Smoke inhalation injury: Difference between revisions
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{{Burn DDX}} | {{Burn DDX}} | ||
{{Inhalation exposure}} | {{Inhalation exposure}} | ||
{{Toxic gas exposure DDX}} | |||
==Evaluation== | ==Evaluation== | ||
*Assess ABCs, [[burns]] resuscitation | *Assess ABCs, [[burns]] resuscitation | ||
*ABG or VBG, carboxyhemoglobin | *[[ABG]] or VBG, carboxyhemoglobin | ||
*[[ECG]], monitor on telemetry | *[[ECG]], monitor on telemetry | ||
*[[Chest x-ray]] | *[[Chest x-ray]] | ||
| Line 57: | Line 58: | ||
**Major burns over 40-60% of [[Estimating body surface area|body surface area]] | **Major burns over 40-60% of [[Estimating body surface area|body surface area]] | ||
''Remember, the intubation will only get more difficult as edema worsens!'' | ''Remember, the intubation will only get more difficult as edema worsens!'' | ||
*Bronchodilators if evidence of bronchospasm | *[[Bronchodilators]] if evidence of bronchospasm | ||
*See [[Carbon monoxide toxicity]] | *See [[Carbon monoxide toxicity]] | ||
*See [[Cyanide toxicity]] | *See [[Cyanide toxicity]] | ||
Latest revision as of 20:35, 8 November 2023
Background
- Main cause of mortality in fire-related death
- Associated with closed-space fires, especially when patient has decreased mental status (e.g. substance use, head injury)
- Thermal injury:
- Due to inhaling superheated gases in an enclosed space
- Direct thermal trauma and associated edema usually limited to upper airway, but lower respiratory tract may be injured if steam inhaled
- Chemical injury:
- Direct toxicity to airways and lung parenchyma from noxious chemicals combusted
Clinical Features
Thermal injury
- Soot around nares or in mouth
- Carbonaceous sputum
- Singed nasal or facial hair
- Dyspnea, stridor, drooling, dysphonia, respiratory distress
Chemical injury
Varies depending on substance burned in fire
- Acrolein: found in wood and petroleum
- Pulmonary edema, bronchorrhea, bronchospasm, VQ mismatch which can cause hypoxemia
- Tearing, conjunctivitis
- Hydrochloric acid: product of polyvinyl chloride (structural component of high-rise buildings, plastics) combustion.
- Can persist in air up to an hour after fire extinguished
- PVCs and other arrhythmias
- Delayed onset (2-12 hours) pulmonary edema
- Dyspnea, chest pain
- Tuolene diisocyanate: seat cushions, carpet, insulation
- Severe bronchospasm
- Nitrogen dioxide: fires involving automobiles, agrecultural waste
- Uncommon but brief exposure can be lethal
- Severe bronchospasm, laryngospasm, pulmonary edema
- Later: interstitial lung disease
Systemic chemical injury
Differential Diagnosis
Burns
- Smoke inhalation injury (airway compromise)
- Chemical injury
- Acrolein
- Hydrochloric acid
- Tuolene diisocyanate
- Nitrogen dioxide
- Systemic chemical injury
- Specific types of burns
- Associated toxicities
Inhalation injury
- Unintentional
- Smoke inhalation injury
- Chloramine
- Hydrocarbons
- Sewer gas
- Hydrazine toxicity
- Nitrogen tetroxide
- Metal fume fever
- Terrorism
- Pulmonary chemical agents
- Ammonia
- Methyl isocyanate
- methyl bromide
- Hydrochloric acid
- Chlorine
- Phosgene
- Bioterrorism
Toxic gas exposure
- Carbon monoxide toxicity
- Chemical weapons
- Cyanide toxicity
- Hydrocarbon toxicity
- Hydrogen sulfide toxicity
- Inhalant abuse
- Methane toxicity
- Smoke inhalation injury
- Ethylene dibromide toxicity
Evaluation
- Assess ABCs, burns resuscitation
- ABG or VBG, carboxyhemoglobin
- ECG, monitor on telemetry
- Chest x-ray
- Low threshold for direct or video laryngoscopy, fiberoptic airway eval
Management
AIRWAY
- Intubate if:
- Respiratory distress, respiratory depression, or altered mental status
- Progressive hoarseness
- Supraglottic or laryngeal edema/inflammation on bronchoscopy or NPL
- Full thickness burns to face or perioral region
- Circumferential neck burns
- Major burns over 40-60% of body surface area
Remember, the intubation will only get more difficult as edema worsens!
- Bronchodilators if evidence of bronchospasm
- See Carbon monoxide toxicity
- See Cyanide toxicity
Disposition
- Respiratory distress or airway compromise will need admission
- Observe for 1-4 hours if no signs or symptoms of inhalation injury develop or if all resolved within 1 hour consider discharging patient home with instructions for return for re-evaluation next day or sooner if pulmonary and/or airway symptoms develop