# Smoke inhalation injuries



## harold1981 (Feb 10, 2017)

We are an ALS-unit and we are dispatched to a residential fire, where a resident has been rescued by bystanders. We find a 35yo male with signs and symptoms of chemical and thermal inhalation injury: The patient is awake, with a GCS of 3/6/5, he is hoarse, has 1st and 2nd degree burns to the face, burned nosehairs and black soot particles in the nose and on the lips and tongue. He is coughing, has a sore throat, an inspiratory stridor, is anxious and in respiratory distress. Auscultation also reveals wheezing bilaterally. He saturates 77% on room air, 85% on 15L per NRB.
We decide that  this patient needs to be intubated and we call for back-up of a HEMS-based CCT-team, with an emergency physician onboard who can perform an RSI. The first available HEMS-unit is 25 minutes away due to weather conditions. The nearest trauma center with burn care capabilities is 35 minutes away.

My question to you: while awaiting the RSI, would you consider one of the following treatments to avoid or at least delay full respiratory failure. Please motivate your choice:

1. nebulization with a B2-agonist and a bronchospasmolyticum (in our case a combi of Albuterol and Ipratropiumbromide)
2. nebulization with epinephrine 5mg
3. nebulization with a corticosteroid (in our case Budesonide)
4. IV corticosteroid (in our case Hydrocortisone 200mg)
4. CPAP
5. assisted ventilations with a BVM with PEEP (eventually under sedation with Midazolam as needed)
6. A combination of these options?


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## STXmedic (Feb 10, 2017)

1) Yes.

2) The hell is a bronchospasmolyticum?.... 

3) This is your homework I assume?


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## NomadicMedic (Feb 10, 2017)

No, I think this is just a discussion question. @harold1981  is a Dutch paramedic and has been on the forums for a while.

I think high flow oxygen is your best bet. Albuterol  is also indicated.

There's been some evidence that shows paramedics (and emergency departments) have been overzealous in the use of early intubation in burn patients. I don't believe this is the case here though. This patient needs emergent intubation.


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## VentMonkey (Feb 10, 2017)

NomadicMedic said:


> No, i think this is just a discussion question. @harold1981There's been some evidence that shows paramedics (and emergency departments) have been overzealous in the use of early intubation in burn patients.* I don't believe this is the case here though. This patient needs emergent intubation*.


This, with my caveat being the _most qualified_ candidate one can find posthaste.


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## EpiEMS (Feb 10, 2017)

Interesting question. Is RSI limited to physicians in your country, @harold1981?

High flow O2 via NRB is certainly indicated, and CPAP could be used (I think...I can't think of why it could be contraindicated here other than some sort of impairment to the seal). You'll want a BVM ready, with how this guy is looking, I'd wager. If I had it in my scope, I'd try an albuterol neb, without a doubt.

I'd definitely be monitoring SpCO and ETCO2, too (regardless of SPO2, obviously).

How about IM epinephrine? I know we use this in reactive airway disease for impending respiratory failure -- wouldn't we get some benefits (i.e. respiratory tract vasoconstriction and bronchodilation) from this too?

I don't think the corticosteroids would have any short-term benefit.


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## VentMonkey (Feb 10, 2017)

Short of not being able to find a landmark this also sounds like an emergent crash airway candidate, i.e., needle or surgical cricothyrotomy; preferably the latter if available. 

Again, I don't know the op's scope, or level of certification in his homeland though.


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## EpiEMS (Feb 10, 2017)

VentMonkey said:


> Short of not being able to find a landmark this also sounds like an emergent crash airway candidate, i.e., needle or surgical cricothyrotomy; preferably the latter if available.



Would it not be preferable to start with temporizing measures if possible? Or are we totally going to lose the airway, no bones about it?


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## VentMonkey (Feb 10, 2017)

EpiEMS said:


> Would it not be preferable to start with temporizing measures if possible? Or are we totally going to lose the airway, no bones about it?


Judging by the ops presented scenario it sounds as though we're already on the brink of losing this airway. 

This is an aggressive airway management candidate, with a pretty narrow window to fool around with other measures. Least to most? Sure, but in the case presented you're high hurdling up to "most" pretty quickly.


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## EpiEMS (Feb 10, 2017)

VentMonkey said:


> This is an aggressive airway management candidate, with a pretty narrow window to fool around with other measures. Least to most? Sure, but in the case presented you're high hurdling up to "most" pretty quickly.



Right, that makes sense. So it's basically a matter of when we need to get invasive rather than a "do we need to get invasive".

(It's sometimes hard to get a picture of a patient like this when I really haven't seen one other than in books and articles.)


