Outline

• Background
• Smoke
• Pathophysiology
• Diagnosis
• Treatment
• Specific Lethal Compounds

http://spanishlakefd.com/firealarms/
 Learning Objectives
• Describe the pathophysiology of inhalation injury
• How is inhalation injury diagnosed?
• What adjunctive measures are used to treat inhalation injury?
• What is the treatment for carbon monoxide and cyanide poisoning?
A Sunday afternoon stroll
thru the fire…

http://www.aeromedix.com/product-exec/parent_id/1/category_id/12/product_id/1074/nm/Safe_Escape_Smoke_Hood
 Epidemiology

• 15-30% of burn admissions have inhalation injury

• Independent predictor of mortality, ↑ by 20%
• Increases pneumonia risk
• Leading diagnosis of those hospitalized and treated on 9/11,
World Trade Center attack
 Anatomic Classification
• Upper airway
• Lower airway
• Systemic toxicity

http://www.monroecc.edu/depts/pstc/backup/parasan4.htm
 SMOKE

• Variable, changes with time burning

• Toxic gases and low ambient oxygen
• Ingredients:
Aldehydes (formaldehyde, acrolein), ammonia, hydrogen sulfide,
sulfur dioxide, hydrogen chloride, hydrogen fluoride, phosgene,
nitrogen dioxide, organic nitriles
• Particulate matter
 Pathophysiology
• Cilia loss, respiratory epithelial sloughing
• Neutrophilic infiltration
• Atelectasis, occlusion by debris/edema
• Pseudomembranes
• Bacterial colonization at 72 hrs

Hubbard et al. J Trauma 1991; 31:1477-1486

Bartley et al. Drug Design, Development and Therapy. 2008; 2: 9–16.
 Secondary Lung Injury
• Unilateral smoke inhalation damages contralateral lung
• Immune response, increased permeability
• Oxygen-derived free radicals
• NO mediated damage (chemotactic factor neuts)
• Eiscosanoids (TXA2→TXB2)
• Reduced phagocytosis in macrophages
 Systemic Effects

• Larger fluid resuscitation (2→5cc/kg/%)

• Additive effect to burns
• 12% pts inhalation injury alone require intubation*
• 62% pts burn + inhalation injury intubated*

Clark et al. J Burn Care Rehabilitation, 1990; 11:121-134

Miller et al. Journal of Burn Care Research. 2009; 30(2) 249-256
• Clinical findings: Diagnosis
• Facial burns (96%)
• Wheezing (47%)
• Carbonaceous sputum (39%)
• Rales (35%)
• Dyspnea (27%)
• Hoarsness (26%)
• Tachypnea (26%)
• Cough (26%)
• Cough and hypersecretion (26%)
 Tools for Diagnosis

• Bronchoscopy
• Pulmonary function testing
• Xenon lung scan
Endorf and Gamelli. Journal of Burn Care and Research. 2007; 28:80-83
 Treatments

• Airway Control
• Chest physiotherapy
• Suctioning
• Therapeutic bronchoscopy
• Ventilatory strategies
• Pharmacologic adjuncts
 Treatment

Control the Airway!!!

• ≥ 40% burn
• Transport

http://www.burnsurgery.com/Betaweb/Modules/initial/bsinitialsec2.htm
 Ventilator Strategies
• Airway pressure release ventilation (APRV)
• Intrapulmonary percussive ventilation (IPV)
• High-frequency percussive ventilation (HFPV)
• High frequency oscillatory ventilation (HFOV)
P/F ratio vs Ventilator Mode
Pharmacologic Intervention

Bartley et al. Drug Design, Development and Therapy. 2008; 2: 9–16.

Pharmacologic Intervention

Bartley et al. Drug Design, Development and Therapy. 2008; 2: 9–16.

