
* Surface-supplied diving
* Unmanned diving

Diving equipment

* Cleaning and disinfection of personal diving equipment
* Human factors in diving equipment design
* List of diving equipment manufacturers

| Basic equipment|

* Diving mask
* Snorkel
* Swimfin

|

Breathing gas|

* Bailout gas
* Bottom gas
* Breathing air
* Decompression gas
* Emergency gas supply
* Heliox
* Hydreliox
* Hydrox
* Nitrox
* Oxygen
* Travel gas
* Trimix

Buoyancy and
trim equipment|

* Avelo diving system
* Buoyancy compensator
* Power inflator
* Dump valve
* Variable buoyancy pressure vessel
* Diving weighting system
* Ankle weights
* Integrated weights
* Trim weights
* Weight belt

Decompression
equipment|

* Decompression buoy
* Decompression chamber
* Decompression cylinder
* Decompression trapeze
* Dive computer
* Diving bell
* Diving shot
* Diving stage
* Jersey upline
* Jonline

Diving suit|

* Atmospheric diving suit
* JIM suit
* Newtsuit
* Dry suit
* Sladen suit
* Standard diving suit
* Rash vest
* Wetsuit
* Dive skins
* Hot-water suit

Helmets
and masks|

* Anti-fog
* Diving helmet
* Free-flow helmet
* Lightweight demand helmet
* Orinasal mask
* Reclaim helmet
* Shallow water helmet
* Standard diving helmet
* Diving mask
* Band mask
* Full-face mask
* Half mask

Instrumentation|

* Bottom timer
* Depth gauge
* Dive computer
* Dive timer
* Diving watch
* Helium release valve
* Electro-galvanic oxygen sensor
* Pneumofathometer
* Submersible pressure gauge

Mobility
equipment|

* Diver propulsion vehicle
* Diving bell
* Closed bell
* Wet bell
* Diving stage
* Swimfin
* Monofin
* PowerSwim
* Towboard
* Wet sub

Safety
equipment|

* Alternative air source
* Octopus regulator
* Pony bottle
* Bolt snap
* Buddy line
* Dive light
* Diver's cutting tool
* Diver's knife
* Diver's telephone
* Through-water communications
* Underwater acoustic communication
* Diving bell
* Diving safety harness
* Emergency gas supply
* Bailout block
* Bailout bottle
* Lifeline
* Screw gate carabiner
* Emergency locator beacon
* Rescue tether
* Safety helmet
* Shark-proof cage
* Snoopy loop
* Navigation equipment
* Distance line
* Diving compass
* Dive reel
* Line marker
* Surface marker buoy
* Silt screw

Underwater
breathing
apparatus|

* Atmospheric diving suit
* Diving cylinder
* Burst disc
* Scuba cylinder valve
* Diving helmet
* Reclaim helmet
* Diving regulator
* Mechanism of diving regulators
* Regulator malfunction
* Regulator freeze
* Single-hose regulator
* Twin-hose regulator
* Full-face diving mask

| Open-circuit
scuba|

* Scuba set
* Bailout bottle
* Decompression cylinder
* Independent doubles
* Manifolded twin set
* Scuba manifold
* Pony bottle
* Scuba configuration
* Sidemount
* Sling cylinder

|

Diving rebreathers|

* Carbon dioxide scrubber
* Carleton CDBA
* Clearance Divers Life Support Equipment
* Cryogenic rebreather
* CUMA
* DSEA
* Dolphin
* Halcyon PVR-BASC
* Halcyon RB80
* IDA71
* Interspiro DCSC
* LAR-5
* LAR-6
* LAR-V
* LARU
* Mark IV Amphibian
* Porpoise
* Ray
* Siebe Gorman CDBA
* Salvus
* Siva

Surface-supplied
diving equipment|

* Air line
* Diver's umbilical
* Diving air compressor
* Gas panel
* Hookah
* Scuba replacement
* Snuba
* Standard diving dress

Diving
equipment
manufacturers|

* AP Diving
* Apeks
* Aqua Lung America
* Aqua Lung/La Spirotechnique
* Beuchat
* René Cavalero
* Cis-Lunar
* Cressi-Sub
* Dacor
* DESCO
* Dive Xtras
* Divex
* Diving Unlimited International
* Drägerwerk
* Faber
* Fenzy
* Maurice Fernez
* Technisub
* Oscar Gugen
* Heinke
* HeinrichsWeikamp
* Johnson Outdoors
* Mares
* Morse Diving
* Nemrod
* Oceanic Worldwide
* Porpoise
* Shearwater Research
* Siebe Gorman
* Submarine Products
* Suunto

Diving support equipment

| Access equipment|

* Boarding stirrup
* Diver lift
* Diving bell
* Diving ladder
* Diving platform (scuba)
* Diving stage
* Downline
* Jackstay
* Launch and recovery system
* Messenger line
* Moon pool

|

Breathing gas
handling|

* Air filtration
* Activated carbon
* Hopcalite
* Molecular sieve
* Silica gel
* Booster pump
* Carbon dioxide scrubber
* Cascade filling system
* Diver's pump
* Diving air compressor
* Diving air filter
* Water separator
* High pressure breathing air compressor
* Low pressure breathing air compressor
* Gas blending
* Gas blending for scuba diving
* Gas panel
* Gas reclaim system
* Gas storage bank
* Gas storage quad
* Gas storage tube
* Helium analyzer
* Nitrox production
* Membrane gas separation
* Pressure swing adsorption
* Oxygen analyser
* Electro-galvanic oxygen sensor
* Oxygen compatibility

