Elias Reed
Admission Snapshot
Chief Complaint
βMy head is pounding, I keep feeling sick, and I canβt remember how I got out of the basement.β
Elias presents after developing headache, dizziness, vomiting, and confusion while livestreaming inside a basement Halloween attraction. A companion reports a brief period of unresponsiveness before emergency responders removed him from the building.
Patient Profile
DOB: 02/14/1995 β’ 5 ft 11 in (180.3 cm) β’ 172 lb (78.0 kg) β’ BMI 24.0
Isolation Status: Standard Precautions
Medical History
- No known chronic medical conditions.
- No previous surgeries.
- No history of seizures, syncope, or diagnosed cardiac disease.
- No known previous carbon monoxide exposure requiring medical treatment.
Home Medications
- No prescribed daily medications.
- No reported over-the-counter medication or supplement use on the day of presentation.
Recent History
Elias is a freelance videographer who creates paranormal livestreams. Tonight, he and a friend entered a basement attraction staged as an abandoned hospital isolation ward. The broadcast featured covered beds, hanging plastic curtains, and a recorded voice repeating, βDo not leave your room.β
After approximately 45 minutes inside, Elias developed a headache and nausea. He attributed the symptoms to the flashing lights and continued filming. His speech became repetitive, and he began asking whether someone had called his name from behind an empty bed.
Viewers initially filled the chat with laughing emojis when the camera dropped to the floor. It continued broadcasting beneath a bed while Elias vomited and stopped responding to his friend. The recorded voice kept repeating its warning. His friend called 911 instead of ending the stream.
Responders identified a running gasoline-powered generator in an adjoining enclosed utility area. A second person reported headache and dizziness. Fire personnel evacuated the building and reported elevated environmental carbon monoxide readings. Elias had no witnessed head strike or seizure activity.
Elias is a nonsmoker and denies recreational drug use or alcohol consumption tonight. History is supplemented by his companion because he cannot recall portions of the event.
Emergency Contact
Nora Reed β’ Sister
589-216-XXXX
Insurance
Individual commercial health insurance plan
Current Care Status
10/30/2026 β’ 2215 β’ Emergency Department, ED-9. Receiving oxygen through a nonrebreather mask at 15 L/min following removal from the exposure. Emergency evaluation includes blood co-oximetry, cardiac assessment, and serial neurologic examinations.
Full Code; Standard Precautions. Poison Control consultation is being requested, with hyperbaric-treatment consultation to be considered based on the exposure history, neurologic findings, and diagnostic results.
Patient Timeline
Elias arrives with headache, vomiting, and incomplete recall after being removed from the basement. His conventional pulse oximeter displays 100% while he repeats questions about what happened.
Elias Reed β’ DOB: 02/14/1995 β’ MRN: 593817
Chief Complaint
βMy head is pounding, I keep feeling sick, and I canβt remember how I got out of the basement.β
History of Present Illness
Elias Reed is a 31-year-old man transported by EMS after developing headache, dizziness, vomiting, and confusion during a paranormal livestream inside a basement Halloween attraction. Symptoms began after approximately 45 minutes inside the building.
His companion reports that Elias became repetitive, dropped his camera, vomited, and was briefly unresponsive for approximately one minute. No witnessed head strike, seizure activity, or intentional ingestion. Elias cannot recall portions of the event.
Responders identified a gasoline-powered generator running in an adjoining enclosed utility area. Another person reported headache and dizziness. Fire personnel evacuated the building and reported elevated environmental carbon monoxide readings.
EMS removed Elias from the exposure at approximately 2150 and started oxygen through a nonrebreather mask at 15 L/min at 2155. Conventional pulse oximetry before oxygen displayed 99% on room air. Oxygen has continued without interruption.
Past Medical History
- No known chronic medical conditions.
- No previous surgeries.
- No history of seizures, syncope, or diagnosed cardiac disease.
- No known previous carbon monoxide exposure requiring treatment.
- No prescribed daily medications.
- No reported medication or supplement use today.
Family History
- Detailed family history deferred during initial emergency evaluation.
Social History
- Freelance videographer who creates paranormal livestreams.
- Nonsmoker.
- Denies recreational drug use or alcohol consumption tonight.
- Exposure occurred during filming inside an enclosed basement attraction.
- History supplemented by companion because of incomplete event recall.
Allergies
No known drug allergies.
Review of Systems
Constitutional: Weakness; no reported fever.
Neurologic: Headache, dizziness, confusion, incomplete recall, and witnessed transient unresponsiveness.
Cardiovascular: No chest pain reported.
Respiratory: Reports feeling that he cannot get a satisfying breath. No reported cough or smoke exposure from a fire.
Gastrointestinal: Nausea and vomiting.
Musculoskeletal: No reported injury or focal extremity pain.
Physical Examination
General: Awake, nauseated, and uncomfortable. Answers questions but repeats requests for an explanation of how he left the basement.
Neurologic: GCS 14: eyes open spontaneously, confused verbal responses, follows commands. Oriented to person and hospital; uncertain of date and events. Pupils equal and reactive. No focal motor deficit. Registers three words but recalls 0/3 after five minutes. Gait testing deferred because of dizziness.
Cardiovascular: Regular tachycardia. BP 108/66 mmHg; peripheral pulses palpable.
Respiratory: RR 24 breaths/min. Lung sounds clear. No stridor, soot, or facial burns. Conventional SpOβ 100% on nonrebreather at 15 L/min.
Abdomen: Soft and nondistended without focal tenderness.
Skin / Trauma: No obvious traumatic injury or burns.
Labs
Specimens collected at 2220 while oxygen continues: carboxyhemoglobin 28.4%, lactate 6.2 mmol/L, bicarbonate 18 mEq/L, and venous pH 7.30.
WBC 10.4 Γ10Β³/Β΅L, hemoglobin 15.1 g/dL, platelets 236 Γ10Β³/Β΅L, sodium 138 mEq/L, potassium 3.8 mEq/L, BUN 16 mg/dL, creatinine 1.0 mg/dL, glucose 118 mg/dL, and high-sensitivity troponin I 18 ng/L.
Diagnostics
ECG at 2220 shows sinus tachycardia without acute ischemic changes. Chest radiograph at 2235 shows no acute pulmonary abnormality.
