Smoke inhalation injuries

[harold1981]

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

 

[E tank]

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

 

[harold1981]

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.

 

[harold1981]

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.

 

[E tank]

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

 

[VentMonkey]

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?

 

[harold1981]

Sedation isn't muscle relaxant.

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

 

[E tank]

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.

 

[harold1981]

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...

 

[harold1981]

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.

 

[VentMonkey]

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?

 

[harold1981]

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

 

[E tank]

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.

 

[harold1981]

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

Definitely

 

[VentMonkey]

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.

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.

 

[VFlutter]

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.

 

[E tank]

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.

 

[VentMonkey]

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.

 

[E tank]

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...

 

[NPO]

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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