Decompression
equipment|

* Air-lock
* Built-in breathing system
* Decompression tables
* Diving bell
* Bell cursor
* Closed bell
* Clump weight
* Launch and recovery system
* Wet bell
* Diving chamber
* Diving stage
* Recreational Dive Planner
* Saturation system

Platforms|

* Dive boat
* Canoe and kayak diving
* Combat rubber raiding craft
* Liveaboard
* Subskimmer
* Diving support vessel
* HMS Challenger (K07)

| Underwater
habitat|

* Aquarius Reef Base
* Continental Shelf Station Two
* Helgoland Habitat
* Scott Carpenter Space Analog Station
* SEALAB
* Tektite habitat

|

Remotely operated
underwater vehicles|

* 8A4-class ROUV
* ABISMO
* Atlantis ROV Team
* COTSBot
* CURV
* Deep Drone
* Épaulard
* Global Explorer ROV
* Goldfish-class ROUV
* Kaikō ROV
* Kaşif ROUV
* Long-Term Mine Reconnaissance System
* Mini Rover ROV
* OpenROV
* ROV KIEL 6000
* ROV PHOCA
* Scorpio ROV
* Sea Dragon-class ROV
* Seabed tractor
* Seafox drone
* SeaPerch
* SJT-class ROUV
* T1200 Trenching Unit
* VideoRay UROVs

Safety equipment|

* Diver down flag
* Diving shot
* ENOS Rescue-System
* Hyperbaric lifeboat
* Hyperbaric stretcher
* Jackstay
* Jonline
* Reserve gas supply

General|

* Diving spread
* Air spread
* Saturation spread
* Hot water system
* Sonar
* Underwater acoustic positioning system
* Underwater acoustic communication

Freediving

| Activities|

* Aquathlon
* Apnoea finswimming
* Freediving
* Haenyeo
* Pearl hunting
* Ama
* Snorkeling
* Spearfishing
* Underwater football
* Underwater hockey
* Underwater rugby
* Underwater target shooting

|

Competitions|

* Nordic Deep
* Vertical Blue
* Disciplines
* Constant weight (CWT)
* Constant weight bi-fins (CWTB)
* Constant weight without fins (CNF)
* Dynamic apnea (DYN)
* Dynamic apnea without fins (DNF)
* Free immersion (FIM)
* No-limits apnea (NLT)
* Static apnea (STA)
* Skandalopetra diving
* Variable weight apnea (VWT)
* Variable weight apnea without fins

Equipment|

* Diving mask
* Diving suit
* Hawaiian sling
* Polespear
* Snorkel (swimming)
* Speargun
* Swimfins
* Monofin
* Water polo cap

Freedivers|

* Deborah Andollo
* Simone Arrigoni
* Peppo Biscarini
* Michael Board
* Sara Campbell
* Derya Can Göçen
* Goran Čolak
* Carlos Coste
* Robert Croft
* Mandy-Rae Cruickshank
* Yasemin Dalkılıç
* Leonardo D'Imporzano
* Flavia Eberhard
* Şahika Ercümen
* Emma Farrell
* Francisco Ferreras
* Pierre Frolla
* Flavia Eberhard
* Mehgan Heaney-Grier
* Elisabeth Kristoffersen
* Andriy Yevhenovych Khvetkevych
* Loïc Leferme
* Enzo Maiorca
* Jacques Mayol
* Audrey Mestre
* Karol Meyer
* Kate Middleton
* Stéphane Mifsud
* Alexey Molchanov
* Natalia Molchanova
* Dave Mullins
* Patrick Musimu
* Guillaume Néry
* Herbert Nitsch
* Umberto Pelizzari
* Liv Philip
* Annelie Pompe
* Stig Severinsen
* Tom Sietas
* Aharon Solomons
* Martin Štěpánek
* Walter Steyn
* Tanya Streeter
* William Trubridge
* Devrim Cenk Ulusoy
* Fatma Uruk
* Danai Varveri
* Alessia Zecchini
* Nataliia Zharkova

Hazards|

* Barotrauma
* Drowning
* Freediving blackout
* Deep-water blackout
* Shallow-water blackout
* Hypercapnia
* Hypothermia

Historical|

* Ama
* Octopus wrestling
* Swimming at the 1900 Summer Olympics – Men's underwater swimming

Organisations|

* AIDA International
* Scuba Schools International
* Australian Underwater Federation
* British Freediving Association
* Confédération Mondiale des Activités Subaquatiques
* Fédération Française d'Études et de Sports Sous-Marins
* Performance Freediving International

Professional diving

| Occupations|

* Ama
* Commercial diver
* Commercial offshore diver
* Hazmat diver
* Divemaster
* Diving instructor
* Diving safety officer
* Diving superintendent
* Diving supervisor
* Haenyeo
* Media diver
* Police diver
* Public safety diver
* Scientific diver
* Underwater archaeologist

| Military
diving|

* Army engineer diver
* Canadian Armed Forces Divers
* Clearance diver
* Frogman
* Minentaucher
* Royal Navy ships diver
* United States military divers
* U.S. Navy diver
* U.S.Navy master diver