Noncontrast head CT at 2240 shows no acute intracranial hemorrhage or mass effect. Oxygen and monitoring maintained during imaging. Cognitive reassessment continues.
Assessment
Acute carbon monoxide poisoning following enclosed-space generator exposure, with transient loss of consciousness, ongoing cognitive impairment, and metabolic acidosis. Conventional SpOβ does not establish adequate tissue oxygen delivery or exclude carbon monoxide toxicity.
Initial ECG and troponin do not demonstrate definite acute myocardial injury. Continue cardiac surveillance and repeat testing.
Plan
- Continue nonrebreather oxygen at 15 L/min without interruption.
- Do not reduce oxygen based solely on conventional SpOβ.
- Continuous cardiac monitoring and frequent neurologic reassessment.
- Repeat co-oximetry, lactate, and venous blood gas at 2320.
- Repeat high-sensitivity troponin I at 0020.
- Repeat ECG for chest pain, rhythm change, or deterioration.
- Prescribed antiemetic and crystalloid replacement for vomiting.
- Consult Dr. Mira Chen, MD, through regional Poison Control.
- Consult Dr. Adrian Mercer, DO, at the outside hyperbaric-capable receiving hospital.
- Arrange monitored interfacility transfer following acceptance.
- NPO, assisted activity, aspiration precautions, and fall precautions.
- Update sister with permission and provide receiving-team handoff.
Provider Information
Dr. Zoe Langston, MD
NSJH Emergency Medicine
Elias Reed β’ DOB: 02/14/1995 β’ MRN: 593817
Arrives on EMS nonrebreather at 15 L/min. Awake and follows commands but repeatedly asks, βDid someone get my camera?β Companion reports approximately one minute of unresponsiveness. Patient cannot recall the episode.
Temperature 36.7Β°C / 98.1Β°F, HR 112, RR 24, BP 108/66, MAP 80, conventional SpOβ 100%. Mask fit and reservoir inflation checked. Oxygen continued without interruption. Lung sounds clear; no soot or burns observed.
Headache 8/10 with nausea and dizziness. GCS 14; oriented to person and hospital, uncertain of date and events. Pupils equal and reactive; moves all extremities. Registers three words and recalls 0/3 after five minutes. Patient does not ambulate.
Peripheral IV patent without redness, swelling, or infiltration. Specimens obtained 2220. Dr. Langston notified at 2228 of carboxyhemoglobin 28.4% and lactate 6.2.
Ondansetron 4 mg IV given 2225. No further emesis through 2245; headache and incomplete recall persist. LR 500 mL started 2230 over 30 minutes. NPO, aspiration precautions, and fall precautions maintained.
Chest radiograph completed. CT transport completed with oxygen, monitoring, and RN accompaniment. Poison Control and outside hyperbaric consultations coordinated. Dr. Adrian Mercer accepts interfacility transfer at 2245. Monitored transport arrangements underway. Sister contacted with permission.
Elias Reed β’ DOB: 02/14/1995 β’ MRN: 593817
Consultant
Dr. Mira Chen, MD β’ Regional Poison Control Medical Toxicologist
Reason for Consultation
Carbon monoxide exposure with transient unresponsiveness, cognitive impairment, and carboxyhemoglobin 28.4%.
Impression
Exposure history and blood co-oximetry support acute carbon monoxide poisoning. Clinical history and neurologic findings must guide treatment alongside the blood concentration.
Recommendations
Continue high-concentration oxygen, serial neurologic examinations, and cardiac monitoring. Obtain prompt hyperbaric consultation. Repeat co-oximetry and lactate while continuing clinical reassessment.
Elias Reed β’ DOB: 02/14/1995 β’ MRN: 593817
Consultant
Dr. Adrian Mercer, DO β’ Receiving Hospital Hyperbaric Medicine
Reason for Consultation
Hyperbaric evaluation after transient loss of consciousness and persistent cognitive impairment.
Recommendations / Transfer Status
Exposure history, neurologic assessment, oxygen timing, and results reviewed with Dr. Langston. Interfacility transfer accepted at 2245. Continue oxygen and monitored transport. Formal receiving examination and treatment documentation pending.
| Order Type | Order Details | Priority | Ordered By | Status | Comments |
|---|---|---|---|---|---|
| Respiratory | Nonrebreather oxygen at 15 L/min continuously for carbon monoxide poisoning | Stat | Dr. Zoe Langston, MD | Active | Started by EMS 2155. Continue through transfer and receiving-service reassessment. Maintain reservoir inflation and mask fit; do not wean based solely on conventional SpOβ. |
| Monitoring | Continuous ECG and SpOβ | Stat | Dr. Zoe Langston, MD | Active | Conventional pulse oximetry does not measure carboxyhemoglobin. Monitor rhythm and respiratory status. |
| Nursing | Vital signs and focused neurologic assessment every 15 minutes until transfer | Urgent | Dr. Zoe Langston, MD | Active | Document GCS, orientation, pupils, movement, and cognition. Escalate reduced responsiveness, seizure, focal deficit, or respiratory deterioration. |
| Dietary | NPO pending neurologic and receiving-service assessment | Immediate | Dr. Zoe Langston, MD | Active | Recent vomiting and altered mental status; aspiration precautions. |
| Activity | Assisted activity only; fall precautions | Immediate | Dr. Zoe Langston, MD | Active | No unassisted ambulation. |
| IV Fluids | LR 500 mL IV once over 30 minutes for replacement following vomiting | Urgent | Dr. Zoe Langston, MD | In Progress | Started 2230; expected completion 2300. Reassess BP, respiratory status, and tolerance. |
| Medication | Ondansetron 4 mg IV once for nausea/vomiting | Stat | Dr. Zoe Langston, MD | Administered 2225 | Reassess response. No recurring PRN order. |