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## VentMonkey (Feb 10, 2017)

EpiEMS said:


> Right, that makes sense. So it's basically a matter of when we need to get invasive rather than a "do we need to get invasive".
> 
> (It's sometimes hard to get a picture of a patient like this when I really haven't seen one other than in books and articles.)


Stridor + wheezes (top to bottom adventitious breath sounds= no bueno), anxiousness, and insignificant improvement with supplemental O2 indicates to me the shop is closing sooner rather than later. This in turn dictates the level of aggression, IMO.


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## NomadicMedic (Feb 10, 2017)

To me, the stridor is more worrisome than the wheezes. I would attribute wheezing to thermal injury or particulate matter leading to bronchoconstriction, but stridor would be indicative of upper airway edema and imminent occlusion.

 If that helicopter doctor doesn't arrive soon, your only option would be a surgical airway.


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## EpiEMS (Feb 10, 2017)

@VentMonkey @NomadicMedic thanks for elucidating! Very helpful. I think I follow the logic on this.


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## NomadicMedic (Feb 10, 2017)

This is worth a read. http://emedicine.medscape.com/article/771194-overview

If you have a LP15 that measures CO and methemoglobin, you way want to consider using your Cyanokit, if it's indicated and if you have a choice on transport, head for the facility with the hyperbaric chamber.

There's nothing I could find that indicates routine use of corticosteroids in the prehospital treatment of thermal inhalation injury, but it may make sense if your online doc agrees.


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## harold1981 (Feb 10, 2017)

EpiEMS said:


> Interesting question. Is RSI limited to physicians in your country, @harold1981?
> 
> High flow O2 via NRB is certainly indicated, and CPAP could be used (I think...I can't think of why it could be contraindicated here other than some sort of impairment to the seal). You'll want a BVM ready, with how this guy is looking, I'd wager. If I had it in my scope, I'd try an albuterol neb, without a doubt.
> 
> ...



Yes, RSI is within the scope of pratice of the HEMS critical care teams. 
I didn{t think of IM epi. That would be an option too.


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## VentMonkey (Feb 10, 2017)

Again, not saying this patient won't benefit from the treatments listed by others on here, but right now as they present your major concern _should be their airway; _all the other medications can come later. Worrying about aggressively managing a seemingly impending closed off airway is much more of a priority. This would be one of those rare cases, nonetheless, do not get side tracked with medications until your oxygenation and ventilation issues (which are clearly lacking) _have_..._been_..._fixed_.

As an aside, once intubated via oral, or surgical means they will now need proper vent management as well, keeping in minding higher airway pressures are most likely inevitable. If your scope allows escharotomies then chances are the chest wall may require that at some point (burns tend to evolve rather rapidly in their manifestations).

If you can't perform any of these measures, and your closest advanced airway providers are 35 minutes away, then start driving in that direction. Sit said patient up, continue providing O2 at the BLS provider level, if you have Albuterol give Albuterol, but at any prehospital provider level I would be cautious with over analytically treating this patient with whatever meds you may, or may not have as you may cause more harm than good.


NomadicMedic said:


> *To me, the stridor is more worrisome than the wheezes. I would attribute wheezing to thermal injury or particulate matter leading to bronchoconstriction, but stridor would be indicative of upper airway edema and imminent occlusion.*


And agreed; this is bad, all bad.


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## harold1981 (Feb 10, 2017)

VentMonkey said:


> Short of not being able to find a landmark this also sounds like an emergent crash airway candidate, i.e., needle or surgical cricothyrotomy; preferably the latter if available.
> 
> Again, I don't know the op's scope, or level of certification in his homeland though.



We can do that as a last resort. However, you´d bypass the swelling of the soft tissue of the pharynx and hopefully get a tube in, but it won´t resolve the respiratory compromise due to the inflammatory process in the lower airways and the lungs. I am still thinking about what can be done with meds prehospitally to slow down the process of respiratory failure and hypoxia. We don´t have online medical control, but we could consult with the HEMS-physician who is enroute. 

Can the RN-guys here tell us more about what will happen in hospital? What meds will they be giving in the ED and the ICU? And is this guy likely to end up on ECMO?


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## EpiEMS (Feb 10, 2017)

@harold1981, just so we have a sense of what you have/can do, could you provide a link or a brief scope of practice? (Also asking because I'm super curious).

For meds, I think it's been covered, no? Albuterol, albuterol/ipratropium, epinephrine, cyanokit for the possible CO exposure, etc.


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## harold1981 (Feb 10, 2017)

Thanks for your input VentMonkey, it sure makes sense. 