| Military
diving
units|

* 7th Marine Brigade [zh]
* Clearance Diving Branch (RAN)
* Commando Hubert
* Combat Divers Service (Lithuania)
* Comando Raggruppamento Subacquei e Incursori Teseo Tesei
* Decima Flottiglia MAS
* Frogman Corps (Denmark)
* Fuerzas Especiales
* Fukuryu
* GRUMEC
* Grup Gerak Khas
* Jagdkommando
* JW Formoza
* JW GROM
* JW Komandosów
* Kommando Spezialkräfte Marine
* KOPASKA
* MARCOS
* Marine Commandos
* Marinejegerkommandoen
* Marine Raider Regiment
* Minedykkerkommandoen
* Namibian Marine Corps Operational Diving Unit
* Naval Diving Unit (Singapore)
* Naval Service Diving Section
* Naval Special Operations Command
* Operational Diving Division (SA Navy)
* Royal Engineers
* Russian commando frogmen
* Sappers Divers Group
* Shayetet 13
* Special Air Service
* Special Air Service Regiment
* Special Actions Detachment
* Special Boat Service
* Special Boat Squadron (Sri Lanka)
* Special Forces Command (Turkey)
* Special Forces Group (Belgium)
* Special Operations Battalion (Croatia)
* Special Service Group (Navy)
* Special Warfare Diving and Salvage
* Tactical Divers Group
* US Marine Corps Force Reconnaissance
* US Marine Corps Reconnaissance Battalions
* US Navy SEALs
* Underwater Construction Teams
* Underwater Demolition Command
* Underwater Demolition Team
* Underwater Offence (Turkish Armed Forces)
* UNGERIN

|

Underwater
work|

* Commercial offshore diving
* Dive leader
* Diver training
* Recreational diver training
* Hazmat diving
* Hyperbaric welding
* Marine construction
* Offshore construction
* Underwater construction
* Media diving
* Pearl hunting
* Police diving
* Potable water diving
* Public safety diving
* Scientific diving
* Ships husbandry
* Sponge diving
* Submarine pipeline
* Underwater archaeology
* Archaeology of shipwrecks
* Underwater cutting and welding
* Underwater demolition
* Underwater inspection
* Nondestructive testing
* Underwater logging
* Underwater photography
* Underwater search and recovery
* Underwater searches
* Underwater videography
* Underwater survey

| Salvage diving|

* SS Egypt
* Kronan
* La Belle
* SS Laurentic
* RMS Lusitania
* Mars
* Mary Rose
* USS Monitor
* HMS Royal George
* Vasa

|

Diving
contractors|

* COMEX
* Helix Energy Solutions Group
* International Marine Contractors Association

Tools and
equipment|

* Abrasive waterjet
* Airlift
* Baited remote underwater video
* In-water surface cleaning
* Brush cart
* Cavitation cleaning
* Pressure washing
* Pigging
* Hot stab
* Lifting bag
* Remotely operated underwater vehicle
* Thermal lance
* Tremie
* Water jetting

Underwater
weapons|

* Limpet mine
* Speargun
* Hawaiian sling
* Polespear

| Underwater
firearm|

* Gyrojet
* Mk 1 Underwater Defense Gun
* Powerhead
* Underwater pistols
* Heckler & Koch P11
* SPP-1 underwater pistol
* Underwater revolvers
* AAI underwater revolver
* Underwater rifles
* ADS amphibious rifle
* APS underwater rifle
* ASM-DT amphibious rifle
* QBS-06

|

Recreational diving

* Recreational dive sites
* Index of recreational dive sites
* List of wreck diving sites
* Outline of recreational dive sites

| Specialties|

* Altitude diving
* Cave diving
* Deep diving
* Ice diving
* Muck diving
* Open-water diving
* Rebreather diving
* Sidemount diving
* Solo diving
* Technical diving
* Underwater photography
* Wreck diving

|

Diver
organisations|

* British Sub-Aqua Club (BSAC)
* Cave Divers Association of Australia (CDAA)
* Cave Diving Group (CDG)
* Comhairle Fo-Thuinn (CFT)
* Confédération Mondiale des Activités Subaquatiques (CMAS)
* Federación Española de Actividades Subacuáticas (FEDAS)
* Fédération Française d'Études et de Sports Sous-Marins (FFESSM)
* International Association for Handicapped Divers (IAHD)
* Quintana Roo Speleological Survey (QRSS)
* Woodville Karst Plain Project (WKPP)

Diving tourism
industry|

* Dive center
* Diving in East Timor
* Diving in the Maldives
* Environmental impact of recreational diving
* Scuba diving tourism
* Scuba diving in the Cayman Islands
* Shark tourism
* Sinking ships for wreck diving sites
* Underwater diving on Guam

Diving events
and festivals|

* Diversnight
* Underwater Bike Race

Diving safety

* Human factors in diving equipment design
* Human factors in diving safety
* Life-support system
* Safety-critical system
* Scuba diving fatalities
* Underwater diving emergency
* Water safety
* Water surface searches

| Diving
hazards|

* List of diving hazards and precautions
* Environmental
* Current
* Delta-P
* Entanglement hazard
* Overhead
* Silt out
* Wave action
* Equipment
* Freeflow
* Use of breathing equipment in an underwater environment
* Failure of diving equipment other than breathing apparatus
* Single point of failure
* Physiological
* Cold shock response
* Decompression
* Nitrogen narcosis
* Oxygen toxicity
* Seasickness
* Uncontrolled decompression
* Diver behaviour and competence
* Lack of competence
* Overconfidence effect
* Panic
* Task loading
* Trait anxiety
* Willful violation

| Consequences|

* Barotrauma
* Decompression sickness
* Drowning
* Hypothermia
* Hypoxia
* Hypercapnia
* Hyperthermia
* Non-freezing cold injury

|

Diving
procedures|

* Ascending and descending
* Emergency ascent
* Boat diving
* Canoe and kayak diving
* Buddy diving
* buddy check
* Decompression
* Decompression practice
* Pyle stop
* Ratio decompression
* Dive briefing
* Dive log
* Dive planning
* Rule of thirds
* Scuba gas planning
* Diver communications
* Diver rescue
* Diver training
* Doing It Right
* Drift diving
* Gas blending for scuba diving
* Night diving
* Rebreather diving
* Scuba gas management
* Solo diving
* Wall diving

