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The blue patient
  1. Adrian Spiteri
  1. Correspondence to Dr Adrian Spiteri, Emergency Department, St George's University Hospitals NHS Foundation Trust, Blackshaw Road, London SW17 0QT, UK; spiteri.adrian{at}

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Clinical introduction

A 46-year-old man was brought to the ED after being found in an enclosed sauna minimally responsive, clammy and confused.

On arrival he was alert, smiling and recalled sniffing a ‘herbal’ bottle followed by nausea, dizziness, poor balance, inability to stand up, shortness of breath, palpitations, sweating and confusion. He had a past history of back pain.

He had blue-purplish skin with central and peripheral cyanosis (figures 1 and 2). His observations were: HR 134 bpm, BP 108/68 mm Hg, RR 32/min, temperature 36.3°C and blood glucose 7.2 mmol/L.

Figure 1

Facial and oral colour on presentation.

Figure 2

Hand colour on presentation.

Pulse-oximeter saturation was 85% on air that only improved to 93% on 15 L/min oxygenation. An arterial blood sample was dark coloured.


What is the diagnosis?

  1. Carbon monoxide …

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