| Laboratory | Co-oximetry, venous blood gas, lactate, CBC, BMP, and high-sensitivity troponin I | Stat | Dr. Zoe Langston, MD | Completed | Collected 2220 while oxygen continued. Document exposure-removal and oxygen-start times. |
| Laboratory | Repeat co-oximetry, lactate, and venous blood gas at 2320 | Scheduled | Dr. Zoe Langston, MD | Ordered | Maintain oxygen during collection; interpret with neurologic findings. |
| Laboratory | Repeat high-sensitivity troponin I at 0020 on 10/31 | Scheduled | Dr. Zoe Langston, MD | Ordered | Include pending testing in transfer handoff. |
| Diagnostic | ECG now; repeat for chest pain, rhythm change, or deterioration | Stat | Dr. Zoe Langston, MD | Initial completed 2220; repeat indication active | Sinus tachycardia without acute ischemic changes. |
| Imaging | Portable chest radiograph | Urgent | Dr. Zoe Langston, MD | Completed 2235 | No acute pulmonary abnormality. |
| Imaging | Noncontrast head CT for loss of consciousness and altered mental status | Urgent | Dr. Zoe Langston, MD | Completed 2240 | Oxygen and monitoring maintained. No acute hemorrhage or mass effect. |
| Consult | Poison Control and outside hyperbaric consultations | Stat | Dr. Zoe Langston, MD | Telephone consultations completed | Dr. Mira Chen contacted 2230; Dr. Adrian Mercer contacted 2235. Transfer accepted 2245. |
| Transfer | Monitored interfacility transfer to hyperbaric-capable receiving hospital | Urgent | Dr. Zoe Langston, MD | In Progress | Continue oxygen. Include unresponsiveness, cognition, results, oxygen duration, and pending studies. |
| Isolation | Standard Precautions | Routine | Dr. Zoe Langston, MD | Active | No transmission-based isolation indicated. |
| Vital Sign | 2215 | Reference Range |
|---|---|---|
| Temperature | 36.7Β°C / 98.1Β°F | 36.1β37.2Β°C / 97β99Β°F |
| Heart Rate | 112 bpm H* | 60β100 bpm |
| Respiratory Rate | 24 breaths/min H* | 12β20 breaths/min |
| Blood Pressure | 108/66 mmHg | Resting reference: <120/<80 mmHg; interpret with perfusion |
| MAP | 80 mmHg | Clinical perfusion target β₯65 mmHg |
| Oxygen Saturation | 100% by conventional pulse oximeter; nonrebreather at 15 L/min | 95β100% conventional SpOβ |
| Pain | 8/10, headache | Subjective scale 0β10 |
| GCS | 14 L* | 15 |
H* = above the listed reference range; L* = below the listed reference range.
| Lab Test | 2220 | Reference Range |
|---|---|---|
| Carboxyhemoglobin β Blood Co-oximetry | 28.4% H* | 0β2% in nonsmokers |
| Lactate | 6.2 mmol/L H* | 0.5β2.2 mmol/L |
| Venous pH | 7.30 L* | 7.31β7.41 β venous reference |
| Bicarbonate β BMP | 18 mEq/L L* | 22β29 mEq/L |
| WBC | 10.4 Γ10Β³/Β΅L | 5β11 Γ10Β³/Β΅L |
| Hemoglobin | 15.1 g/dL | Male: 14β16.5 g/dL |
| Platelets | 236 Γ10Β³/Β΅L | 150β450 Γ10Β³/Β΅L |
| Sodium | 138 mEq/L | 135β145 mEq/L |
| Potassium | 3.8 mEq/L | 3.5β5.0 mEq/L |
| BUN | 16 mg/dL | 10β20 mg/dL |
| Creatinine | 1.0 mg/dL | 0.6β1.2 mg/dL |
| Glucose | 118 mg/dL H* | 60β100 mg/dL β fasting reference |
| High-Sensitivity Troponin I | 18 ng/L | 0β19 ng/L β reporting assay reference |
H* = above the listed reference range; L* = below the listed reference range. *Glucose is compared with the fasting reference, but fasting status is not confirmed; this result alone does not establish diabetes. Troponin and venous pH use reporting-laboratory reference ranges. Co-oximetry was collected after exposure removal and oxygen initiation.
- Blood Co-oximetry β Completed: Collected 2220; carboxyhemoglobin 28.4%, communicated 2228.
- ECG β Completed 2220: Sinus tachycardia without acute ischemic changes.
- Chest Radiograph β Completed 2235: No acute pulmonary abnormality.
- Head CT β Completed 2240: No acute intracranial hemorrhage or mass effect.
- Cognitive Assessment β Completed: Registers three words; delayed recall 0/3. Repeated questions and incomplete recall documented.
- Repeat Studies β Ordered: Co-oximetry, lactate, and venous blood gas at 2320; troponin at 0020.
- Before removal β Approximately one minute of unresponsiveness reported; no witnessed seizure or head strike.
- 2150 β Removed from exposure.
- 2155 β EMS starts nonrebreather oxygen at 15 L/min.
- 2215 β Arrives at NSJH ED-9.
- 2220 β Specimens collected and ECG completed.
- 2225 β Ondansetron administered.
- 2228 β Carboxyhemoglobin and lactate reported to Dr. Langston.
- 2230 β Dr. Mira Chen consulted through Poison Control; LR started.
- 2235 β Chest radiograph completed; Dr. Adrian Mercer contacted.
- 2240 β Head CT completed with oxygen and monitoring maintained.
- 2245 β Dr. Mercer accepts transfer to the outside hospital.
Review exposure history, neurologic findings, oxygen readings, blood results, and current orders.
A conventional two-wavelength pulse oximeter cannot reliably distinguish carboxyhemoglobin from oxyhemoglobin, making its displayed saturation misleading. Carbon monoxide interferes with oxygen delivery and cellular oxygen use despite that reading. The enclosed generator exposure, another symptomatic person, unresponsiveness, confusion, impaired recall, carboxyhemoglobin 28.4%, and lactate 6.2 require urgent attention.
Continue prescribed oxygen rather than reducing it based on SpOβ. Assess airway protection, respiratory status, cognition, and rhythm, and promptly communicate deterioration. Blood co-oximetry and serial clinical assessment are more useful than conventional saturation alone for evaluating this exposure.
Transient loss of consciousness, persistent confusion, recall of 0/3, and carboxyhemoglobin 28.4% support urgent hyperbaric consultation. The decision incorporates clinical history and neurologic findings rather than a concentration alone. A CT without hemorrhage does not establish normal cognition or exclude carbon monoxide-related injury.