We are an all ALS-system. We are expected to do the clinical reasoning. Maybe it would be helpfull if I explained our system a bit in another thread.


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## harold1981 (Feb 10, 2017)

EpiEMS said:


> @harold1981, just so we have a sense of what you have/can do, could you provide a link or a brief scope of practice? (Also asking because I'm super curious).
> 
> For meds, I think it's been covered, no? Albuterol, albuterol/ipratropium, epinephrine, cyanokit for the possible CO exposure, etc.



Offcourse, give me a sec.


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## VentMonkey (Feb 10, 2017)

harold1981 said:


> And is this guy likely to end up on ECMO?


I'm not completely following you here, must be this Kern County water today. As far as ECMO, it's a life-sustaining (see: often last ditch effort) common in patient who develop things such as ARDS. I don't think you're quite understanding the importance of properly oxygenating, and ventilating, especially in this type of patient; it takes precedence.

ARDS is the end result of a cascade of most unfortunate pathologies often seen in the ICU (i.e., the later non-prehospital phases of the patients outcome), so yes, they certainly may end up on ECMO, but early and proper oxygenation, and ventilation (then whatever meds you want to fool with prehospitally I suppose) will help curtail said patient from being placed on v-v ECMO. I just don't understand why you'd want it to get to this, but hey, good luck in Denmark.


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## harold1981 (Feb 10, 2017)

Don´t you worry VentMonkey. We´ll focus on the oxygenation, properly ventilating the patient and anticipating airway compromise, while we wait for RSI. Just wondering what _else _we can do in those 25 minutes that can be helpful. 
The Netherlands. What Denmark


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## E tank (Feb 10, 2017)

NomadicMedic said:


> To me, the stridor is more worrisome than the wheezes. I would attribute wheezing to thermal injury or particulate matter leading to bronchoconstriction, but stridor would be indicative of upper airway edema and imminent occlusion.




This ^^^....pretty alarming but I'd find at least a little consolation hearing the stridor because that meant air was moving at least. But the stridor is the big problem. 

Here's a bold statement just for argument's sake...what about a little anxiolysis with some fentanyl or even versed? A more relaxed patient can be coached to slow his inspiratory effort to achieve a higher tidal volume through a narrowing airway. Jacking him up with epi might create more discomfort and panic.

My $ 0.02


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## harold1981 (Feb 10, 2017)

ALS scope of practice:

Manual airway maneouvres, oro- and nasopharyngeal airways, suctioning/deep suctioning, laryngeal masks, ET-intubation, needle or surgical cricothomy, manual ventilation with BVM, mechanical ventilation, CPAP, needle thoracosynthesis, IV/IO-infusion, defibrillation, external pacing, cardioversion, AICD-correction, immobilization in vacuum-mattress, splinting with vacuumsplints, burn care, automated chest compressions, bladder catheterization, emergency childbirth, infuserpumps. We carry ASA, adenosine, adrenaline, amiodarone, atropine, budesonide, clemastine, esketamine, fentanyl, furosemide, glucagon, glucose, lactated ringers, hydrocortisone, lidocaine, midazolam, morphine, naloxone, nitroglycerine, ondansetron, oxytocine, paracetamol, salbutamol, ipratropiumbromide, heparin, ticagrelor, tranexaminic acid, xylometazoline and oxygen. We use LP15,  scoop stretchers, stairchairs and  our stretchers are very different in operation. We have standing orders, no online medical direction.  When we treat and release, we call the patient´s general practitioner or the GP on duty to hand over care.    

HEMS scope of practice:

Neonatal or pediatric intubation, thrombolysis, cyanokit, thoraxdrainage, emergency surgical procedures (like field thoracotomy, ceasarean section or amputation), complex airway management (they have videolaryngoscopy, and other tools), RSI, video-ultrasound, a wide range of medication including antibiotics, mannitol, hypotonic cristalloids, loads of drugs that are used in ICU and anesthesia and whole blood.  

All units that respond to emergencies in the Netherlands, are staffed with an EMT and a RN specialized in prehospital care. Rapid responders are either a RN in a solo-vehicle or on a motorcycle. Many agencies have a subdivision for patient transport services (PTS), using ambulance vehicles with only oxygen, an AED and equipment for a comfortable ride.  PTS is strictly separated from EMS by the controlrooms. There is a MICU-subdivision for the interclinical ICU-transfers, some regions have specialized ambulances for neonatal transfers and bariatric patients.  There are 4 HEMS-teams in the Netherlands around the clock for 17million people.  

Hope this helps.