Risk
management|

* Checklist
* Hazard identification and risk assessment
* Hazard analysis
* Job safety analysis
* Risk assessment
* Hyperbaric evacuation and rescue
* Risk control
* Hierarchy of hazard controls
* Incident pit
* Lockout–tagout
* Permit To Work
* Redundancy
* Safety data sheet
* Situation awareness

| Diving team|

* Bellman
* Chamber operator
* Diver medical technician
* Diver's attendant
* Diving supervisor
* Diving systems technician
* Gas man
* Life support technician
* Stand-by diver

|

Equipment
safety|

* Breathing gas quality
* Testing and inspection of diving cylinders
* Hydrostatic test
* Sustained load cracking
* Diving regulator
* Breathing performance of regulators

Occupational
safety and
health|

* Association of Diving Contractors International
* International Marine Contractors Association
* Code of practice
* Contingency plan
* Diving regulations
* Emergency response plan
* Diving safety officer
* Diving superintendent
* Diving supervisor
* Operations manual
* Standard operating procedure

Diving medicine

| Diving
disorders|

* List of signs and symptoms of diving disorders
* Cramp
* Motion sickness
* Surfer's ear

| Pressure
related|

* Alternobaric vertigo
* Barostriction
* Barotrauma
* Air embolism
* Aerosinusitis
* Barodontalgia
* Dental barotrauma
* Middle ear barotrauma
* Pulmonary barotrauma
* Compression arthralgia
* Decompression illness
* Dysbarism

| Oxygen|

* Freediving blackout
* Hyperoxia
* Hypoxia
* Oxygen toxicity

|

Inert gases|

* Avascular necrosis
* Decompression sickness
* Dysbaric osteonecrosis
* Inner ear decompression sickness
* Isobaric counterdiffusion
* Taravana
* High-pressure nervous syndrome
* Hydrogen narcosis
* Nitrogen narcosis

Carbon dioxide|

* Hypercapnia
* Hypocapnia

Breathing gas
contaminants|

* Carbon monoxide poisoning

Immersion
related|

* Asphyxia
* Drowning
* Hypothermia
* Immersion diuresis
* Instinctive drowning response
* Laryngospasm
* Salt water aspiration syndrome
* Swimming-induced pulmonary edema

Treatment|

* Demand valve oxygen therapy
* First aid
* Hyperbaric medicine
* Hyperbaric treatment schedules
* In-water recompression
* Oxygen therapy
* Therapeutic recompression

Personnel|

* Diving Medical Examiner
* Diving Medical Practitioner
* Diving Medical Technician
* Hyperbaric nursing

Screening|

* Atrial septal defect
* Effects of drugs on fitness to dive
* Fitness to dive
* Psychological fitness to dive

Research|

| Researchers in
diving physiology
and medicine|

* Arthur J. Bachrach
* Albert R. Behnke
* Peter B. Bennett
* Paul Bert
* George F. Bond
* Robert Boyle
* Alf O. Brubakk
* Albert A. Bühlmann
* John R. Clarke
* Guybon Chesney Castell Damant
* Kenneth William Donald
* William Paul Fife
* John Scott Haldane
* Robert William Hamilton Jr.
* Henry Valence Hempleman
* Leonard Erskine Hill
* Brian Andrew Hills
* Felix Hoppe-Seyler
* Christian J. Lambertsen
* Simon Mitchell
* Charles Momsen
* Neal W. Pollock
* John Rawlins
* Charles Wesley Shilling
* Edward D. Thalmann
* Jacques Triger

|

Diving medical
research
organisations|

* Aerospace Medical Association
* Divers Alert Network (DAN)
* Diving Diseases Research Centre (DDRC)
* Diving Medical Advisory Council (DMAC)
* European Diving Technology Committee (EDTC)
* European Underwater and Baromedical Society (EUBS)
* National Board of Diving and Hyperbaric Medical Technology
* Naval Submarine Medical Research Laboratory
* Royal Australian Navy School of Underwater Medicine
* Rubicon Foundation
* South Pacific Underwater Medicine Society (SPUMS)
* Southern African Underwater and Hyperbaric Medical Association (SAUHMA)
* Undersea and Hyperbaric Medical Society (UHMS)
* United States Navy Experimental Diving Unit (NEDU)

Law

* Civil liability in recreational diving
* Diving regulations
* Duty of care
* List of legislation regulating underwater diving
* Investigation of diving accidents
* Convention on the Protection of the Underwater Cultural Heritage