Maintain oxygen without interruption, cardiac monitoring, neurologic assessment, IV access, and aspiration and fall precautions. Handoff includes exposure-removal and oxygen-start times, the unresponsive episode, cognition, studies, and pending testing. Escalate seizure, reduced responsiveness, chest pain, dysrhythmia, or respiratory deterioration without waiting for transport.
Elias reports less headache and nausea but still cannot recall the rescue or retain three words. Repeat results are available while transfer preparations continue.
Elias Reed β’ DOB: 02/14/1995 β’ MRN: 593817
Chief Concern
βMy head isnβt pounding as much, but I still donβt remember anyone carrying me out.β
Interval History
Nonrebreather oxygen at 15 L/min has continued without interruption since 2155. Headache decreased from 8/10 to 4/10. Nausea subsided without further vomiting after ondansetron. LR 500 mL completed at 2300.
Repeat co-oximetry, lactate, and venous blood gas collected at 2320. Elias is now oriented Γ4 but cannot recall the rescue. He registers three words and recalls 0/3 after five minutes.
When his companion plays part of the livestream, Elias recognizes the recorded warning but does not remember dropping the camera or becoming unresponsive. Dr. Adrian Mercer accepted outside-hospital transfer at 2245 and received an update at 2335. Hyperbaric treatment has not yet begun.
Past Medical History
- No known chronic conditions or previous surgeries.
- No history of seizures, syncope, or cardiac disease.
- No prescribed daily medications.
- No known previous carbon monoxide exposure requiring treatment.
Family History
- Detailed history not yet obtained during emergency treatment.
Social History
- Freelance paranormal videographer; nonsmoker.
- Denies alcohol or recreational drug use tonight.
- Companion witnessed exposure and unresponsiveness.
- Sister Nora Reed contacted with permission.
Allergies
No known drug allergies.
Review of Systems
Constitutional: Less weakness.
Neurologic: Headache 4/10, intermittent dizziness, incomplete recall, and difficulty retaining new information. No new focal weakness.
Cardiovascular: No chest pain.
Respiratory: No current dyspnea.
Gastrointestinal: Nausea subsided; no further vomiting.
Psychological: Concern about memory gap and transfer.
Physical Examination
General: Awake and conversant; less uncomfortable.
Neurologic: GCS 15; oriented Γ4. Pupils equal and reactive; symmetric movement. Registers three words; delayed recall 0/3. Gait testing deferred because of dizziness.
Cardiovascular: Regular rhythm, HR 96, BP 116/72, MAP 87; pulses palpable.
Respiratory: RR 18; clear lung sounds. Conventional SpOβ 100% on nonrebreather at 15 L/min.
Abdomen: Soft without focal tenderness.
Devices: IV patent; mask reservoir inflated.
Labs
At 2320: carboxyhemoglobin 14.1%, lactate 3.1 mmol/L, venous pH 7.36. CBC and BMP not repeated. Initial troponin 18 ng/L; repeat remains due at 0020.
Diagnostics
Earlier ECG showed sinus tachycardia without ischemic changes. Current telemetry shows sinus rhythm without sustained dysrhythmia. Chest radiograph and head CT previously completed. Delayed recall remains impaired.
Assessment
Acute carbon monoxide poisoning with witnessed transient loss of consciousness and persistent cognitive impairment despite partial symptomatic and laboratory response. Improved orientation and decreasing carboxyhemoglobin do not establish complete neurologic recovery.
No current chest pain or sustained dysrhythmia. Cardiac biomarker reassessment remains pending. Continue accepted transfer to the outside hyperbaric service.
Plan
- Continue nonrebreather at 15 L/min throughout transfer.
- Do not wean based solely on conventional SpOβ or declining COHb.
- Continue cardiac monitoring and vital/neuro checks every 15 minutes.
- Communicate persistent recall impairment to Dr. Adrian Mercer.
- Coordinate 0020 troponin with receiving team if transfer occurs first.
- Repeat ECG for new symptoms or deterioration.
- Maintain NPO, assisted activity, aspiration and fall precautions.
- Use brief explanations and verify understanding; include sister with permission.
Provider Information
Dr. Zoe Langston, MD
NSJH Emergency Medicine
Elias Reed β’ DOB: 02/14/1995 β’ MRN: 593817
Awake and oriented Γ4. States, βI remember that voice, but I donβt remember getting outside.β Registers three words; recalls 0/3 after five minutes. Follows commands with symmetric movement. No seizure or new focal deficit.
Temperature 36.8Β°C / 98.2Β°F, HR 96, RR 18, BP 116/72, MAP 87, conventional SpOβ 100% on nonrebreather at 15 L/min. Mask fit, oxygen connection, and reservoir checked. Clear lung sounds; denies chest pain and dyspnea.
Headache 4/10 with intermittent dizziness. No further vomiting. LR completed 2300. IV patent without redness, swelling, or infiltration. No maintenance fluid ordered.
Repeat specimens collected 2320 without interrupting oxygen. Results and persistent delayed-recall impairment reviewed with Dr. Langston.
NPO, aspiration and fall precautions maintained. Transfer packet includes exposure and oxygen timing, neuro assessments, treatments, imaging, results, and pending troponin order. Dr. Adrian Mercer updated at 2335. Sister informed with permission; transport arrangements continue.
Elias Reed β’ DOB: 02/14/1995 β’ MRN: 593817
Consultant
Dr. Adrian Mercer, DO β’ Receiving Hospital Hyperbaric Medicine
Reason for Consultation
Updated assessment before accepted interfacility transfer.
Impression
Headache and nausea decreased; COHb now 14.1%. Recall remains 0/3 despite full orientation. Prior unresponsiveness and ongoing cognitive deficits remain relevant to treatment decisions.
Recommendations
Proceed with monitored transfer. Continue oxygen and neurologic assessment. Send initial and repeat studies and pending cardiac testing. Formal receiving examination and treatment remain pending.
