Case: Apartment Fire
50 yo M found unconscious in burning apartment building.
Initial vitals: HR 130, RR 33, BP 80/48, O2 Sat 90%, Temp 97.2F
Exam: Drowsy, coughing, AOx1, soot in nares and in oropharynx, stridor; partial thickness burn to anterior arms bilaterally, anterior legs and anterior chest; no circumferential burns
Patient arrives confused, hypotensive, tachycardic, tachypneic with soot around the airway. Patient quickly becomes less responsive and more hypoxic, RR declines
Patient is intubated with DL (Note: that first attempt success often decreases due to severe airway edema, so intubate early!)
Initial Labs:
Elevated lactate and a carboxyhemoglobin of 10% (normal level is up to 3% in non-smokers)
Learning Objectives:
Consider early intubation in smoke inhalation injury patients
Look for signs of respiratory distress, stridor, accessory muscle use, new onset hoarseness, significant soot in the oropharynx/face
You can use nasopharyngoscope to take a look at the airway - if it appears beefy red or there is soot, prepare for intubation soon
If possible, try to use 7.5 ETT or larger to allow for bronchoscopy if needed during ICU admission
Consider trauma in all burn injury patients
Perform your primary and secondary survey as you normally would. Treat the burns later
Cyanide poisoning
Typically a clinical diagnosis, think of enclosed fires
AMS + soot in mouth/nose (60% likelihood of cyanide poisoning)
AMS+ soot + hypotension/cardiac arrest (80% likelihood)
Labs suspicious for CN poisoning: AG metabolic acidosis or high lactic acid (>8)
Antidote = hydroxocobalamine (cyanokit) 5g given over 15 min
Side effects: red urine, red skin, hypertension, also interferes with some lab tests
Happy learning!
References:
Helman, A. Fish, J. Ivankovic, M. Kovacs, G. Burn and Inhalation Injuries: ED Wound Care, Resuscitation and Airway Management. Emergency Medicine Cases. May, 2019. https://emergencymedicinecases.com/burn-inhalation-injuries/. Accessed [Nov 24, 2020]
Written by Emily DeDonato, MD
Cook County Health, Simulation Fellow
For more Sim information: https://www.chicagosimfellowship.com/features.