History of underwater diving

* History of decompression research and development
* History of dive computers
* History of Diving Museum
* History of scuba diving
* List of researchers in underwater diving
* Lyons Maritime Museum
* Man in the Sea Museum
* Timeline of atmospheric diving suits
* Timeline of diving technology
* Pearling in Western Australia
* US Navy decompression models and tables

| Archeological
sites|

* SS Commodore
* USS Monitor
* Queen Anne's Revenge
* Whydah Gally

|

Underwater art
and artists|

* The Diver
* Jason deCaires Taylor

Engineers
and inventors|

* Jerónimo de Ayanz y Beaumont
* William Beebe
* Georges Beuchat
* Giovanni Alfonso Borelli
* Joseph-Martin Cabirol
* John R. Clarke
* Jacques Cousteau
* Charles Anthony Deane
* John Deane
* Louis de Corlieu
* Auguste Denayrouze
* Ted Eldred
* Henry Fleuss
* Émile Gagnan
* Karl Heinrich Klingert
* Peter Kreeft
* Christian J. Lambertsen
* Yves Le Prieur
* John Lethbridge
* Ernest William Moir
* Joseph Salim Peress
* Auguste Piccard
* Joe Savoie
* Willard Franklyn Searle
* Gordon Smith
* Augustus Siebe
* Pierre-Marie Touboulic
* Jacques Triger

Historical
equipment|

* Aqua-Lung
* RV Calypso
* SP-350 Denise
* Magnesium torch
* Nikonos
* Porpoise regulator
* Standard diving dress
* Sub Marine Explorer
* Vintage scuba

| Diver
propulsion
vehicles|

* Advanced SEAL Delivery System
* Cosmos CE2F series
* Dry Combat Submersible
* Human torpedo
* Motorised Submersible Canoe
* Necker Nymph
* R-2 Mala-class swimmer delivery vehicle
* SEAL Delivery Vehicle
* Shallow Water Combat Submersible
* Siluro San Bartolomeo
* Welfreighter
* Wet Nellie

|

Military and
covert operations|

* Raid on Alexandria (1941)
* Sinking of the Rainbow Warrior

Scientific projects|

* 1992 cageless shark-diving expedition
* Mission 31

Awards and events|

* Hans Hass Award
* International Scuba Diving Hall of Fame
* London Diving Chamber Dive Lectures
* NOGI Awards
* Women Divers Hall of Fame

Incidents|

| Dive boat incidents|

* Sinking of MV Conception

|

Diver rescues|

* Alpazat cave rescue
* Tham Luang cave rescue

Early diving|

* John Day (carpenter)
* Charles Spalding
* Ebenezer Watson

Freediving fatalities|

* Stephen Keenan
* Loïc Leferme
* Audrey Mestre
* Nicholas Mevoli
* Natalia Molchanova

Offshore
diving incidents|

* Byford Dolphin diving bell accident
* Drill Master diving accident
* Star Canopus diving accident
* Stena Seaspread diving accident
* Venture One diving accident
* Waage Drill II diving accident
* Wildrake diving accident

Professional
diving fatalities|

* Roger Baldwin
* John Bennett
* Victor F. Guiel Jr.
* Francis P. Hammerberg
* Craig M. Hoffman
* Peter Henry Michael Holmes
* Johnson Sea Link accident
* Edwin Clayton Link
* Gerard Anthony Prangley
* Per Skipnes
* Robert John Smyth
* Albert D. Stover
* Richard A. Walker
* Lothar Michael Ward
* Joachim Wendler
* Bradley Westell
* Arne Zetterström

Scuba diving
fatalities|

* 1973 Mount Gambier cave diving accident
* Ricardo Armbruster
* Allan Bridge
* David Bright
* Berry L. Cannon
* Cotton Coulson
* Cláudio Coutinho
* E. Yale Dawson
* Deon Dreyer
* Milan Dufek
* Sheck Exley
* Maurice Fargues
* Fernando Garfella Palmer
* Guy Garman
* Steve Irwin
* death
* Jim Jones
* Henry Way Kendall
* Artur Kozłowski
* Yuri Lipski
* Kirsty MacColl
* Linnea Mills
* Agnes Milowka
* François de Roubaix
* Chris and Chrissy Rouse
* Dave Shaw
* Wesley C. Skiles
* Dewey Smith
* Rob Stewart
* Esbjörn Svensson
* Josef Velek

Publications

| Manuals|

* NOAA Diving Manual
* U.S. Navy Diving Manual
* Basic Cave Diving: A Blueprint for Survival
* Underwater Handbook
* Bennett and Elliott's physiology and medicine of diving
* Encyclopedia of Recreational Diving
* The new science of skin and scuba diving
* Professional Diver's Handbook
* Basic Scuba

|

Standards and
Codes of Practice|

* Code of Practice for Scientific Diving (UNESCO)
* DIN 7876
* IMCA Code of Practice for Offshore Diving
* ISO 24801 Recreational diving services — Requirements for the training of recreational scuba divers

General non-fiction|

* The Darkness Beckons
* Goldfinder
* The Last Dive
* Shadow Divers
* The Silent World: A Story of Undersea Discovery and Adventure

Research|

* List of Divers Alert Network publications

Dive guides|

Training and registration

| Diver
training|

* Competence and assessment
* Competency-based learning
* Refresher training
* Skill assessment
* Diver training standard
* Diving instructor
* Diving school
* Occupational diver training
* Commercial diver training
* Military diver training
* Public safety diver training
* Scientific diver training
* Recreational diver training
* Introductory diving
* ISO training standards
* Teaching method
* Muscle memory
* Overlearning
* Stress exposure training

| Skills|

* Combat sidestroke
* Diver navigation
* Diver trim
* Ear clearing
* Frenzel maneuver
* Valsalva maneuver
* Finning techniques
* Scuba skills
* Buddy breathing
* Low impact diving
* Diamond Reef System
* Surface-supplied diving skills
* Underwater searches

