Carbon Monoxide Poisoning in Tents—A Review☆

This review discusses the overlooked problem of carbon monoxide (CO) poisoning within small tents. It summarizes previous case reports, reviews the toxicity of CO, and attempts to draw conclusions from experimental work. Finally, practical recommendations are developed on avoiding CO poisoning within tents. The term carbon monoxide was used in a search of the Medline database covering the years 1966 to 2003. The results were combined with the terms atmosphere or camps or stoves or climbs or mountains or tents or poisons. The resulting articles were reviewed, and those relevant to this problem were obtained. Hard copies were hand searched for further relevant articles until no more citations could be found. Three original articles were impossible to obtain but have been cited to assist others seeking to find them. Other data and articles were obtained from the Ministry of Defence but are unpublished for security reasons. This review discusses the overlooked problem of carbon monoxide (CO) poisoning within small tents. It summarizes previous case reports, reviews the toxicity of CO, and attempts to draw conclusions from experimental work. Finally, practical recommendations are developed on avoiding CO poisoning within tents. The term carbon monoxide was used in a search of the Medline database covering the years 1966 to 2003. The results were combined with the terms atmosphere or camps or stoves or climbs or mountains or tents or poisons. The resulting articles were reviewed, and those relevant to this problem were obtained. Hard copies were hand searched for further relevant articles until no more citations could be found. Three original articles were impossible to obtain but have been cited to assist others seeking to find them. Other data and articles were obtained from the Ministry of Defence but are unpublished for security reasons. Laboratory work and computer modeling have predicted that a dangerous level of carbon monoxide (CO) could be reached inside tents within 30 minutes.1.Cohen M.A. Air pollution exposures to campers inside of tents: A study of the use of camping stoves and lanterns.in: Proceedings International Specialty Conference Indoor Air Quality Cold Climates, Ottawa, Ontario, Canada; May1985Google Scholar Numerous anecdotal reports about possible CO poisoning among outdoor enthusiasts also exist.2.Foutch R.G. Henrichs W. Carbon monoxide poisoning at high altitudes.Am J Emerg Med. 1988; 6: 596-598Abstract Full Text PDF PubMed Scopus (19) Google Scholar The first literature reports of the dangers posed by CO within tents and snow caves date back to early exploration of higher latitudes in the 1930s. Narrow escapes from episodes of poisoning in the Antarctic, which caused the authors and their companions to collapse, were reported by Amundsen in 1911.3.Byrd R. Alone. Adventure Library, New York, NY1938Google Scholar Similar episodes in the Arctic were recorded by Steffanson,4.Stefansson W. Unsolved Mysteries of the Arctic. Macmillan, New York, NY1939Google Scholar who reviewed a number of other Arctic accidents in which symptoms of CO poisoning may have been present. Frequent symptoms of poisoning have been reported within tents and snow caves in Norway5.Irving L. Scholander P. Edwards G. Experiments on carbon monoxide poisoning in tents and snow houses.J Ind Hyg Toxicol. 1942; 24: 213Google Scholar and during Antarctic overwintering in crates while using Primus stoves.6.Pugh L. Carbon monoxide hazard in Antarctica.BMJ. 1959; 34: 192-196Crossref Scopus (7) Google Scholar The author has personal knowledge of a poisoning episode that occurred when a soldier was sitting up inside the door of an open tent while cooking. He lost consciousness and collapsed but rapidly returned to a normal level of consciousness when laid down and dragged to an area of clear ventilation. The first reported fatalities from CO poisoning inside tents came from a temperate climate. A 10-year review (1979–1988) of all accidental CO deaths in California revealed that 10 of 136 deaths were associated with camping equipment—7 from lanterns or lamps and 3 from stoves.7.Girman J.R. Chang Y.L. Hayward S.B. et al.Causes of unintentional deaths from carbon monoxide poisonings in California.West J Med. 1998; 168: 158-165PubMed Google Scholar Other temperate-zone reports include 1 fatality from an alcohol stove inside a campervan in Germany,8.Rupp W. Nadjem H. Thoma K.H. Alcohol stove as a source of CO poisoning in a camper[in German].Arch Kriminol. 