Smoke inhalation injury: Difference between revisions
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*Carbonaceous sputum | *Carbonaceous sputum | ||
*Singed nasal or facial hair | *Singed nasal or facial hair | ||
*Dyspnea, stridor, drooling, dysphonia, respiratory distress | *[[Dyspnea]], [[stridor]], drooling, [[dysphonia]], [[respiratory distress]] | ||
===Chemical injury=== | ===Chemical injury=== | ||
''Varies depending on substance burned in fire'' | ''Varies depending on substance burned in fire'' | ||
*Acrolein: found in wood and petroleum | *Acrolein: found in wood and petroleum | ||
**Pulmonary edema, bronchorrhea, bronchospasm, VQ mismatch which can cause hypoxemia | **[[Pulmonary edema]], bronchorrhea, bronchospasm, VQ mismatch which can cause [[hypoxemia]] | ||
**Tearing, conjunctivitis | **Tearing, [[conjunctivitis]] | ||
*Hydrochloric acid: product of polyvinyl chloride (structural component of high-rise buildings, plastics) combustion. | *[[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 | **Can persist in air up to an hour after fire extinguished | ||
**PVCs and other | **PVCs and other [[arrhythmias]] | ||
**Delayed onset (2-12 hours) pulmonary edema | **Delayed onset (2-12 hours) [[pulmonary edema]] | ||
** | **[[Dyspnea]], [[chest pain]] | ||
*Tuolene diisocyanate: seat cushions, carpet, insulation | *Tuolene diisocyanate: seat cushions, carpet, insulation | ||
**Severe bronchospasm | **Severe bronchospasm | ||
*Nitrogen dioxide: fires involving automobiles, agrecultural waste | *Nitrogen dioxide: fires involving automobiles, agrecultural waste | ||
**Uncommon but brief exposure can be lethal | **Uncommon but brief exposure can be lethal | ||
**Severe bronchospasm, laryngospasm, pulmonary edema | **Severe bronchospasm, laryngospasm, [[pulmonary edema]] | ||
**Later: interstitial lung disease | **Later: [[interstitial lung disease]] | ||
===Systemic chemical injury=== | ===Systemic chemical injury=== | ||
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*ABG or VBG, carboxyhemoglobin | *ABG or VBG, carboxyhemoglobin | ||
*[[ECG]], monitor on telemetry | *[[ECG]], monitor on telemetry | ||
*Chest x-ray | *[[Chest x-ray]] | ||
*Low | *Low threshold for direct or video [[laryngoscopy]], fiberoptic airway eval | ||
==Management== | ==Management== | ||
'''AIRWAY''' | '''AIRWAY''' | ||
*Intubate if: | *[[Intubate]] if: | ||
**Respiratory distress, respiratory depression, or altered mental status | **Respiratory distress, respiratory depression, or altered mental status | ||
**Progressive hoarseness | **Progressive hoarseness | ||
Revision as of 18:23, 13 October 2019
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
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