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## harold1981 (Feb 10, 2017)

E tank said:


> This ^^^....pretty alarming but I'd find at least a little consolation hearing the stridor because that meant air was moving at least. But the stridor is the big problem.
> 
> Here's a bold statement just for argument's sake...what about a little anxiolysis with some fentanyl or even versed? A more relaxed patient can be coached to slow his inspiratory effort to achieve a higher tidal volume through a narrowing airway. Jacking him up with epi might create more discomfort and panic.
> 
> My $ 0.02



Normally I am a fan of having a relaxed patient. But in this case I don´t think I would want him on Versed. I need his muscle power to move air in and out.


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## E tank (Feb 10, 2017)

harold1981 said:


> Normally I am a fan of having a relaxed patient. But in this case I don´t think I would want him on Versed. I need his muscle power to move air in and out.



Sedation isn't muscle relaxant.

Just read your list of on board meds...ticagrelor? Wow.. progressive program...anyway, (es)ketamine would be an alternative choice, IMO


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## VentMonkey (Feb 10, 2017)

harold1981 said:


> Normally I am a fan of having a relaxed patient. But in this case I don´t think I would want him on Versed. I need his muscle power to move air in and out.


Yes, but again, the high pitched breath sounds (stridor) indicates that there is very little air movement to begin with, which in turn tells us (me) that aggressive airway control is imminent.

Not to mention the SPO2 was only ~85% with (presumably) high-flow O2 @ 15 lpm NRB, and a good waveform pleth.

Furthermore, inducing an amnestic effect for a procedure that seems not preventable at this point in a surgical airway doesn't seem unfounded. What meds are you so adamant about giving @harold1981, and why?


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## harold1981 (Feb 10, 2017)

E tank said:


> Sedation isn't muscle relaxant.



We use Versed as a sedation drug and anxiolitic, but it also has muscle relaxing and anticonvulsive properties.


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## E tank (Feb 10, 2017)

harold1981 said:


> We use Versed as a sedation drug and anxiolitic, but it also has muscle relaxing and anticonvulsive properties.


 
Well, technically that is true, but not clinically relevant muscle relaxation and certainly not at the dose we're talking about here. Like I said above, ketamine could calm someone like this as well, were the sedation route taken. I guess my point wasn't the choice of drug per se, rather just to get the patient not to be in so much distress as to panic.


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## harold1981 (Feb 10, 2017)

Noooo, I am not dying to give _any _meds. I can see that proper management of the A and the B is my number one priority... Okay, so I perform the surgical airway. Now I have a tube in and I can ventilate him, but for half an hour that he is lying on that stretcher, it doesn´t solve the other problems that threaten his oxygenation: a worsening inflammatory reaction, edema, bronchospasm...


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## harold1981 (Feb 10, 2017)

E tank said:


> Well, technically that is true, but not clinically relevant muscle relaxation and certainly not at the dose we're talking about here. Like I said above, ketamine could calm someone like this as well, were the sedation route taken. I guess my point wasn't the choice of drug per se, rather just to get the patient not to be in so much distress as to panic.



I do like the idea of having a less distressed patient who is also in less pain. Absolutely.


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## VentMonkey (Feb 10, 2017)

harold1981 said:


> Now I have a tube in and I can ventilate him, but for half an hour that he is lying on that stretcher, it doesn´t solve the other problems that threaten his oxygenation: a worsening inflammatory reaction, edema, bronchospasm...


I am afraid we are of two different thought processes.

Out of curiosity are we hand-bagging this patient for the next 30 minutes? If not, what are yout ventilator settings, and do or do they not, how or how don't they, play into proper oxygenation (yes, even in the first half hour) of an impending inflammatory cascade in this case?


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## harold1981 (Feb 10, 2017)

After the cricothomy we´d be handbagging the patient with a BVM with PEEP, taking turns.


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## E tank (Feb 10, 2017)

harold1981 said:


> After the cricothomy we´d be handbagging the patient with a BVM with PEEP, taking turns.



NOW I'd sedate the patient, as in anesthetize him.


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## harold1981 (Feb 10, 2017)

E tank said:


> NOW I'd sedate the patient, as in anesthetize him.



Definitely


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## VentMonkey (Feb 10, 2017)

harold1981 said:


> After the cricothomy we´d be handbagging the patient with a BVM with PEEP, taking turns.


For half an hour? What setting is your PEEP valve at? I fail to see how with changes in the way most modern prehospital ventilators deliver ventilations to patients post-intubation in the field that this patient should not be on a ventilator.


E tank said:


> NOW I'd sedate the patient, as in anesthetize him.