 Airway Obstructive Casts
• Mucus secretions
• Denuded airway epithelial cells
• Inflammatory cells
• Fibrin
• -Solidifies airway content
• Several studies shown reduction in size of casts with fibrinolytic agents (tPA)
Casts
TOXIC GASES
 Carbon Monoxide (CO)

• CO from incomplete combustion

• CO + Hb → COHb (affinity 200-250x)
• LEFT shift of oxy-Hb curve (Haldane effect)
• CO binding to intracellular cytochromes and metalloproteins
(myoglobin)
• “Two compartment” pharmacokinetics
• Animal experiment 64% COHb transfusion
 CO Toxicity Symptoms

• “Cherry-red lips, cyanosis, retinal hemorrhage”- rare

• CNS and Cardiovascular
• ↑ RR, ↑HR, dysrhythmias, MI, ↓BP, coma, seizures
• Delayed neuropsychiatric syndrome (3-240d)
• Cognitive/personality changes/parkinsonianism
• Spontaneous resolution
Signs and Symptoms

Weaver LK. N Engl J Med 2009;360:1217-25.

 CO Toxicity Diagnosis
• Pulse oximetry false HIGH COHb Symptoms
SpO2 %
0-5 Normal
• Need cooximetry direct
measurement of COHb 15-20 Headache, confusion,
fatigue
• Older ABG analyzers (estimate off dissolved 20-40 Hallucination, vision
PO2)
Δ’s
• MRI – lesions globus 40-60 Combative, coma
pallidus/basal ganglia/deep
60 + Cardiopulmonary
white matter arrest
 CO Toxicity Diagnosis
• Pulse oximetry false HIGH COHb Symptoms
SpO2 %
0-5 Normal
• Need cooximetry direct
measurement of COHb 15-20 Headache, confusion,
fatigue
• Older ABG analyzers (estimate off dissolved 20-40 Hallucination, vision
PO2)
Δ’s
• MRI – lesions globus 40-60 Combative, coma
pallidus/basal ganglia/deep
60 + Cardiopulmonary
white matter arrest
 CO Toxicity Treatment
• OXYGEN
• Half-life COHb (min)

RA 100% 100% O2
1ATM O2 2.5 ATM
Male 240 47 22

Female 168 33 15

• Carbogen – normobaric, normocapnic, hyperventilation (4.5-4.8%

CO2)
• Hyperbaric oxygen???
 Cyanide (CN)
• Combustion of synthetics (plastics, foam, varnish, paints, wool, silk)
• Binds to cytochrome c oxidase – dose dependent
• Uncouple mitochondria
• Aerobic → anaerobic = Lactic acid
• Half-life 1-3 hours
 CN Toxicity Symptoms

• Dyspnea
• Tachypnea
• Vomiting
• Bradycardia
• Hypotension
• Giddiness/Coma/Siezures
• Death
* The smell of bitter almonds on the breath suggests exposure (cannot be detected by
60% of the population)
 CN Toxicity Diagnosis

• No rapid assay
• High lactate (>10mmol/L) (s/s, 87%/94%)
• Metabolic acidosis
• Elevated mixed venous saturation (<10% a-v) difference
• High index of suspicion
** Also get: COHb and Methemoglobin levels
 Cyanokit (Hydroxocobalamin)
• 70mg/kg dose (5g vials)
• Combines with cyanide to from cyanocobalamin (Vit B12)
• Red membranes/urine
• Hypertension, Anaphylaxis
• 5% increase COHb, interfere with HD
LFTs/Cr/Fe levels
 Cyanide Antidote Kit (CAK)
Amyl nitrite pearls, sodium nitrite, and sodium thiosulfate

• Amyl nitrate and sodium nitrate induce methemoglobin

• Methemoglobin+cyanide→releases cyanide from CC
• Sodium thiosulfate enhances cyandide→thiocynate→renal
excretion
• Avoid nitrate portion in pts with inhalation injury (COHb >10%)
• Vasodilation and hypotension
 Acquired Methemolgobinemia
• NO2, NO, benzene gases → oxidation of iron
• Fe2+ → Fe3+
• Shift curve to LEFT
• Blood “Chocolate brown color”
• Normal PaO2, pulse ox >85%
• Tx: Methylene blue (1-2 mg/kg Q 30-60min)
The Toilet Snorkel

http://www.icbe.org/2006/01/18/the-toilet-snorkel/
Thank You!