Smoke inhalation

Question 1

A 43 year old woman presents after a house fire where she was trapped for 30 minutes. She is short of breath and her oxygen saturation at room air is 85%. How would you assess and manage her?

Answer 1

Impression
Three key concerns in this presentation
1. Smoke inhalation, CO poisoning
2. Airway burns and risk of airway obstruction
3. Cyanide poisoning with burning household items

Goals
- Simultaneous A to E assessment focusing on A/B
- call for senior help
- consider additional injuries (burns), and ?need for transfer/retrieval to burns unit/ICU

Question 2

Smoke inhalation - Assessment

Answer 2

Assessment
- Call for senior help
- Consider ICU/retrieval to burns unit

A - patent, maintaining. Low threshold for intubation if indication of airway burns (increasing oedema makes it harder). Consider use of naseondoscopy to assess upper airway for evidence o f burns, otherwise any indication of burnt facial hair, cherry red lips (CO poisoning), other facial burns, eschars, or audible stridor then intubate to secure airway
o anaesthetics involvement for difficult intubation

B - Given low sats would be starting supplemental 02 at Fi02 of 100% (given ?CO poisoning), then via ventilator If intubated. Consider administering nebulised salbutamol if bronchospasm involved.
o suction for any particulate debris

C - as usual plus ECG, 2xIVC access for fluids, and bloods: ABG/VBG (carboxyhaemaglobin, Pa02 level, acidosis, lactate), cyanide level, FBC/UEC/LFT (baseline, organ damage, etc), serial ABGs.

D - GCS, as per the rest

E - Exposure: looking for other burn sites, assessing for % of body covered, calling burns unit/plastics for input
- parkland formula for fluid resus in significant burns

Question 3

Smoke inhalation - History

Answer 3

History
- MIST AMPLE
- Mechanism, what if known substances burned?

Question 4

Smoke inhalation - Examination

Answer 4

Examination
As per A to E

Question 5

Smoke inhalation - Investigations

Answer 5

Investigations
As per A to E

Imaging - CXR
Other- fibre-optic bronchoscopy to confirm inhalation injury - only one HD stable

Question 6

Smoke inhalation- Management

Answer 6

Management
Acute is as per the A to E in order to secure airway, correct hypoxia and ensure HD stability.
- consider need for early intubation for protection of airway

Supportive
- monitoring
- Analgesia, fluids, NGT
- Pulmonary support - mucolytics, bronchodilators

Definitive
- CO poisoning: 100%Fi02 through non-rebreather or ventilator if tubed, consider hyperbaric oxygen
- Cyanide poisoning: consult toxicologist as complex, specific antidotes including hydroxycobalamin
- Burns: referral/retrieval to burns unit