Silent Killer: A Case Report on Carbon Monoxide Poisoning

Carbon monoxide (CO) poisoning is associated with various sources of combustion, but its occurrence from hookah (waterpipe) smoking is often under-recognized. Hookah smoking can produce high levels of CO due to the burning of charcoal, leading to CO toxicity even in the absence of tobacco use. Symptoms of CO poisoning can be nonspecific, often delaying diagnosis in the emergency department (ED).

We report here a 37-year-old male brought in by ambulance after being found down by a bystander. The patient became unresponsive and apneic. Venous blood gas showed a pH of 7.40, PCO₂ 43 mmHg, PO₂ 43 mmHg, HCO₃ 27 mEq/L, and a CO of 24.9%. The patient underwent hyperbaric oxygen therapy and was admitted to the intensive care unit (ICU). CO level normalized and the patient was extubated the following day with improvement in mental status. The patient recounted his memory of the prehospitalization events, admitting to smoking hookah in a hookah parlor earlier in the day. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Hookah-related CO poisoning is frequently overlooked, as symptoms are broad. Pulse oximetry is unreliable in detecting CO toxicity, making carboxyhemoglobin measurement essential for diagnosis. Emergency physicians should maintain a high level of suspicion. Early recognition and oxygen therapy are key to preventing severe complications, including delayed neuropsychiatric effects.