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the County Consult

A Cook County Hospital Emergency Medicine Blog for up-to-date medicine and more.

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Sim Corner: A House Fire

April 8, 2021

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.

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