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Sounds perfect Wahhhh, I don’t wanna
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Hey New Nurse
lamentations44

Hey new nurse,

You terrified yet? Have you wanted to quit or reconsider your career choice yet?

If not… you probably will.

But, little nurse- take heart. Please take heart. You are not alone.

That confident nurse you admire so much, the one whose work is done on time and is always available...

confessionsofanewgradnurse

Beautiful.

populationpensive

Inhalation Injury

This is a quick guide to inhalation injury. I’ll review what YOU can do as a PCP if you suspect inhalation injury, how to identify it, as well as what I do in my specialty. For information regarding burns in general or when to refer to a burn center, please see my post about burn center referrals. Keep in mind, inhalation injury is the most common immediate cause of death in a large burn patient and should ALWAYS be on your differential in patients coming from a fire in an enclosed space. Be prepared, I’ll probably say that like 100 times. 

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Risk Factors

  • More common in the elderly, immobile, and children
  • Fire in an ENCLOSED space
  • Carbonaceous sputum
  • Raspy or hoarse voice
  • Facial burns (2nd degree or worse)
  • Singed facial hair
  • Arterial PaO2 < 60 mmHg
  • Carboxyhemoglobin >15%
  • Bronchospasm or wheezing
  • Metabolic acidosis 
  • Alcohol and drug use + fire 

Pathophysiology

Inhalation injury can be devastating for 2 very important reasons 

  1. Smoke and inhaled irritants cause airway edema and mucosal sloughing, leading to loss of a patent airway.
  2. Burning things creates poisons which can be inhaled and kill you.

Organic things combust into carbon which is carcinogenic and an airway irritant. Synthetic things often combust into hydrogen cyanide. This can be inhaled as well and cause cyanide poisoning. Annnd then of course there is carbon monoxide. 

Hydrogen Cyanide poisoning - colorless gas with the smell of bitter almonds. Cyanide kills people because it impairs oxidative phosphorylation. It impairs a cell’s ability to utilize oxygen and produce ATP. 

Carbon monoxide poisoning - colorless and odorless gas. CO kills people because it has 200 x the binding affinity to hemoglobin as oxygen does. CO that binds prevents O2 from binding. However, this also means that remaining O2 on the hemoglobin will bind more tightly to the hemoglobin molecule and will not be delivered to the tissues. 

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Important History

  • Inhalation injuries do NOT occur just because someone has a burn to the face. In fact, they are RARE when a fire has taken place out doors (campfires, brush fires, etc).
  • Suspect inhalation injury in any patient coming from a house/building fire or a car fire. Essentially, any enclosed space.
  • Syncope + a house fire? Higher index of suspicion
  • Does your patient smoke? Do they have existing lung disease? Have a higher index of suspicion. 
  • Was extrication from the fire prolonged? 
  • Again, ENCLOSED SPACES
  • Kids are at a high risk because they tend to hide in closets during a fire rather than escape. The elderly or immobile have physical barriers to escape. 

PCP Steps

  • #1: If the history supports possible injury and the patient has a change in voice/declining respiratory status, INTUBATE THEM. You will NEVER be at fault for protecting an airway. 
  • If you suspect CO poisoning, make sure the patient is on FiO2 of 100%
  • If your facility is able, get the following labs: BMP, ABG, carboxyhgb
  • If you have high index of suspicion and are able, administer hydroxycobalamin to reverse cyanide toxicity - be aware, this will turn their urine maroon like red wine. Do not be alarmed.
  • If you have ANY suspicion of inhalation injury, they must be sent to a local burn center. 
  • REMEMBER: SpO2 saturations CANNOT tell you if someone has CO poisoning. This is because a pulse oximeter is only measuring binding affinity of oxygen to hemoglobin, not the amount of oxygen present in the tissues. Someone can have CO poisoning and have normal SpO2. Only a carboxyhemoglobin (and a good physical exam) can tell you if CO poisoning has occurred. I would like to point out that the stereotypical “cherry red skin” appearance of CO poisoning is NOT often reliable. This is particularly the case in a burn patient whose burns alone will cloud your ability to determine this. 

Burn Center Management

If we suspect cyanide poisoning and hydroxycobalamin hasn’t been administered, we will do that. If we have a patient with moderate to severe CO poisoning, we will send them for hyperbaric oxygen therapy. We will usually do 1 to 3 dives at 2 atm for 2 hours each to help offload the CO. The theory here is that you expose the patient to higher atmospheric pressure and 100% FiO2 to force the CO off of the hemoglobin. 