Naturally, the CRNA wants to anesthetize. Lol, you are correct though, this is now our airway to manage until you hand off care, which is why I vote for a ventilator with the appropriate settings.

The patho behind burn victims regardless of their location can often be beyond what one can do in the field @harold1981. Fix and treat what you can: oxygenation and ventilation, fluid loss, thermogenesis. Let the doctors and nurses worry about long-term palliative care, that is their job, not ours.


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## VFlutter (Feb 10, 2017)

harold1981 said:


> Can the RN-guys here tell us more about what will happen in hospital? What meds will they be giving in the ED and the ICU? And is this guy likely to end up on ECMO?



I did not work at a burn center so my experience is limited in that aspect however if they are unable to oxygenate the patient conventionally they may try inhaled Flolan, which basically shunts blood to the non-injured areas of the lung that are capable of gas exchange. If that does not work they may be a candidate for VV ECMO. However I can't find much literature about inhalation injuries specifically.


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## E tank (Feb 10, 2017)

VentMonkey said:


> For half an hour? What setting is your PEEP valve at? I fail to see how with changes in the way most modern prehospital ventilators deliver ventilations to patients post-intubation in the field that this patient should not be on a ventilator.
> 
> Naturally, the CRNA wants to anesthetize. Lol, you are correct though, this is now our airway to manage until you hand off care, which is why I vote for a ventilator with the appropriate settings.
> 
> The patho behind burn victims regardless of their location can often be beyond what one can do in the field @harold1981. Fix and treat what you can: oxygenation and ventilation, fluid loss, thermogenesis. Let the doctors and nurses worry about long-term palliative care, that is their job, not ours.



Well, when all you have is a hammer, every problem looks like a nail  .....Absolutely agree on the ventilator. With those kinds of transport times, would have thought that was a foregone conclusion. But back to the sedation bit, lacking NMB's, which the OP is, mechanically ventilating someone like this is a challenge, let alone someone lacking in paralysis and/or heavy sedation.


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## VentMonkey (Feb 10, 2017)

E tank said:


> Well, when all you have is a hammer, every problem looks like a nail  .....Absolutely agree on the ventilator. With those kinds of transport times, would have thought that was a foregone conclusion. But back to the sedation bit, lacking NMB's, which the OP is, mechanically ventilating someone like this is a challenge, let alone someone lacking in paralysis and/or heavy sedation.


So then may I ask: what business does one have emergently intubating a patient without proper fundamental (basic) prehospital vent management knowledge?

I would argue that some understanding is required, and that ventilator management supercedes (figuratively) blindly intubating someone in such a critical state.

I may or may not catch flack for that, but meh.


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## E tank (Feb 10, 2017)

VentMonkey said:


> So then may I ask: what business does one having emergently intubating a patient without proper fundamental (basic) prehospital vent management knowledge?
> 
> I would argue that some understanding is required, and that ventilator management supercedes (figuratively) blindly intubating someone in such a critical state.
> 
> I may or may not catch flack for that, but meh.


 
Well, that's another question altogether best directed at the OP. But giving the benefit of the doubt and as this apparently is an academic exercise meant for hypothetical conversation and learning, I might add that unanticipated surgical airways are, under the very best surgical and logistical conditions, astonishing CF's as you are undoubtedly aware. The ease with which the hypothetical patient's airway was secured, I'm sure, was for clarity for the rest of the conversation. Your results may vary...


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## NPO (Feb 10, 2017)

Side bar:
Same patient. Same situation.
HEMS is definitely indicated, but say they are unavailable. 35 minute transport to burn center.

My protocol allows versed after securing the airway with an ET tube. 

Other drugs available are your standard ALS meds; morphine, fentanyl, bronchodilators, etc.

Needle cric is in scope too.

How do you proceed? Give him the versed? I don't much like the idea of waiting with this patient 

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## Carlos Danger (Feb 10, 2017)

Albuterol for sure, before anything else. Dexamethasone and ketorolac IV.

There's a very good chance this guy doesn't need to be intubated.

If he does end up needing intubation, it will already likely require a cric, which means there is little to lose by first trying some more conservative therapies.