2000; 206: 8-13PubMed Google Scholar a propane gas stove inside a large tent in the state of Georgia (United States) that killed an adult and 3 children, and a charcoal grill inside a tent in the same state that killed an adult and child.9.Centers for Disease Control and PreventionCarbon monoxide poisoning deaths associated with camping–Georgia, March 1999.JAMA. 1999; 282: 1326PubMed Google Scholar An average of 30 fatalities per year from 1990 to 1994 as a result of CO poisoning in tents within the United States has been reported.9.Centers for Disease Control and PreventionCarbon monoxide poisoning deaths associated with camping–Georgia, March 1999.JAMA. 1999; 282: 1326PubMed Google Scholar,10.Schwartz R.B. Ledrick D.J. Lindman A.L. A comparison of carbon monoxide levels during the use of a multi-fuel camp stove.Wilderness Environ Med. 2001; 12: 236-238Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar The author has personal experience as the medical attendant during an episode of CO poisoning resulting in the deaths of 2 Royal Marines in Norway, although a third Royal Marine in the same tent survived (Ministry of Defence, unpublished report, 1993). The military 4-man tent had been pitched tactically the night before (dug into the snow, resulting in snow walls higher than the tent, and a camouflage net placed over the top). Subzero temperatures, moderate winds, and light snow characterized the 12 hours after entering the tent before a camping stove was lit to prepare breakfast. There was no need to leave the tent to collect snow during this time, as a snow-storage bag had been prepared the previous night. Other Marines had normal verbal contact with the tent dwellers 100 minutes after the stove was lit and again 140 minutes after it was lit. In retrospect, the tent inhabitants were noted as sounding incoherent during the second episode of verbal contact, although this was assumed at the time to be a result of sleepiness. When no verbal contact could be established 240 minutes after stove lighting, all 3 men were pulled from the tent unresponsive; only 1 survived despite resuscitation efforts. Very few literature reports of CO poisoning at altitude exist, and this may be because of the similarity in symptoms with acute mountain sickness (AMS). One of the few reports involves 2 episodes of severe (but nonfatal) poisoning at 5200 m (17 060 feet) on Mount McKinley in 1985. In the first episode, 2 climbers had been melting snow inside an igloo with a white gas stove for an extended period. They suffered headache, insomnia, tachycardia, tachypnoea, and ataxia, all of which improved rapidly when they were moved outside. In the second episode, comments were made about the difficulty of making a differential diagnosis between dehydration, AMS, and CO poisoning.11.Seibert R. Climbs and expeditions—Alaska.Am Alpine J. 1986; 28: 139-142Google Scholar Two male climbers were fatally poisoned (postmortem carboxyhaemoglobin [COHb] levels of 57% and 66%) by a butane stove inside their tent at 4300 m (14 100 feet) on Mount McKinley in 1988. They were discovered with their heads near the vestibule/stove 24 hours after retiring to their tent to cook. The stove was found to be one-quarter turned on, presumably for a low simmer, and the tent was zipped up with all the vents closed because the snowfall had been heavy.2.Foutch R.G. Henrichs W. Carbon monoxide poisoning at high altitudes.Am J Emerg Med. 1988; 6: 596-598Abstract Full Text PDF PubMed Scopus (19) Google Scholar An account of CO poisoning inside a tent on Mount Everest's South Col has recently been reported.12.Krakauer J. Into Thin Air—A Personal Account of the Everest Disaster. Pan Books, Chatham, UK1997Google Scholar Basal serum COHb concentration is about 0.7% as a result of haem catabolism,13.Coburn R.F. Blakemore W.S. Forster R.E. Endogenous carbon monoxide production in man.J Clin Invest. 