Most patients with suspected inhalation injury are (thankfully) intubated by the time they arrive to our burn unit. The first thing we do is bronchoscopy to confirm inhalation and categorize it. We grade inhalation injury using the AIS - Abbreviated Injury Score:

  • Grade 0 - no injury 
  • Grade 1 - mild injury - minor or patchy areas of erythema/carbonaceous deposits 
  • Grade 2 - moderate injury - larger areas of erythema, carbonaceous sputum, bronchorrhea, or partial obstruction
  • Grade 3 - severe injury - severe inflammation of the airway with friability, copious carbonaceous deposits and areas of partial/full obstruction 
  • Grade 4 - massive injury - evidence of mucosal sloughing, necrosis, and endoluminal obliteration
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Patients with a grade 0 or 1 injury will likely be extubated a couple of hours later if they are otherwise healthy. Sometimes, we keep patients with existing lung disease on the vent with a grade 1 so that we can give aggressive suctioning and medications to optimize their vent wean. 

Anyone with a grade 2 or high will likely take longer to extubate, at least 24 hours - more than that if the injury is worse or if they have existing lung disease. Smokers tend to suffer much more than people with health lungs, as do asthma and COPD pts. 

We have an inhalation protocol for our ventilated patients which consists of the following:

  1. Heparin 5,000 U inhaled solution Q4h x 7 days
  2. Mucomyst 3 mL inhaled solution Q4h x 7 days 
  3. Albuterol 2.5 mg inhaled solution Q4h x 7 days

We give albuterol and mucomyst together and alternate with the heparin so that the patient is receiving treatment every 2 hours. We do this to help flush out toxins, open the airway, and breakup/thin out blood clots (hence the heparin). Bad inhalation injuries will have bronchial bleeding and heparin helps remove and prevent further blood clots from clogging up the bronchi. 

From here, we wean patients off the vent! If a patient needs a vent for > 1 week or has had failure to wean for a variety of reasons, we will usually give them a tracheostomy. 

And now you know!

pablr physician assistant physician associate pa-c burn medicine inhalation injury medblr trauma burn unit burns nurblr
populationpensive

Pt with EtOH cirrhosis and portal HTN, hypotensive and maxed out on pressors got me like

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Originally posted by justalittletumblweed

3 unit of blood later and we finally got him to SICU. Talk about sphincter tightening. Couldn’t give him IV fluid because A.) lungs are shit and B.) liver can’t handle said fluid. I was anticipating another code situation real quick. 

pablr pa-c physician assistant physician associate burn medicine critical care frig
roachleakage beetledrink

I had a dream a while ago that Coach McGuirk was canonically a trans man

talkinganimals

Khyle’s subconscious show us the forbidden trans headcannons I guess

talkinganimals

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“It’s called being transgender, Brendon. You seriously haven’t heard of this?”

“No? But I get the feeling you’re gonna tell me, hah, all about it.”

“That’s funny, Brendon. You’re a real comedian. They teach you that in school? Instead of teaching you about things that actually matter?”

“I don’t…really pay attention, you know, so I wouldn’t know.”

“That’s good, Brendon. Don’t. School’s a joke. You shouldn’t trust anything they tell you in there. Don’t trust people who tell you you can be your own boss, either. It’s not all extra long breaks and working from home. I have a closet full of gluten free protein shakes. I can’t use one-third of my crappy apartment because it’s filled to the brim with inedible sludge. If a guy in a polo shirt ever tries to talk to you? Don’t trust him.”

“Uh, Coach, I don’t mean to poke holes here, but is that not what you wear, like, every day?”

“What? This is a body suit, Brendon. In what world is this a polo shirt?”

“Well I mean it’s got the little collar on it, so…”

“And then it just keeps going? Is that how you think polo shirts work? They can just go down as far as they like, decide they wanted to be a pair of pants all along? Shirts don’t get to choose their destiny, Brendon. They’re shirts.”

“Kind of feels like we’re all just shirts trying to be pants sometimes, doesn’t it, Coach?”

“What the hell is that supposed to mean?”

“Um–”

“That’s exactly the kind of stuff I’m talking about. Don’t let them feed you crap like that in there.”

“You know, Coach McGuirk, you still haven’t told me why you’re wearing that.”

“Well, Brendon, let me answer your question with another question: if the only thing you have to drink in your house are four year old protein shakes, and it’s the middle of the night and you’re a little bit drunk and maybe not thinking that clearly, do you drink them and immediately ralph them back up onto the outfit you usually wear to work?”

“Uh–”

“Yes, Brendon. The answer is yes.”

marchingfishes

@beetledrink