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## HMartinho (Feb 11, 2017)

harold1981 said:


> We are an ALS-unit and we are dispatched to a residential fire, where a resident has been rescued by bystanders. We find a 35yo male with signs and symptoms of chemical and thermal inhalation injury: The patient is awake, with a GCS of 3/6/5, he is hoarse, has 1st and 2nd degree burns to the face, burned nosehairs and black soot particles in the nose and on the lips and tongue. He is coughing, has a sore throat, an inspiratory stridor, is anxious and in respiratory distress. Auscultation also reveals wheezing bilaterally. He saturates 77% on room air, 85% on 15L per NRB.
> We decide that  this patient needs to be intubated and we call for back-up of a HEMS-based CCT-team, with an emergency physician onboard who can perform an RSI. The first available HEMS-unit is 25 minutes away due to weather conditions. The nearest trauma center with burn care capabilities is 35 minutes away.
> 
> My question to you: while awaiting the RSI, would you consider one of the following treatments to avoid or at least delay full respiratory failure. Please motivate your choice:
> ...





harold1981 said:


> Normally I am a fan of having a relaxed patient. But in this case I don´t think I would want him on Versed. I need his muscle power to move air in and out.



In this specific case, I don't think that a combi of salbutamol and ipratropium bromide is an reasonable option. I would prefer a combi of salbutamol and budesonide, and some IV hydrocortisone.
How is his vitals? HR and blood pressure?
Despite of that, I will give IV paracetamol/acetaminophen and some morphine and diazepam. I understand your worry about muscle relaxant effect, but in this specific case, excessive respiratory muscle effort can contribute to exhaustion, and worsen the entire patient condition. Morphine is excellent not only for relieving pain, but for its anxiolytic properties, especially in combination with a low dose of benzodiazepine.


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## harold1981 (Feb 11, 2017)

VentMonkey said:


> So then may I ask: what business does one have emergently intubating a patient without proper fundamental (basic) prehospital vent management knowledge?
> 
> I would argue that some understanding is required, and that ventilator management supercedes (figuratively) blindly intubating someone in such a critical state.
> 
> I may or may not catch flack for that, but meh.



Like most guys here, I enjoy this forum as a great place of learning and sharing of work experiences. I don´t feel the need to judge, or to be judged or to compete.


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## Handsome Robb (Feb 11, 2017)

My question is is he truly an inhalation injury of the thermal nature or is it reactive to the particulate matter and noxious fumes with thermal injury limited to the oropharynx? 

It's extremely rare to have thermal injuries to the lower airways due to our natural protective mechanisms, i.e. Laryngospams when superheated gases are introduced to the oropharynx. 

I would lean towards conventional management of bronchoconstriction after we've controlled his airway. 

I'd personally like to use ketamine for our induction and pain management as the bronchodilatory effects are going to be beneficial in this patient. 

After that duonebs, IV steroids and possibly mag PRN. I'd be hesitant to use epinephrine as he is already going to have a massive catecholamine dump from the exorbitant amount of pain he's in from the burns.  


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## VentMonkey (Feb 11, 2017)

I have none of those options available to be aside from the bronchodilators, standard RSI meds, and a ventilator. With what was presented in your initial post, I am sticking by my guns on this one. They're buying them self at least some airway setup, eagle eyed observation, and oxygenation/ ventilation techniques at best, and most likely for/ from me, an aggressive airway.

I think not having certain meds vs. having them also dictates not only options obviously, but train of thoughts. They'll end up intubated most ricky-tick at the ED. This isn't a "so why not" reason, but it seems logical. I still think they're behind the eight ball, and would go in with a ready to aggressively protect the airway mindset. Typically I am more than happy with conservative measures, here? Not so much.


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## StCEMT (Feb 11, 2017)

Having never encountered a burn like this before, this would be a bit of a fly by the seat of your pants moment for me. Have the partner set up a neb and an NC to maybe squeeze in a bit more O2. Laryngoscope roll is coming out, scalpel and DL supplies, cut a tube down in case I decide to cut. Ketamine would probably be my drug of choice, whether I go pain dose or full sedation dose. Strider worries me, so I would be leaning more towards take the airway after oxygenation from the beginning and drawing back as we get more going and a better picture if it seems appropriate. Also distance from hospital is a deciding factor. If we can be there in 4, I am much more likely to try to make sure he is hemodynamically a good pt to intubate and letting a doc do it.


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## DesertMedic66 (Feb 11, 2017)

I would be up s*** creek with this patient. No RSI, no surgical cric, not even a needle cric. Call for airship and wait is really my only option.


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## NomadicMedic (Feb 11, 2017)

I would also be screwed. No RSI or surgical/needle airways here either.


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## Carlos Danger (Feb 11, 2017)

I used to fly for a program that transported lots of burn patients, as we were the transport program for a regional burn center. I have transported this exact patient quite a few times.

These patients often get intubated by nervous paramedics and ED docs, but the reality is few need it. Most never manifest any significant airway swelling, just airway reactivity to the smoke and inhaled particles.