Poison Control
Dr. Mira Chenβs earlier recommendations remain in effect. No new Poison Control consultation documented this interval.
| Order Type | Order Details | Priority | Ordered By | Status | Comments |
|---|---|---|---|---|---|
| Respiratory | Nonrebreather oxygen at 15 L/min continuously for CO poisoning | Stat | Dr. Zoe Langston, MD | Active | Continue through transfer and receiving reassessment. Maintain mask fit and reservoir; do not wean based solely on conventional SpOβ. |
| Monitoring | Continuous ECG and SpOβ | Stat | Dr. Zoe Langston, MD | Active | Monitor rhythm and respiration; conventional oximetry does not measure COHb. |
| Nursing | Vital signs and focused neuro assessment every 15 minutes | Urgent | Dr. Zoe Langston, MD | Active | Document cognition and report neurologic, cardiac, or respiratory deterioration. |
| Dietary | NPO pending receiving assessment | Immediate | Dr. Zoe Langston, MD | Active | Aspiration precautions. |
| Activity | Assisted activity; fall precautions | Immediate | Dr. Zoe Langston, MD | Active | Intermittent dizziness; no unassisted ambulation. |
| IV Fluids β Status Update | LR 500 mL IV once over 30 minutes | Urgent | Dr. Zoe Langston, MD | Completed 2300 | No maintenance fluid ordered; maintain patent access. |
| Medication β Status Update | Ondansetron 4 mg IV once | Stat | Dr. Zoe Langston, MD | Administered 2225 | No recurring PRN order. Obtain new order if further treatment required. |
| Laboratory β Status Update | Initial co-oximetry, blood gas, lactate, CBC, BMP, and troponin | Stat | Dr. Zoe Langston, MD | Completed 2220 | Results included in transfer documentation. |
| Laboratory β Status Update | Repeat co-oximetry, lactate, and venous blood gas | Scheduled | Dr. Zoe Langston, MD | Completed 2320 | COHb 14.1%, lactate 3.1, venous pH 7.36. |
| Laboratory | Repeat high-sensitivity troponin I at 0020 on 10/31 | Scheduled | Dr. Zoe Langston, MD | Ordered; not yet due | Coordinate collection with outside receiving team. |
| Diagnostic | Repeat ECG for chest pain, rhythm change, or deterioration | Urgent if indicated | Dr. Zoe Langston, MD | Active | Initial ECG completed; no new indication documented. |
| Imaging β Status Update | Chest radiograph | Urgent | Dr. Zoe Langston, MD | Completed 2235 | No acute pulmonary abnormality. |
| Imaging β Status Update | Noncontrast head CT | Urgent | Dr. Zoe Langston, MD | Completed 2240 | No acute hemorrhage or mass effect; neuro reassessment continues. |
| Consult | Poison Control and outside hyperbaric consultation | Stat | Dr. Zoe Langston, MD | Completed by telephone; updated 2335 | Dr. Mira Chen and Dr. Adrian Mercer. Receiving examination pending. |
| Transfer | Monitored interfacility transfer to hyperbaric-capable hospital | Urgent | Dr. Zoe Langston, MD | In Progress | Continue oxygen. Communicate unresponsiveness, recall impairment, oxygen duration, studies, and pending troponin. |
| Education | Explain oxygen and transfer; verify understanding | Routine | Dr. Zoe Langston, MD | In Progress | Brief explanations and repetition; include sister with permission. |
| Isolation | Standard Precautions | Routine | Dr. Zoe Langston, MD | Active | No transmission-based isolation indicated. |
| Vital Sign | 2215 | 2330 | Reference Range |
|---|---|---|---|
| Temperature | 36.7Β°C / 98.1Β°F | 36.8Β°C / 98.2Β°F | 36.1β37.2Β°C / 97β99Β°F |
| Heart Rate | 112 bpm H* | 96 bpm | 60β100 bpm |
| Respiratory Rate | 24 breaths/min H* | 18 breaths/min | 12β20 breaths/min |
| Blood Pressure | 108/66 mmHg | 116/72 mmHg | Resting reference: <120/<80 mmHg; interpret with perfusion |
| MAP | 80 mmHg | 87 mmHg | Clinical perfusion target β₯65 mmHg |
| Oxygen Saturation | 100% conventional SpOβ; nonrebreather at 15 L/min | 100% conventional SpOβ; nonrebreather at 15 L/min | 95β100% conventional SpOβ |
| Pain | 8/10, headache | 4/10, headache | Subjective scale 0β10 |
| GCS | 14 L* | 15 | 15 |
H* = above the listed reference range; L* = below the listed reference range.
| Lab Test | 2220 | 2320 | Reference Range |
|---|---|---|---|
| Carboxyhemoglobin | 28.4% H* | 14.1% H* | 0β2% in nonsmokers |
| Lactate | 6.2 mmol/L H* | 3.1 mmol/L H* | 0.5β2.2 mmol/L |
| Venous pH | 7.30 L* | 7.36 | 7.31β7.41 |
| Bicarbonate β BMP | 18 mEq/L L* | Not repeated | 22β29 mEq/L |
| WBC | 10.4 Γ10Β³/Β΅L | Not repeated | 5β11 Γ10Β³/Β΅L |
| Hemoglobin | 15.1 g/dL | Not repeated | Male: 14β16.5 g/dL |
| Platelets | 236 Γ10Β³/Β΅L | Not repeated | 150β450 Γ10Β³/Β΅L |
| Sodium | 138 mEq/L | Not repeated | 135β145 mEq/L |
| Potassium | 3.8 mEq/L | Not repeated | 3.5β5.0 mEq/L |
| BUN | 16 mg/dL | Not repeated | 10β20 mg/dL |
| Creatinine | 1.0 mg/dL | Not repeated | 0.6β1.2 mg/dL |
| Glucose | 118 mg/dL H* | Not repeated | 60β100 mg/dL β fasting reference |
| High-Sensitivity Troponin I | 18 ng/L | Not repeated; due 0020 | 0β19 ng/L β assay reference |
H* = above the listed reference range; L* = below the listed reference range. *Initial glucose is compared with the fasting reference; fasting status was not confirmed. Oxygen continued during both collections. Troponin and venous pH use reporting-laboratory reference ranges.
- Co-oximetry β Repeat Completed 2320: COHb 14.1%; initial 28.4%.
- Cognitive Assessment β Repeated: Oriented Γ4; delayed recall 0/3. Rescue-related gap persists.
- ECG β Previously Completed: Sinus tachycardia without ischemic changes.
