Death in a Carbon Dioxide Therapy Bath: A Case Report and Review of the Literature

Abstract

Carbon dioxide (CO₂) therapy is the subcutaneous or transcutaneous administration of CO₂ for therapeutic purposes. Carbon dioxide therapy is used for localized lipolysis, to treat chronic skin conditions, and is a safe treatment. Full-body CO₂ baths are offered in European spa centers, in which the clients are placed into full body bags infused with CO₂ at an optimal concentration range between 1000 and 1400 mg/L (516 000-722 500 ppm). Commercially manufactured, air-tight bags and accompanying apparatus designed to provide CO₂ baths can be purchased for home use. Few human CO₂-related deaths have been reported. They have been mostly accidental, consisting of persons trapped in a closed environment in the presence of “dry ice” or solid CO₂. There have been no reported deaths of a human undergoing a CO₂ therapy at home. We present a case of a middle-aged male found at home completely inside an air-sealed bag wrapped tightly around his body. The bag was connected to a working pump and a CO₂ gas tank. The pump was connected through an inflow and outflow circuit to the bag. The inflow tubing for CO₂ gas delivery was partially disrupted, while the outflow tubing was intact. The autopsy and toxicology were unremarkable. The cause of death was determined to be asphyxia by vitiated atmosphere as evident by the displacement of oxygen by CO₂ and low pressure created inside a “CO₂ therapy bath.” The manner of death was accidental.

Introduction

Carbon dioxide (CO₂) therapy, or carboxytherapy, refers to the transcutaneous administration of CO₂ gas for therapeutic purposes. Historically, use of CO₂ was first noted in 1932 in French spas for the treatment of peripheral artery disease (1). Various methodologies of carboxytherapy have been utilized over the years in various naturopathic and complementary medical settings. The “wet carbon dioxide” bath was first conceptualized from the natural spring baths, found in the Europe. In the clinical setting, CO₂ gas is infused into the affected areas for localized lipolysis and treatment of chronic wounds or other skin conditions. It is also utilized as the insufflation gas in laparoscopic minimally invasive surgeries. It is considered to be a safe, inert gas, and the most common side effect, hypercapnia, is well tolerated (2).

The use of dry CO₂ has been popularized recently in European medical spas that offer full-body CO₂ baths in which the clients are placed into full body bags with only their heads sticking out, and CO₂ gas is infused into the bags until an optimal gas concentration between 1000 and 1400 mg/L (516 000-722 500 ppm) is obtained. Currently, commercially manufactured, air-tight bags and accompanying apparatus that are designed to provide CO₂ baths can be purchased for use at home.

The Center for Disease Control has designated 100 000 ppm (196 mg/L) of CO₂ as immediately dangerous and exposure to lower levels, starting at 84 000 ppm (164 mg/L) for 60 minutes, as potentially fatal (3). The deadly properties of CO₂ have been utilized for the euthanasia of wild and laboratory animals as it requires no injection, handling or transfer, is painless, and relatively safe to the technician. Despite the safety profile of CO₂ gas, a few human CO₂-related deaths have been reported. They have been mostly accidental, consisting of persons trapped in a closed environment in the presence of high concentration of CO₂ gas. There have been no reported human deaths while undergoing a CO₂ therapy at home to date.

Case Study

We present a case of a middle-aged male who was a self-employed fitness and wellness counselor. He lived alone in an apartment and communicated with the family members regularly. There was no history of substance or alcohol use disorder or history of psychiatric illness. He was quite active on social media and recently left a Facebook comment about receiving a new tank for presumed wellness reasons.

A wellness check was performed by a doorman by the family request after they were not able to contact him for a couple of days. The body was found at home inside an air-sealed CO₂ therapy bag wrapped tightly around his body. Upon discovering the bag, the doorman immediately called 911. The Fire Department responded along with emergency medical services and, after seeing the tank apparatus, withdrew from the scene and requested the HazMat unit. The HazMat team went inside with appropriate personal protective equipment (level B), opened all windows for ventilation, unplugged apparatus from the wall, and confirmed that there were no elevated carbon monoxide (CO) levels or other potential toxins, fumes, flammables, explosives, or other dangerous conditions present. They found that the tank contained CO₂ and was empty. Upon determining the apartment to be safe, the medical legal investigator from the Office of Chief Medical Examiner processed the scene.

The body was discovered in a large neoprene bag, attached to the tank apparatus, on the floor. The bag was connected to a working pump attached to an aluminum tank (tare weight 26.7 lb/12 kg) that was filled with CO₂ gas. The pump was connected to the bag by two tubes, creating an inflow and outflow circuit. The inflow tube for CO₂ gas delivery was partially disrupted, while the outflow tubing was intact.