|

Recreational
scuba
certification
levels|

| Core diving skills|

* Advanced Open Water Diver
* Autonomous diver
* CMAS* scuba diver
* CMAS** scuba diver
* Introductory diving
* Low Impact Diver
* Master Scuba Diver
* Open Water Diver
* Supervised diver

|

Leadership skills|

* Dive leader
* Divemaster
* Diving instructor
* Master Instructor

Specialist skills|

* Rescue Diver
* Solo diver

Diver training
certification
and registration
organisations|

* European Underwater Federation (EUF)
* International Diving Regulators and Certifiers Forum (IDRCF)
* International Diving Schools Association (IDSA)
* International Marine Contractors Association (IMCA)
* List of diver certification organizations
* National Oceanic and Atmospheric Administration (NOAA)
* Nautical Archaeology Society
* Recreational diver course referral
* World Recreational Scuba Training Council (WRSTC)

| Commercial diver
certification
authorities|

* Australian Diver Accreditation Scheme (ADAS)
* Commercial diver registration in South Africa
* Divers Institute of Technology
* Health and Safety Executive (HSE)
* Department of Employment and Labour

|

Commercial diving
schools|

* Divers Academy International
* Norwegian diver school

Free-diving
certification
agencies|

* AIDA International (AIDA)
* Confédération Mondiale des Activités Subaquatiques (CMAS)
* Performance Freediving International (PI)
* Scuba Schools International (SSI)

Recreational
scuba
certification
agencies|

* American Canadian Underwater Certifications (ACUC)
* American Nitrox Divers International (ANDI)
* Association nationale des moniteurs de plongée (ANMP)
* British Sub-Aqua Club (BSAC)
* Comhairle Fo-Thuinn (CFT)
* Confédération Mondiale des Activités Subaquatiques (CMAS)
* Federación Española de Actividades Subacuáticas (FEDAS)
* Fédération Française d'Études et de Sports Sous-Marins (FFESSM)
* Federazione Italiana Attività Subacquee (FIAS)
* Global Underwater Explorers (GUE)
* International Association for Handicapped Divers (IAHD)
* International Association of Nitrox and Technical Divers (IANTD)
* International Life Saving Federation (ILS)
* Israeli Diving Federation (TIDF)
* National Academy of Scuba Educators (NASE)
* National Association of Underwater Instructors (NAUI)
* Nederlandse Onderwatersport Bond (NOB)
* Professional Association of Diving Instructors (PADI)
* Professional Diving Instructors Corporation (PDIC)
* Professional Technical and Recreational Diving (ProTec)
* Rebreather Association of International Divers (RAID)
* Sub-Aqua Association (SAA)
* Scuba Diving International (SDI)
* Scuba Educators International (SEI)
* Scottish Sub Aqua Club (ScotSAC)
* Scuba Schools International (SSI)
* Türkiye Sualtı Sporları Federasyonu (TSSF)
* United Diving Instructors (UDI)
* YMCA SCUBA Program

Scientific diver
certification
authorities|

* American Academy of Underwater Sciences (AAUS)
* CMAS Scientific Committee

Technical diver
certification
agencies|

* American Nitrox Divers International (ANDI)
* British Sub-Aqua Club (BSAC)
* Confédération Mondiale des Activités Subaquatiques (CMAS)
* Diving Science and Technology (DSAT)
* Federazione Italiana Attività Subacquee (FIAS)
* International Association of Nitrox and Technical Divers (IANTD)
* Professional Association of Diving Instructors (PADI)
* Professional Diving Instructors Corporation (PDIC)
* Professional Technical and Recreational Diving (ProTec)
* Rebreather Association of International Divers (RAID)
* Trimix Scuba Association (TSA)
* Technical Extended Range (TXR)

| Cave
diving|

* Cave Divers Association of Australia (CDAA)
* Cave Diving Group (CDG)
* Global Underwater Explorers (GUE)
* National Speleological Society#Cave Diving Group (CDG)
* National Association of Underwater Instructors (NAUI)
* Technical Diving International (TDI)

|

Military diver
training centres|

* Defence Diving School
* Navy Diving Salvage and Training Center
* Underwater Escape Training Unit

Military diver
training courses|

* United States Marine Corps Combatant Diver Course

Underwater sports

| Surface snorkeling|

* Finswimming

|

Snorkeling/breath-hold|

* Spearfishing
* Underwater football
* Underwater hockey
* Australia
* Turkey
* Underwater rugby
* Colombia
* United States
* Underwater target shooting

Breath-hold|

* Aquathlon
* Apnoea finswimming
* Freediving

Open Circuit Scuba|

* Immersion finswimming
* Sport diving
* Underwater cycling
* Underwater orienteering
* Underwater photography

Rebreather|

* Underwater photography

Sports governing
organisations
and federations|

* International
* AIDA International
* Confédération Mondiale des Activités Subaquatiques)
* National
* AIDA Hellas
* Australian Underwater Federation
* British Freediving Association
* British Octopush Association
* British Underwater Sports Association
* Comhairle Fo-Thuinn
* Federación Española de Actividades Subacuáticas
* Fédération Française d'Études et de Sports Sous-Marins
* South African Underwater Sports Federation
* Türkiye Sualtı Sporları Federasyonu
* Underwater Society of America)

Competitions|

* 14th CMAS Underwater Photography World Championship
* Underwater Hockey World Championships
* Underwater Orienteering World Championships
* Underwater Rugby World Championships