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## StCEMT (Feb 11, 2017)

Remi said:


> I used to fly for a program that transported lots of burn patients, as we were the transport program for a regional burn center. I have transported this exact patient quite a few times.
> 
> These patients often get intubated by nervous paramedics and ED docs, but the reality is few need it. Most never manifest any significant airway swelling, just airway reactivity to the smoke and inhaled particles.


So as someone who would be the nervous medic, where have you found that line to be in your experience?


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## VentMonkey (Feb 11, 2017)

Remi said:


> These patients often get intubated by nervous paramedics and ED docs, but the reality is few need it. Most never manifest any significant airway swelling, just airway reactivity to the smoke and inhaled particles.


In the OP's original post, he states an improved SPO2 from the 70's to 85% with 15 lpm NRB, including the other s/s. This doesn't sound like adequate oxygenation, and/ or ventilation by any means, nervous or not.

He also states he felt the patient requires RSI, and was awaiting his HEMS provider to provide such therapies. I can't imagine said patients theoretical airway not closing sooner rather than later.

At least the way the scenario was built, it seems imminent. I'm all ears from one provider to another with more experience, though.


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## TXmed (Feb 11, 2017)

Im not sure if anyone has mentioned this before me but i would administer a cyank kit either before or during RSI if this patient was inside a house fire.


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## VentMonkey (Feb 11, 2017)

TXmed said:


> Im not sure if anyone has mentioned this before me but i would administer a cyank kit either before or during RSI if this patient was inside a house fire.


I think @NomadicMedic made mention of it on page 1, TX.


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## E tank (Feb 11, 2017)

There are lots of sources for indications for intubation of burn patients. These indicators vary from author to author or center to center, but  this hypothetical patient meets criteria for intubation for at least a couple of them that I'm aware of  just by virtue of his stridor and distress alone.  But, the question is not if, but by whom and when.

Once stridor is present, a greater than 50% reduction of airway diameter is taking place. Some sources put it at  .5 to .8 mm if stridor is present. Any attempt at intubation would require horsing a  downsized tube through that narrowing, or using an eschmann/bougie followed by a tube. 

The odds of the first look being the last look because of bloodying up/losing  the airway from traumatic DL are not insignificant.  Then you force the surgical airway. 

The patient improved his sats to the mid-eighties with some O2 so I'd take that as a very hopeful sign. I'd consider any saturation in the 80's as money in the bank and do everything in my power to keep him there or better. The only way I'd vote for a field advanced airway is if the guy rolled his eyes back and became unresponsive. Beyond that, limp him to the hospital trying to keep him conscious with his sats in the eighties. Pretty likely you could to that in the time frame given in the scenario.
Way too much to go wrong. Let the guys with the knives and fancy scopes and toys do it if you can


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## VentMonkey (Feb 11, 2017)

E tank said:


> There are lots of sources for indications for intubation of burn patients. These indicators vary from author to author or center to center, but  this hypothetical patient meets criteria for intubation for at least a couple of them that I'm aware of  just by virtue of his stridor and distress alone. * But, the question is not if, but by whom and when*.
> 
> Once stridor is present, a greater than 50% reduction of airway diameter is taking place. Some sources put it at  .5 to .8 mm if stridor is present. Any attempt at intubation would require horsing a  downsized tube through that narrowing, or using an eschmann/bougie followed by a tube.
> 
> ...


Good post, tank. It provided some good insight regarding reasons behind choosing the most advanced provider for this scenario.

May I counter the bolded statement with this?

With a 30 minute transport time, assuming said patient has normally healthy lung compliance how would this fit into being afforded a certain skillset for a certain situation such as this, not implementing said skillset, knowing the effects of prolonged hypoxia, and inadequate oxygenation/ ventilation? 

I understand the "more harm than good", and lack of appropriate training by advanced field providers as a whole, but at what point does one, or is it "fitting" for one to enter such a protocol, and deem it acceptable or justifiable?


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## E tank (Feb 11, 2017)

First off let me say that I in no way meant to suggest that the field skill set was not up to the task in the given patient. It's just that at the hospital there are unlimited resources and personnel with expertise in different disciplines that would be directly beneficial to this guy. I wouldn't intubate this guy in the hospital without a surgeon and another anesthetist.  I'd tell Archie Brain not to try a field airway here, but that's just my personal opinion. Others might not think twice about it and do fine. Some ER doc might even blow heat at you for not intubating him, but I wouldn't. 