1963; 42: 1172-1178Crossref PubMed Scopus (174) Google Scholar although half of nonsmokers have COHb concentration greater than 1.5%.14.Stewart R.D. The effect of carbon monoxide on humans.Ann Rev Pharm. 1975; 15: 409-423Crossref PubMed Scopus (122) Google Scholar Carboxyhaemoglobin concentration may reach 4% to 6% in persons with diseases or drugs that increase haemolysis or haem catabolism such as haemolytic anaemia, 8% to 16% after using paint stripper, and up to 20% in heavy smokers.14.Stewart R.D. The effect of carbon monoxide on humans.Ann Rev Pharm. 1975; 15: 409-423Crossref PubMed Scopus (122) Google Scholar Outside urban air has been noted to have a CO concentration up to 3 ppm.15.Dubois L. Zdrojewski A. Monkman J.L. The analysis of carbon monoxide in urban air at the ppm level, and the normal carbon monoxide value.J Air Pollut Control Assoc. 1966; 16: 135-139Crossref PubMed Scopus (8) Google Scholar Carbon monoxide is a chemical asphyxiant gas with a haemoglobin affinity 200 to 250 times greater than that of oxygen (O2). Carbon monoxide also interferes with cellular oxidation by binding myoglobin, cytochrome oxidase, cytochrome P-450, hydroperoxidases, and other haem proteins. Because it has an affinity for tissues with a high O2 demand, its main targets are the neurologic system, cardiac tissue, and fetus.16.Health and Safety Executive, UK GovernmentCarbon monoxide: health hazards and precautionary measures. Guidance Note.2nd ed. HSE Books, Sudbury, Ontario, Canada1998Google Scholar The half-life of COHb is 4 to hours at level, minutes with O2 at level, and minutes with O2 at a of 3 R.D. et to carbon Environ PubMed Scopus Google Scholar Carbon monoxide a in the O2 with of O2 as a result of a in and Safety Executive, UK GovernmentCarbon monoxide: health hazards and precautionary measures. Guidance Note.2nd ed. HSE Books, Sudbury, Ontario, Canada1998Google P. and carbon monoxide PubMed Scopus (7) Google to carbon monoxide and a Google Scholar COHb concentration from a CO be by the R.F. Forster R.E. of the that the carboxyhaemoglobin concentration in man.J Clin Invest. PubMed Scopus Google Scholar are this between CO concentration and COHb concentration has been with experimental work R.D. The effect of carbon monoxide on humans.Ann Rev Pharm. 1975; 15: 409-423Crossref PubMed Scopus (122) Google of carbon monoxide (CO) concentration to carboxyhaemoglobin concentration symptoms to be because it is a of CO concentration and time before and be noted with as as 1 of to 100 ppm unpublished R. J. Carbon monoxide to on the and J Environ Google Scholar The first and of CO toxicity is with COHb concentration greater than The first is a headache, the of which is the is The of COHb is are R.D. et to carbon Environ PubMed Scopus Google Scholar 2 summarizes of the symptoms and their to unpublished and Safety Executive, UK GovernmentCarbon monoxide: health hazards and precautionary measures. Guidance Note.2nd ed. HSE Books, Sudbury, Ontario, Canada1998Google R.D. et to carbon Environ PubMed Scopus Google and CO in the UK are by the health and to a COHb concentration greater than in The exposures are 200 ppm for minutes and 30 ppm for and Safety Executive, UK GovernmentCarbon monoxide: health hazards and precautionary measures. Guidance Note.2nd ed. HSE Books, Sudbury, Ontario, Canada1998Google Scholar Other state that in of 200 ppm could be and up to 24 hours to collapse, which levels of ppm (Ministry of Defence, unpublished into ppm is on in urban and reach 100 ppm during R.D. The effect of carbon monoxide on humans.Ann Rev Pharm. 