Underwater divers

| Pioneers
of diving|

* Eduard Admetlla i Lázaro
* Aquanaut
* Mary Bonnin
* Amelia Behrens-Furniss
* James F. Cahill
* Jacques Cousteau
* Billy Deans
* Dottie Frazier
* Trevor Hampton
* Hans Hass
* Hannes Keller
* Dick Rutkowski
* Teseo Tesei
* Arne Zetterström

|

Underwater
scientists
archaeologists and
environmentalists|

* Michael Arbuthnot
* Robert Ballard
* George Bass
* Mensun Bound
* Louis Boutan
* Jeffrey Bozanic
* Hugh Bradner
* Cathy Church
* Eugenie Clark
* James P. Delgado
* Sylvia Earle
* John Christopher Fine
* George R. Fischer
* Anders Franzén
* Honor Frost
* Fernando Garfella Palmer
* David Gibbins
* Graham Jessop
* Swietenia Puspa Lestari
* Pilar Luna
* Robert F. Marx
* Anna Marguerite McCann
* Innes McCartney
* Charles T. Meide
* Mark M. Newell
* Lyuba Ognenova-Marinova
* John Peter Oleson
* Mendel L. Peterson
* Richard Pyle
* Andreas Rechnitzer
* William R. Royal
* Margaret Rule
* Gunter Schöbel
* Stephanie Schwabe
* Myriam Seco
* E. Lee Spence
* Robert Sténuit
* Peter Throckmorton
* Cristina Zenato

Scuba record
holders|

* Pascal Bernabé
* Jim Bowden
* Mark Ellyatt
* Sheck Exley
* Nuno Gomes
* Claudia Serpieri
* Krzysztof Starnawski

Underwater
filmmakers
and presenters|

* Samir Alhafith
* David Attenborough
* Ramón Bravo
* Jean-Michel Cousteau
* Richie Kohler
* Paul Rose
* Andy Torbet
* Ivan Tors
* Andrew Wight
* James Cameron

Underwater
photographers|

* Doug Allan
* Tamara Benitez
* Georges Beuchat
* Adrian Biddle
* Jonathan Bird
* Eric Cheng
* Neville Coleman
* Jacques Cousteau
* John D. Craig
* Ben Cropp
* Bernard Delemotte
* David Doubilet
* Candice Farmer
* John Christopher Fine
* Rodney Fox
* Ric Frazier
* Stephen Frink
* Peter Gimbel
* Monty Halls
* Hans Hass
* Henry Way Kendall
* Rudie Kuiter
* Joseph B. MacInnis
* Luis Marden
* Agnes Milowka
* Noel Monkman
* Pete Oxford
* Steve Parish
* Zale Parry
* Pierre Petit
* Leni Riefenstahl
* Peter Scoones
* Brian Skerry
* Wesley C. Skiles
* E. Lee Spence
* Philippe Tailliez
* Ron Taylor
* Valerie Taylor
* Albert Tillman
* John Veltri
* Stan Waterman
* Michele Westmorland
* John Ernest Williamson
* J. Lamar Worzel

Underwater
explorers|

* Caves
* Graham Balcombe
* Sheck Exley
* Martyn Farr
* Jochen Hasenmayer
* Jill Heinerth
* Jarrod Jablonski
* William Hogarth Main
* Tom Mount
* Jack Sheppard
* Bill Stone
* Reefs
* Arthur C. Clarke
* Wrecks
* Leigh Bishop
* John Chatterton
* Clive Cussler
* Bill Nagle
* Valerie van Heest
* Aristotelis Zervoudis

Aquanauts|

* Andrew Abercromby
* Joseph M. Acaba
* Clayton Anderson
* Richard R. Arnold
* Serena Auñón-Chancellor
* Michael Barratt (astronaut)
* Robert A. Barth
* Robert L. Behnken
* Randolph Bresnik
* Timothy J. Broderick
* Justin Brown
* Berry L. Cannon
* Scott Carpenter
* Gregory Chamitoff
* Steve Chappell
* Catherine Coleman
* Robin Cook
* Craig B. Cooper
* Fabien Cousteau
* Philippe Cousteau
* Timothy Creamer
* Jonathan Dory
* Pedro Duque
* Sylvia Earle
* Jeanette Epps
* Sheck Exley
* Albert Falco
* Andrew J. Feustel
* Michael Fincke
* Satoshi Furukawa
* Ronald J. Garan Jr.
* Michael L. Gernhardt
* Christopher E. Gerty
* David Gruber
* Chris Hadfield
* Jeremy Hansen
* José M. Hernández
* John Herrington
* Paul Hill
* Akihiko Hoshide
* Mark Hulsbeck
* Emma Hwang
* Norishige Kanai
* Les Kaufman
* Scott Kelly
* Karen Kohanowich
* Timothy Kopra
* Dominic Landucci
* Jon Lindbergh
* Kjell N. Lindgren
* Michael López-Alegría
* Joseph B. MacInnis
* Sandra Magnus
* Thomas Marshburn
* Matthias Maurer
* K. Megan McArthur
* Craig McKinley
* Jessica Meir
* Simone Melchior
* Dorothy Metcalf-Lindenburger
* Andreas Mogensen
* Karen Nyberg
* John D. Olivas
* Takuya Onishi
* Luca Parmitano
* Nicholas Patrick
* Tim Peake
* Thomas Pesquet
* Marc Reagan
* Garrett Reisman
* Kathleen Rubins
* Dick Rutkowski
* Tara Ruttley
* David Saint-Jacques
* Josef Schmid
* Robert Sheats
* Dewey Smith
* Steve Squyres
* Heidemarie Stefanyshyn-Piper
* Robert Sténuit
* Hervé Stevenin
* Nicole Stott
* James Talacek
* Daniel M. Tani
* Robert Thirsk
* Bill Todd
* Mark T. Vande Hei
* Koichi Wakata
* Rex J. Walheim
* Shannon Walker
* John Morgan Wells
* Joachim Wendler
* Douglas H. Wheelock
* Peggy Whitson
* Dafydd Williams
* Jeffrey Williams
* Sunita Williams
* Reid Wiseman
* Kimiya Yui