There was no sign of forced entry, and no suicidal notes were discovered. Various over-the-counter vitamins, supplements, medical testing strips, and cannabinoid derivatives (cannabidiol oil) were found, but no prescription medications or illicit substances were seen.

Of note, the autopsy findings of asphyxia that include petechiae, cyanosis, congestion, fluidity of the blood, and dilatation of the right side of the heart, better known as Adelson’s obsolete diagnostic quintet, were not seen (4). In this case, those findings were obscured due to the moderate decomposition changes. The toxicology was negative for the common drugs of abuse and was not performed to test for cannabinoid derivatives. Further investigation revealed that the “CO₂ therapy bath” was purchased online through a company that sells at home CO₂ therapy devices. The empty gas tank was purchased online and filled through a local welding supply center.

Discussion

Carbon dioxide gas occurs naturally in the atmosphere and makes up approximately 0.03% of the atmosphere. Carbon dioxide is heavier than air, colorless, and odorless at low concentration, but at high concentration has a sharp, acidic odor. At standard temperature and pressure, the density of CO₂ is about 1.67 times that of air.

Inhalation of CO₂ may produce hyperventilation, headaches, dizziness, tachycardia, and cardiac arrhythmias. If the concentration is very high, the sequelae include unconsciousness, asphyxia, and ultimately death (5). The mechanism of action is postulated to be the displacement of atmospheric oxygen from the respiratory system, usually when the concentration of CO₂ rises above 5%, or 50 000 ppm, of the ambient atmosphere. Since these deaths are rare, the majority of cases are accidental. Two instances of workplace-related accidental deaths due to inhalation of high concentration of CO₂ from dry ice being kept in a cold storage freezer have been described (6, 7). An accidental death of a male who was found in a steel fermentation tank used to produce wine has also been described (8). There have also been natural disasters with large number of fatalities due to exposure to high CO₂ concentrations without warning. In August 1986, a limnic eruption at Lake Nyos in Northwestern Cameroon killed 1746 people and 3500 livestock in a matter of minutes due to release of CO₂ dissolved in the water (9). Although large quantities of CO₂, gaseous or solid form, are relatively accessible to persons, very few cases of suicidal deaths from asphyxia in the setting of high concentration of CO₂ have been published (10, 11).

In our case, the decedent’s body was completely enveloped inside the bag. The rupture of the inflow tube expectedly permitted CO₂ gas to fill up the room, instead of the bag. High concentration of the gas likely ensued, since the tank was found empty in a room with closed windows. The intact outflow tube was attached to the vacuum component of the pump. Since the pump was functional and the decedent’s head was placed inside the bag, instead of positioned through the neck seal, the bath eventually collapsed. A vacuum tight seal was created around his entire body, in keeping with the initial discovery at the scene. No CO₂ detector or an alarm system was in use.

Although it was unclear why the deceased decided to use the CO₂ therapy bath on the floor at home alone, there was no evidence to suspect that this death was a suicide, or even a homicide. In fact, he was very active on social media and even made posts alluding to his plan to perform the CO₂ therapy bath. The cause of death was determined to be asphyxia by vitiated atmosphere as evident by the displacement of oxygen by CO₂ and low pressure created inside a “CO₂ therapy bath.” The manner of death was determined to be an accident.

There has been a lot of publicity and regulations regarding CO and the life-threatening safety hazards it poses, but not much regarding CO₂. In the 2018 edition of the International Fire Code, the requirements for CO₂ operations are found in chapter 53 and stipulate the proper ventilation and alarm system that must be in place in a location where CO₂ tanks, piping, and equipment with more than 100 pounds (45.4 kg) of CO₂ are used or stored (12). An at home CO₂ therapy bath by itself does not violate the fire code. However, the CO₂ gas required for the operation of this equipment might need tighter legislation since even a small quantity of gas can be dangerous or fatal if used in an enclosed space without appropriate safety or alarm equipment.

Conclusion

This is the first known reported case of an accidental death due to asphyxia by vitiated atmosphere by the displacement of oxygen by CO₂ and low pressure, while undergoing CO₂ therapy bath at home. A careful scene investigation, ruling out other causes of death, and examination of the deceased’s social media imprint was key in determining the cause and manner of death in this instance, since there were no abnormal findings at autopsy and toxicological studies were unremarkable.

Authors

Julian Samuel MD, Mount Sinai West Medical Center - Pathology and Laboratory Medicine

Roles: Data acquisition, analysis and/or interpretation, manuscript creation and/or revision, approved final version for publication, accountable for all aspects of the work, general supervision, general administrative support, writing assistance and/or technical editing.

Zhanna Georgievskaya MD, City of New York Office of Chief Medical Examiner

Roles: Project conception and/or design, data acquisition, analysis and/or interpretation, manuscript creation and/or revision, approved final version for publication, accountable for all aspects of the work, principal investigator of the current study, general supervision, writing assistance and/or technical editing.