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Features of the CO poisoning with low carboxyhemoglobin (COHb) levels remain to be characterized. This study collected a total of 307 CO poisoning cases from Shanghai Public Security Bureau, an official organization that handles the most complicated and life-threatening cases across Shanghai municipality in China, and regrouped these cases into three categories: group 1, 10% &lt;\u2009COHb% &lt;\u200930% (n\u2009=\u200958); group 2, 30% \u2264\u2009COHb% &lt;\u200950% (n\u2009=\u200979); group 3, COHb% \u2265\u200950% (n\u2009=\u2009170). Epidemiological, demographic, and forensic aspects of the CO poisoning cases, particularly those with low COHb levels, were analyzed. Our results showed that group 2 and 3 were mostly observed in younger victims (\u2264\u200930\u00a0years), while group 1 equally distributed to all age groups (<jats:italic>p<\/jats:italic>\u2009=\u20090.03). All the CO poisoning from group 2 and 3 occurred in enclosed spaces, whereas cases from group 1 died additionally\u00a0in outdoor spaces (<jats:italic>p<\/jats:italic>\u2009=\u20090.01). 81.03% of group 1 cases died in fire circumstances, while only 45.57% from group 2 and 30.59% from group 3 were fire-related (<jats:italic>p<\/jats:italic>\u2009=\u20090.00). Accordingly, group 1 was mostly related with fire burns, while group 2 or 3 were largely associated with gas leakage (<jats:italic>p<\/jats:italic>\u2009=\u20090.00). A combination with alcohol, but not other psychotropic drugs, associated with significant higher levels of blood COHb% in fire-unrelated (<jats:italic>p<\/jats:italic>\u2009=\u20090.021) but not fire-related cases (<jats:italic>p<\/jats:italic>\u2009=\u20090.23). Five extremely low COHb% (&lt;\u200930%)-related poisoning deaths were negative of any cardiopulmonary pathology and psychoactive substances. In conclusion, CO poisoning with low COHb% significantly associates with fire circumstances and outdoor spaces and has no age preference. Further diagnostic markers mandates to be identified in order to avoid disputes in cases of extremely low COHb%-related poisoning.<\/jats:p>","DOI":"10.1038\/s41598-021-97436-8","type":"journal-article","created":{"date-parts":[[2021,9,17]],"date-time":"2021-09-17T10:04:13Z","timestamp":1631873053000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":17,"title":["Acute carbon monoxide poisoning with low saturation of carboxyhaemoglobin: a forensic retrospective study in Shanghai, China"],"prefix":"10.1038","volume":"11","author":[{"given":"Zheng","family":"Liu","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hang","family":"Meng","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Juntian","family":"Huang","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Pascal","family":"Kwangwari","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kaijun","family":"Ma","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bi","family":"Xiao","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Liliang","family":"Li","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2021,9,17]]},"reference":[{"key":"97436_CR1","doi-asserted-by":"publisher","first-page":"636","DOI":"10.1111\/1556-4029.14206","volume":"65","author":"M Zanaboni","year":"2020","unstructured":"Zanaboni, M. et al. 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