Writers and journalists|

* Michael C. Barnette
* Victor Berge
* Philippe Diolé
* Gary Gentile
* Bret Gilliam
* Bob Halstead
* Hillary Hauser
* Trevor Jackson
* Steve Lewis
* John Mattera

Rescuers|

* Craig Challen
* Richard Harris
* Rick Stanton
* John Volanthen

Frogmen|

* Lionel Crabb
* Ian Edward Fraser
* Sydney Knowles
* James Joseph Magennis

Commercial salvors|

* Keith Jessop

Science of underwater diving

* List of researchers in underwater diving

| Diving
physics|

* Metre sea water
* Neutral buoyancy
* Underwater acoustics
* Modulated ultrasound
* Underwater vision
* Underwater computer vision

|

Diving
physiology|

* Blood shift
* Cold shock response
* Diving reflex
* Equivalent narcotic depth
* Maximum operating depth
* Physiological response to water immersion
* Thermal balance of the underwater diver
* Underwater vision
* Work of breathing

| Decompression
theory|

* Decompression models:
* Bühlmann decompression algorithm
* Haldane's decompression model
* Reduced gradient bubble model
* Thalmann algorithm
* Thermodynamic model of decompression
* Varying Permeability Model
* Equivalent air depth
* Oxygen window
* Physiology of decompression

|

Diving
environments|

* Underwater exploration
* Deep-sea exploration

| Classification|

* List of diving environments by type
* Altitude diving
* Benign water diving
* Confined water diving
* Deep diving
* Inland diving
* Inshore diving
* Muck diving
* Night diving
* Open-water diving
* Black-water diving
* Blue-water diving
* Penetration diving
* Cave diving
* Torricellian chamber
* Ice diving
* Wreck diving
* Recreational dive sites
* Underwater environment
* Underwater diving environment

|

Impact|

* Environmental impact of recreational diving
* Low impact diving

Other

* Bathysphere
* Defense against swimmer incursions
* Diver detection sonar
* Offshore survey
* Rugged compact camera
* Underwater domain awareness
* Underwater vehicle

| Deep-submergence
vehicle|

* Aluminaut
* DSV Alvin
* American submarine NR-1
* Bathyscaphe
* Archimède
* FNRS-2
* FNRS-3
* Harmony class bathyscaphe
* Sea Pole-class bathyscaphe
* Trieste II
* Deepsea Challenger
* Ictineu 3
* JAGO
* Jiaolong
* Konsul-class submersible
* Limiting Factor
* Russian submarine Losharik
* Mir
* Nautile
* Pisces-class deep submergence vehicle
* DSV Sea Cliff
* DSV Shinkai
* DSV Shinkai 2000
* DSV Shinkai 6500
* DSV Turtle
* DSV-5 Nemo

|

Submarine rescue|

* International Submarine Escape and Rescue Liaison Office
* Submarine Escape and Rescue system (Royal Swedish Navy)
* McCann Rescue Chamber
* Submarine rescue ship

| Deep-submergence
rescue vehicle|

* LR5
* LR7
* MSM-1
* Mystic-class deep-submergence rescue vehicle
* DSRV-1 Mystic
* DSRV-2 Avalon
* NATO Submarine Rescue System
* Priz-class deep-submergence rescue vehicle
* Russian deep submergence rescue vehicle AS-28
* Russian submarine AS-34
* ASRV Remora
* SRV-300
* Submarine Rescue Diving Recompression System
* Type 7103 DSRV
* URF (Swedish Navy)

|

Submarine escape|

* Escape trunk
* Submarine escape training facility
* Submarine Escape Training Facility (Australia)

| Escape set|

* Davis Submerged Escape Apparatus
* Momsen lung
* Steinke hood
* Submarine Escape Immersion Equipment

|

Special
interest
groups|

* Artificial Reef Society of British Columbia
* CMAS Europe
* Coral Reef Alliance
* Divers Alert Network
* Green Fins
* Finger Lakes Underwater Preserve Association
* Karst Underwater Research
* Nautical Archaeology Program
* Nautical Archaeology Society
* Naval Air Command Sub Aqua Club
* PADI AWARE
* Reef Check
* Reef Life Survey
* Rubicon Foundation
* Save Ontario Shipwrecks
* SeaKeys
* Sea Research Society
* Society for Underwater Historical Research
* Society for Underwater Technology
* Underwater Archaeology Branch, Naval History & Heritage Command

Neutral buoyancy
facilities for
Astronaut training|

* Neutral Buoyancy Laboratory
* Neutral buoyancy pool
* Neutral buoyancy simulation as a training aid
* Neutral Buoyancy Simulator
* Space Systems Laboratory
* Yuri Gagarin Cosmonaut Training Center

Other|

* Nautilus Productions
* Helicopter Aircrew Breathing Device
* Scuba diving therapy
* Seabed mining

* Category
* Commons
* Glossary
* Indexes: Dive sites
* Divers
* Diving
* Outline
* Portal

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