1975; 15: 409-423Crossref PubMed Scopus (122) Google Scholar have CO production inside small experimental with of or inside tents and snow The main are and their are and J. Carbon monoxide as a hazard of Scopus Google Scholar with a Primus stove used on Antarctic inside a An of 3 1 the were with snow, and the stove until it L. Carbon monoxide hazard in Antarctica.BMJ. 1959; 34: 192-196Crossref Scopus (7) Google Scholar used a Primus stove inside a to a stove with a stove melting An air in at and the were and the CO production of a stove on a low in a O2 atmosphere with no A was to an O2 to O2 levels in 3 to to and greater than et R.B. Ledrick D.J. Lindman A.L. A comparison of carbon monoxide levels during the use of a multi-fuel camp stove.Wilderness Environ Med. 2001; 12: 236-238Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar used an as a of a snow to CO production from a stove for while for It experimental a level of of to a of and CO et A. et of carbon monoxide levels during of and to with a camping stove.Wilderness Environ Med. 15: Full Text Full Text PDF PubMed Google Scholar the of et to a of from the of the This had the of an of O2 for which an time with no stove while the to CO production levels et L. Scholander P. Edwards G. Experiments on carbon monoxide poisoning in tents and snow houses.J Ind Hyg Toxicol. 1942; 24: 213Google Scholar the COHb concentration of inside and snow caves in a of on Mount United States) during the He a of with a Primus the to Antarctic L. Carbon monoxide hazard in Antarctica.BMJ. 1959; 34: 192-196Crossref Scopus (7) Google Scholar COHb concentration in tent melting snow for 2 hours with those their tents for 3 He used a Primus stove in tents made of heavy He also the CO while melting for 3 hours inside a tent in a et M.A. et monoxide in on Med. 1988; Google Scholar CO concentration during to with and stoves in snow and at from to 5200 m 060 feet) while Mount McKinley in 1988. 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Carbon monoxide hazard in Antarctica.BMJ. 1959; 34: 192-196Crossref Scopus (7) Google Scholar noted that air and CO tent walls be by snow, and He also that a tent had after only 30 ppm CO while melting for 3 hours inside this tent in a et M.A. et monoxide in on Med. 1988; Google Scholar have that is the for a snow and have noted times in tents than in snow They recorded their CO concentration while in snow caves and the of tents in Carbon monoxide production is with a and is by or contact with the unpublished L. Carbon monoxide hazard in Antarctica.BMJ. 1959; 34: 192-196Crossref Scopus (7) Google J. Carbon monoxide as a hazard of Scopus Google A. et of carbon monoxide levels during of and to with a camping stove.Wilderness Environ Med. 15: Full Text Full Text PDF PubMed Google A of Carbon Arctic Carbon monoxide from in snow caves at high Environ Med. 2001; 12: Full Text Full Text PDF PubMed Scopus Google H. Carbon monoxide from small camping and from stoves Google of carbon carbon and during the use of gas stoves Google Scholar et Carbon monoxide from in snow caves at high Environ Med. 2001; 12: Full Text Full Text PDF PubMed Scopus Google Scholar found a small but relevant increase in CO concentration during and after in snow et M.A. et monoxide in on Med. 1988; Google Scholar noted CO greater than ppm of the time during to in a of and snow Carbon monoxide production has been to be higher while melting snow or than when the is unpublished L. Carbon monoxide hazard in Antarctica.BMJ. 1959; 34: 192-196Crossref Scopus (7) Google Scholar COHb concentration has been found with when with the tent or snow et Carbon monoxide from in snow caves at high Environ Med. 2001; 12: Full Text Full Text PDF PubMed Scopus Google Scholar a small but relevant increase in COHb concentration during and after cooking. L. 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Experiments on carbon monoxide poisoning in tents and snow houses.J Ind Hyg Toxicol. 1942; 24: 213Google Scholar and A. et of carbon monoxide levels during of and to with a camping stove.Wilderness Environ Med. 15: Full Text Full Text PDF PubMed Google Scholar noted that in of stoves to lit with a but to and CO with a low of the dangers of low and may from the low stove found after the fatalities on Mount R.G. Henrichs W. Carbon monoxide poisoning at high altitudes.Am J Emerg Med. 1988; 6: 596-598Abstract Full Text PDF PubMed Scopus (19) Google Scholar Carbon monoxide production is also when a which may be more when are A. et of carbon monoxide levels during of and to with a camping stove.Wilderness Environ Med. 15: Full Text Full Text PDF PubMed Google Scholar et R.B. Ledrick D.J. Lindman A.L. 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