Smoke inhalation injuries

[Carlos Danger]

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.

 

[HMartinho]

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?

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.

 

[harold1981]

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.

 

[Handsome Robb]

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]

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.

 

[StCEMT]

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.

 

[DesertMedic66]

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.

 

[NomadicMedic]

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

 

[Carlos Danger]

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.

 

[StCEMT]

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?

 

[VentMonkey]

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.

 

[TXmed]

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.

 

[VentMonkey]

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.

 

[E tank]

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

 

[VentMonkey]

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

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?

 

[E tank]

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

 

[Carlos Danger]

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.

 

[medicsb]

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.

 

[EpiEMS]

Possibly silly question, but might video laryngoscopy help?

 

[TXmed]

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