Smoke inhalation injuries

[harold1981]

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?

 

[STXmedic]

1) Yes.

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

3) This is your homework I assume?

 

[NomadicMedic]

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.

 

[VentMonkey]

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.

 

[EpiEMS]

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.

 

[VentMonkey]

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.

 

[EpiEMS]

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?

 

[VentMonkey]

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.

 

[EpiEMS]

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.)

 

[VentMonkey]

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.

 

[NomadicMedic]

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.

 

[EpiEMS]

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

 

[NomadicMedic]

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.

 

[harold1981]

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.

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.

 

[VentMonkey]

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.

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.

 

[harold1981]

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?

 

[EpiEMS]

@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.

 

[harold1981]

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.

 

[harold1981]

@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.

 

[VentMonkey]

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.