On December 27, 1990, three children, aged 6, 10, and 11 years, died as a result of carbon monoxide (CO) inhalation while riding in the back of their parents' pickup truck, which had a camper shell cover. The family was returning overnight to Georgia from Mississippi, and the children were sleeping in the back of the truck. After 50 miles of travel, they stopped at a service station; the children did not complain of headache or other problems. During a second stop 250 miles further, the children appeared to be asleep. On arrival at their destination in Georgia, following a total drive of 550 miles, the children could not be aroused; resuscitation attempts were unsuccessful. The parents and two younger children riding in the truck cab were asymptomatic.

Autopsy examinations revealed that the three children had carboxyhemoglobin (COHb) levels of 15%-20%, 23%-28%, and 31%-36% and that cerebral edema was present in each. No evidence was found of other cause(s) of death. COHb levels were not measured in the parents and the two other children.

An inspection of the 1970 truck by the Georgia Bureau of Investigation found that the muffler had been replaced, but the original tailpipe was not securely joined to the muffler. Several holes in the wall of the truck bed behind the cab allowed fumes leaking from the muffler to enter the enclosed bed. In addition, the camper shell cover was attached to the truck without a gasket, and the rear door of the cover was loose. Reported by: J Brown, Georgia Bureau of Investigation; T Young, MD, Fulton County Medical Examiner's Office, Atlanta; J Wilber, MD, Acting State Epidemiologist, Div of Public Health, Georgia Dept of Human Resources. Air Pollution and Respiratory Health Activity, Div of Environmental Hazards and Health Effects, Center for Environmental Health and Injury Control, CDC.

Editorial Note

Editorial Note: Death from CO poisoning associated with vehicles is entirely preventable. The three deaths described in this report were caused by the combination of an aging vehicle, a defective exhaust system, and passengers being transported in an inadequately ventilated space.

Any moving vehicle with a vertical rear tailgate or door (e.g., a station wagon or pickup truck with a camper shell cover) creates negative air pressure behind it. Because of this vacuum, opening the rear window of a camper or station wagon can result in high concentrations of exhaust fumes entering the vehicle. Holes in the body of the vehicle or leaks around windows or doors may also allow fumes to enter the passenger compartment.

Of 68 deaths attributed to CO poisoning in vehicles in Maryland during 1966-1971, the implicated vehicles were considerably older (mean: 7.6 years) than the total sample of registered cars (mean: 4.4 years) (p less than 0.01) (1). Of the 68 deaths, 51 (75%) occurred in cars that had a defective exhaust system and/or holes in the fender panels, floor, or trunk. Thirty-three (49%) deaths occurred among persons with measurable blood alcohol levels; in 18 (26%) of the 68, blood alcohol levels were greater than 0.1 mg divided by L. Most deaths occurred in parked cars in which the motor was running to provide heat (1).

The relation between COHb levels and clinical manifestations varies. The COHb levels in the children in this report were lower than levels generally present in survivors of CO poisoning (however, resuscitation attempts may have lowered the COHb levels before samples were obtained).

Since 1968, the average quantity of CO produced by new cars has been reduced by greater than 90%, largely because of engineering improvements to comply with Clean Air Act regulations. Although a primary goal of the regulations is to reduce ambient CO in urban areas, a collateral benefit is increased safety for persons exposed to automobile exhaust fumes in enclosed places. The 1990 amendments to the Clean Air Act should result in further reduction of CO emissions by mandating the introduction of oxygenated fuels and more advanced pollution control systems (2).

CO production by vehicles can be minimized by regular preventive maintenance, inspection of exhaust systems, and emissions testing. Use of leaded gasoline in cars with catalytic converters or bypassing the pollution-control systems will result in production of higher levels of CO and nitrogen oxides. Annual inspections of vehicles should include an examination for rust holes or defects in the body or floor that could permit exhaust fumes to enter the passenger compartment.

References

1. Baker SP, Fisher RS, Masemore WC, Sopher IM. Fatal unintentional carbon monoxide poisoning in motor vehicles. Am J Public Health 1972;62:1463-7.

2. US House of Representatives. Conference report on S. 1630, Clean Air Act Amendments of 1990. Vol 101. Congressional Record H13101-H13203 (1990).

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