As far as his oxygenation goes, a guy like this is able to tolerate this level of hypoxia (80's) for way longer than the time it would take to get him to the hospital. Way longer. Respiratory acidosis is very well tolerated in young healthy folks like this as far as long term effects go  and even helps unload O2 from the hemoglobin to the tissues. Bottom line is, for this patient, this day, you have some time, IMHO


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## Carlos Danger (Feb 11, 2017)

VentMonkey said:


> In the OP's original post, he states an improved SPO2 from the 70's to 85% with 15 lpm NRB, including the other s/s. This doesn't sound like adequate oxygenation, and/ or ventilation by any means, nervous or not.
> 
> He also states he felt the patient requires RSI, and was awaiting his HEMS provider to provide such therapies. I can't imagine said patients theoretical airway not closing sooner rather than later.
> 
> At least the way the scenario was built, it seems imminent. I'm all ears from one provider to another with more experience, though.



I don't know if the guy in this scenario really needed to be intubated or not. I wasn't there.

All I'm saying is that while respiratory s/s are common following smoke inhalation, they are usually due to bronchoconstriction that is reversible with standard therapies. The airway edema  / "throat closing off" scenario that we have drilled into our heads in every burn course is actually pretty rare. Few of us will ever see it in our careers, even if we deal with burn patients regularly.


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## medicsb (Feb 12, 2017)

As a physician (resident), I've worked in a burn ICU.  I have seen numerous patients with severe airway burns (been present for the bronchoscopy and have personally seen the how edematous the tracheal mucosa becomes and the sloughing of tissue in the the trachea).  One of the more severe cases we used high frequency oscillatory ventilation, but this was combination of airway burn and severe smoke inhalation.  While we (EMS and EM) may "over intubate", I find it hard to predict who will fly and who will not.  So, I am ok with intubating early and often when there is reason to believe there may be airway burns.  

All the meds suggested likely will NOT make a difference.  Steroids take hours to take effect and not likely to overcome the swelling and inflammation involved with a burn.  Additionally, if the patient has external burns, steroids put the patient at increased risk from infection.  Bronchodilators will help with lower airway bronchospasm, but will do nothing to help upper airway and tracheal swelling.  Nebulizer epi?  Not sure it would help, but I'd give it a try.  

In the scenario presented, going 30 minutes without airway management could be deadly.  Depending on comfort, I would recommend nasal intubation if RSI is not an option.  

Really, it is tough to say what should be done in the prehospital setting.  At least in the US, airway management is typically a weakness insofar as initial training and ongoing experience.  Paramedics have difficulty intubating cardiac arrest patients without airway swelling, so I am not sure what to suggest other than wait for a flight crew or move fast to the hospital.


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## EpiEMS (Feb 12, 2017)

Possibly silly question, but might video laryngoscopy help?


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## TXmed (Feb 12, 2017)

While intubation success is important. I think the biggest issue is what is going to be your treatment plan pre, during, and post airway management. 

If your treatment plan revolves around just an E.T. tube you probably shouldnt RSI. But if you have a plan in place ie: peep levels, inhaled epi, etc. Then carry out your plan


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## medicsb (Feb 13, 2017)

TXmed said:


> While intubation success is important. I think the biggest issue is what is going to be your treatment plan pre, during, and post airway management.
> 
> If your treatment plan revolves around just an E.T. tube you probably shouldnt RSI. But if you have a plan in place ie: peep levels, inhaled epi, etc. Then carry out your plan



Pre and post intubation management is a given, no?  Are people intubating and not ventilating?  For the short duration in the prehospital setting, PEEP is not an absolute necessity.  Post ETI sedation is.  Inhaled epi probably won't do t anything, so NBD if it's not done.

In the ICU, mucolytics and beta agonists are part and parcel, but in the prehospital setting I don't think it's an absolute must.


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## Carlos Danger (Feb 13, 2017)

EpiEMS said:


> Possibly silly question, but might video laryngoscopy help?


Not a silly question. But the problem with these patients isn't usually the ability to visualize the glottis, it's that the tissues inside the airway and/or pharynx are swollen.

Of course they can still have other factors (obesity, reduced cervical ROM for whatever reason) that make visualization difficult, and VL therefore helpful.


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## NomadicMedic (Feb 13, 2017)

I could see VL being advantageous because it would reduce the trauma that is inflicted on an airway from multiple DL attempts. Looking and atttempting to pass a tube more than once might very well turn that airway into hamburger.


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## NPO (Feb 24, 2017)

What about nebulized epi? Or racemic epi? Does it have any merit with smoke and heat inhalation injuries?

I gave nebulized epi yesterday for croup and it made me think, it's a similar process, so would it be feasible?

Sent from my Pixel XL using Tapatalk


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