- Telemetry β Ongoing: Sinus rhythm without sustained dysrhythmia.
- Chest Radiograph β Previously Completed: No acute pulmonary abnormality.
- Head CT β Previously Completed: No acute hemorrhage or mass effect.
- Repeat Troponin β Ordered: Due 0020; result unavailable.
- Outside Hyperbaric Evaluation β Pending: Dr. Adrian Mercer accepted transfer; treatment not begun.
- 2245 β Dr. Adrian Mercer accepts outside-hospital transfer.
- 2300 β LR infusion completed.
- Oxygen remains uninterrupted at 15 L/min.
- 2320 β Repeat specimens collected.
- COHb 14.1%, lactate 3.1, venous pH 7.36.
- 2330 β GCS 15 and orientation Γ4; delayed recall remains 0/3.
- Headache 4/10; no further vomiting.
- 2335 β Dr. Mercer updated with results and persistent cognitive findings.
- Transfer packet includes pending 0020 troponin.
- Transport arrangements continue; hyperbaric treatment not yet begun.
Review response to oxygen, repeat results, cognition, and transfer plans.
These changes support a response to oxygen but do not establish complete recovery. Elias still recalls 0/3 words and cannot remember the rescue. Full orientation and GCS 15 do not exclude a specific cognitive deficit. Witnessed loss of consciousness and persistent memory impairment remain reasons for hyperbaric evaluation.
COHb decreases with oxygen and does not reliably represent the full extent of injury. Continue the accepted transfer plan and communicate the updated examination. Do not cancel transfer or reduce oxygen solely because a blood value or conventional saturation appears reassuring.
Maintain oxygen, verify mask fit and reservoir inflation, and continue cardiac and neurologic monitoring. Keep IV access patent and maintain NPO, aspiration precautions, and assisted activity. Escalate new neurologic findings, chest pain, dysrhythmia, or respiratory deterioration immediately.
Handoff includes exposure details, unresponsiveness, removal and oxygen times, initial and repeat results, and persistent delayed-recall impairment. Include imaging, medication and fluid administration, and pending troponin. This supports continuity without assuming that better orientation or laboratory trends mean neurologic concerns have resolved.
Elias has completed hyperbaric treatment and is breathing room air without headache or nausea. Discharge assessment includes cognition, activity tolerance, a safe destination, and follow-up.
Elias Reed β’ DOB: 02/14/1995 β’ MRN: 593817
Chief Concern
βMy head feels normal again. Could the memory problems come back after I go home?β
Interval History
Departed NSJH at 2350 on 10/30 with oxygen and monitoring. Arrived at this outside receiving hospital at 0030. Dr. Adrian Mercer reassessed the exposure, loss of consciousness, and persistent delayed-recall impairment.
Hyperbaric treatment began 0130 and completed 0345 per Dr. Mercerβs treatment record, without a treatment-limiting complication. Returned to observation.
Repeat co-oximetry, lactate, venous blood gas, and BMP collected 0400. Oxygen continued until Dr. Mercerβs reassessment at 0530, when it was discontinued. Symptom-free on room air since then.
Troponin scheduled for 0020 was collected at 0035 after arrival because patient was in transit at the scheduled time. Actual collection time documented. This specimen preceded hyperbaric treatment.
Headache, nausea, and dizziness resolved. Oriented Γ4 with delayed recall 3/3. Accurately repeats the care plan. Memory gap remains for the unresponsive interval. NPO discontinued 0500; breakfast tolerated 0700. Supervised ambulation and discharge teach-back remain pending.
Past Medical History
- No chronic conditions or previous surgeries.
- No history of seizure, syncope, or cardiac disease.
- No prescribed daily medications.
- Current admission: CO poisoning with unresponsiveness and cognitive impairment.
Family History
- No additional relevant history obtained during this interval.
Social History
- Freelance videographer; nonsmoker.
- Denies alcohol or recreational drugs during the event.
- Sister Nora Reed can provide transportation and stay with him.
- Home is separate from the exposure site.
- Attraction remains closed pending safety clearance.
Allergies
No known drug allergies.
Review of Systems
Constitutional: No current weakness or unusual fatigue.
Neurologic: No headache, dizziness, numbness, or weakness. Retains current instructions; memory gap remains for unresponsive interval.
Cardiovascular: No chest pain or palpitations.
Respiratory: No dyspnea.
Gastrointestinal: No nausea or vomiting; breakfast tolerated.
HEENT: No new ear pain or hearing change.
Psychological: Concern about symptom recurrence.
Physical Examination
General: Awake, comfortable, and participatory.
Neurologic: GCS 15; oriented Γ4. Pupils equal and reactive; speech clear. Follows multistep commands; symmetric movement. Delayed recall 3/3. Supervised ambulation pending.
Cardiovascular: Regular rhythm, HR 78, BP 118/74, MAP 89; pulses palpable.
Respiratory: RR 16; clear lung sounds. SpOβ 99% room air. Oxygen off since 0530.
Abdomen: Soft, nondistended, nontender.
Devices: IV patent; telemetry continues.
Labs
At 0400: COHb 1.3%, lactate 1.4 mmol/L, venous pH 7.40, bicarbonate 24 mEq/L, sodium 139, potassium 4.0, BUN 15, creatinine 0.9, glucose 96. CBC not repeated.
Troponin collected 0035 before hyperbaric treatment: 11 ng/L; initial 18 ng/L.
Diagnostics
Telemetry without sustained dysrhythmia. Earlier ECG, chest radiograph, and head CT reviewed. Hyperbaric record documents completion 0345. Current delayed recall 3/3. No repeat imaging ordered.
Assessment
CO poisoning after oxygen and hyperbaric treatment, with resolution of current symptoms and measurable delayed-recall impairment. No current evidence of respiratory compromise, sustained dysrhythmia, or evolving myocardial injury.
Memory gap for the unresponsive interval does not alone establish ongoing inability to form memories. Current recovery does not eliminate delayed neurologic risk. Discharge readiness requires activity assessment, teaching, follow-up arrangements, and a safe destination.
Plan
- Continue observation on room air and reassess symptoms and cognition.
- Complete supervised ambulation and assess balance and tolerance.
- Oral intake as tolerated.
- No routine repeat testing without new indication.
- Written delayed-neurologic warning symptoms and return instructions.
- Repeat medical and neurologic examination by approximately 11/14.
- Confirm sisterβs transport and support; patient not to drive himself.
- No return to attraction before safety clearance.
- Discharge only after reassessment and an entered discharge order.
Provider Information
Dr. Elena Voss, MD
Outside Receiving Hospital β’ Internal Medicine
Elias Reed β’ DOB: 02/14/1995 β’ MRN: 593817
Awake and oriented Γ4. States, βI can remember what everyone is telling me now, but the part under the bed is still gone.β Delayed recall 3/3 after five minutes. Accurately describes treatment and identifies sister as planned ride home.
Temperature 36.8Β°C / 98.2Β°F, HR 78, RR 16, BP 118/74, MAP 89, SpOβ 99% room air. Pain 0/10. No headache, dizziness, nausea, chest pain, palpitations, dyspnea, focal weakness, or speech change.
Hyperbaric treatment completed 0345. Oxygen discontinued 0530 per Dr. Mercer. No recurrence of symptoms. Breakfast tolerated 0700. IV patent without infiltration; telemetry sinus rhythm.
Ambulation assessment pending; instructed to request assistance. Teaching begun with patient and sister. Written instructions and formal teach-back in progress. Sister confirms transportation and support. Findings communicated to Dr. Elena Voss. No discharge order entered.
Elias Reed β’ DOB: 02/14/1995 β’ MRN: 593817
Consultant
Dr. Adrian Mercer, DO β’ Hyperbaric Medicine
Reason for Consultation
Post-treatment reassessment following CO poisoning with neurologic impairment.
Impression
Treatment completed 0345 without a treatment-limiting complication. Headache, nausea, and dizziness resolved. Repeat co-oximetry and lactate reviewed.
Recommendations
Discontinue oxygen at 0530; continue room-air observation. Reassess cognition and activity tolerance before discharge. Written delayed-symptom instructions and follow-up. No additional hyperbaric session scheduled; reassess if concerns recur.
Elias Reed β’ DOB: 02/14/1995 β’ MRN: 593817
Consultant
Jordan Ellis, RN, CCM β’ Case Manager
Reason for Consultation
Transportation, support, and follow-up after interfacility transfer.
Assessment
Sister can provide transportation and stay with Elias. Home is separate from the exposure site. Attraction remains closed pending clearance.
Recommendations
Assist with medical and neurologic reassessment within approximately two weeks. Confirm appointment details or a clear scheduling plan before discharge. Provide written instructions to patient and sister.
| Order Type | Order Details | Priority | Ordered By | Status | Comments |
|---|---|---|---|---|---|
| Observation | Continue monitored observation after hyperbaric treatment | Routine | Dr. Elena Voss, MD | Active | Assess recurrence and complete discharge-readiness evaluation. |
| Monitoring | Continuous telemetry until discharge or further order | Routine | Dr. Elena Voss, MD | Active | Report chest pain, palpitations, or rhythm changes. |
| Nursing | Vitals, SpOβ, and focused neuro assessment every 2 hours | Routine | Dr. Elena Voss, MD | Active | Replaces ED every-15-minute schedule; reassess immediately for symptoms. |
| Respiratory β Status Update | Nonrebreather oxygen at 15 L/min | Status update | Dr. Adrian Mercer, DO | Discontinued 0530 | Observe on room air after clinical reassessment. Conventional SpOβ alone does not exclude toxicity. |
| Procedure β Status Update | Hyperbaric oxygen treatment per protocol | Urgent treatment | Dr. Adrian Mercer, DO | Completed 0345 | Began 0130; no additional session scheduled. |
| Dietary | Regular diet as tolerated | Routine | Dr. Elena Voss, MD | Active from 0500 | Replaces NPO. Breakfast tolerated. |
| Activity | Supervised ambulation before discharge | Routine | Dr. Elena Voss, MD | Pending | Assess balance, dizziness, headache, dyspnea, and tolerance; assisted activity until completed. |
| Laboratory β Status Update | Post-treatment co-oximetry, lactate, venous blood gas, and BMP | Scheduled | Dr. Adrian Mercer, DO | Completed 0400 | Reviewed; no additional routine specimens ordered. |
| Laboratory β Status Update | Repeat troponin originally due 0020 | Scheduled | Dr. Zoe Langston, MD; continued by Dr. Elena Voss, MD | Collected 0035; resulted | Delayed while in transit. Result 11 ng/L; collected before hyperbaric treatment. |
| Diagnostic | Repeat ECG for chest pain, rhythm change, or deterioration | Urgent if indicated | Dr. Elena Voss, MD | Active | No new indication documented. |
| IV Fluids β Status Update | LR 500 mL IV once | Status update | Dr. Zoe Langston, MD | Completed 2300 on 10/30 | No maintenance fluid; oral intake tolerated. |
| Medication β Status Update | Ondansetron 4 mg IV once | Status update | Dr. Zoe Langston, MD | Administered 2225 on 10/30 | No recurring order; no further vomiting. |
| Device Management | Maintain IV until discharge decision; remove after discharge order if no further treatment required | Routine | Dr. Elena Voss, MD | Active | Assess site and patency. |
| Education | Written delayed-neurologic warning symptoms and return instructions with teach-back | Routine | Dr. Elena Voss, MD | In Progress | Include sister with permission. |
| Safety Education | No return to exposure site before safety clearance | Routine | Dr. Elena Voss, MD | Active | Safe generator use and functioning CO alarms; no equipment retrieval before clearance. |
| Consult | Case management for transport, support, and follow-up | Routine | Dr. Elena Voss, MD | In Progress | Jordan Ellis, RN, CCM; sister available. |
| Follow-Up | Medical and neurologic reassessment in approximately 2 weeks, by 11/14 | Routine | Dr. Elena Voss, MD | Scheduling in progress | Earlier evaluation for new or recurrent symptoms. |
| Discharge Planning | Provider reassessment after ambulation and teaching | Routine | Dr. Elena Voss, MD | Pending | No discharge order; confirm readiness, follow-up, and transport. |
| Isolation | Standard Precautions | Routine | Dr. Elena Voss, MD | Active | No transmission-based isolation indicated. |
| Vital Sign | 2215 (10/30) | 2330 (10/30) | 0800 (10/31) | Reference Range |
|---|---|---|---|---|
| Temperature | 36.7Β°C / 98.1Β°F | 36.8Β°C / 98.2Β°F | 36.8Β°C / 98.2Β°F | 36.1β37.2Β°C / 97β99Β°F |
| Heart Rate | 112 bpm H* | 96 bpm | 78 bpm | 60β100 bpm |
| Respiratory Rate | 24 breaths/min H* | 18 breaths/min | 16 breaths/min | 12β20 breaths/min |
| Blood Pressure | 108/66 mmHg | 116/72 mmHg | 118/74 mmHg | Resting reference: <120/<80 mmHg; interpret with perfusion |
| MAP | 80 mmHg | 87 mmHg | 89 mmHg | Clinical perfusion target β₯65 mmHg |
| Oxygen Saturation | 100% conventional SpOβ; nonrebreather at 15 L/min | 100% conventional SpOβ; nonrebreather at 15 L/min | 99% room air | 95β100% conventional SpOβ |
| Pain | 8/10, headache | 4/10, headache | 0/10 | Subjective scale 0β10 |
| GCS | 14 L* | 15 | 15 | 15 |
H* = above the listed reference range; L* = below the listed reference range.
| Lab Test | 2220 (10/30) | 2320 (10/30) | 10/31 | Reference Range |
|---|---|---|---|---|
| Carboxyhemoglobin | 28.4% H* | 14.1% H* | 1.3% at 0400 | 0β2% in nonsmokers |
| Lactate | 6.2 mmol/L H* | 3.1 mmol/L H* | 1.4 mmol/L at 0400 | 0.5β2.2 mmol/L |
| Venous pH | 7.30 L* | 7.36 | 7.40 at 0400 | 7.31β7.41 |
| Bicarbonate β BMP | 18 mEq/L L* | Not repeated | 24 mEq/L at 0400 | 22β29 mEq/L |
| WBC | 10.4 Γ10Β³/Β΅L | Not repeated | Not repeated | 5β11 Γ10Β³/Β΅L |
| Hemoglobin | 15.1 g/dL | Not repeated | Not repeated | Male: 14β16.5 g/dL |
| Platelets | 236 Γ10Β³/Β΅L | Not repeated | Not repeated | 150β450 Γ10Β³/Β΅L |
| Sodium | 138 mEq/L | Not repeated | 139 mEq/L at 0400 | 135β145 mEq/L |
| Potassium | 3.8 mEq/L | Not repeated | 4.0 mEq/L at 0400 | 3.5β5.0 mEq/L |
| BUN | 16 mg/dL | Not repeated | 15 mg/dL at 0400 | 10β20 mg/dL |
| Creatinine | 1.0 mg/dL | Not repeated | 0.9 mg/dL at 0400 | 0.6β1.2 mg/dL |
| Glucose | 118 mg/dL H* | Not repeated | 96 mg/dL at 0400 | 60β100 mg/dL β fasting reference |
| High-Sensitivity Troponin I | 18 ng/L | Not repeated | 11 ng/L at 0035 β before HBOT | 0β19 ng/L β assay reference |
H* = above the listed reference range; L* = below the listed reference range. *Initial glucose is compared with the fasting reference; fasting status was not confirmed. Troponin was collected 0035, before HBOT began at 0130. Other 10/31 specimens were collected at 0400 after treatment. Troponin and venous pH use reporting-laboratory reference ranges.
- Hyperbaric Treatment β Completed 0345: Dr. Mercerβs record documents 0130β0345 without treatment-limiting complication.
- Co-oximetry β Completed 0400: COHb 1.3%; earlier 28.4% and 14.1%.
- Cognitive Assessment β Repeated 0800: Oriented Γ4; delayed recall 3/3. Retains care plan; event gap persists.
- ECG β Previously Completed: No acute ischemic changes; no new repeat indication.
- Telemetry β Ongoing: Sinus rhythm without sustained dysrhythmia.
- Troponin β Repeat Completed: 11 ng/L at 0035 before HBOT; initial 18 ng/L.
- Chest Radiograph β Previously Completed: No acute pulmonary abnormality.
- Head CT β Previously Completed: No acute hemorrhage or mass effect.
- Supervised Ambulation β Pending: Required before discharge reassessment.
- 10/30 β’ 2350 β Departs NSJH with oxygen and monitoring.
- 10/31 β’ 0030 β Arrives at outside receiving hospital; Dr. Mercer reassesses.
- 0035 β Troponin collected; delay from 0020 documented. Specimen precedes HBOT.
- 0130 β Hyperbaric treatment begins.
- 0345 β Treatment completed; returns to observation.
- 0400 β Post-treatment specimens collected.
- 0500 β NPO discontinued.
- 0530 β Dr. Mercer discontinues oxygen after reassessment.
- 0700 β Breakfast tolerated.
- 0745 β Jordan Ellis, RN, CCM confirms transportation and support; follow-up planning continues.
- 0800 β Dr. Elena Voss reassesses; symptom-free, GCS 15, delayed recall 3/3.
- Ambulation and teach-back pending; no discharge order entered.
Review treatment response, outstanding discharge tasks, and follow-up needs.
Symptom resolution, stability off oxygen, recall 3/3, and accurate understanding support recovery. COHb 1.3%, lactate 1.4, and venous pH 7.40 provide supporting data. Interpret results alongside neurologic and cardiac assessment, rather than as the only discharge criteria.
Complete ambulation, verify absence of recurrent symptoms, and confirm understanding, transport, support, and follow-up. A gap for the unresponsive interval differs from inability to retain new information, but new cognitive problems require reassessment. Discharge follows provider review of outstanding tasks.
Neurologic symptoms can develop after initial recovery. Seek prompt evaluation for new memory difficulty, confusion, behavior changes, imbalance, or other neurologic symptoms. Seizure, loss of consciousness, focal weakness, severe confusion, chest pain, or breathing difficulty requires emergency care.
Arrange medical and neurologic reassessment in approximately two weeks, sooner for symptoms. Do not return to the attraction or retrieve equipment before safety clearance. Generators must not operate indoors or in enclosed spaces; emphasize working CO alarms. Use teach-back with patient and sister.