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Thermal and Inhalation Injury Chapter 39 Written by : Melissa Dearing – LSC-Kingwood Thermal and Inhalation Injury Chapter 39 Written by : Melissa Dearing – LSC-Kingwood

Epidemiology n In the U. S. n Results in 60, 000 hospitalizations annually n Epidemiology n In the U. S. n Results in 60, 000 hospitalizations annually n 6000 deaths annually n Mortality the highest in n Young n elderly children

Epidemiology n In pediatric thermal injuries: n Less than 5% are the result of Epidemiology n In pediatric thermal injuries: n Less than 5% are the result of chemical or electrical burns n 10 -15% result from flame burns n When associated with smoke inhalation are the most deadly n Scalding burns account for 75 -80%

Prevention n Smoke detectors that work n Keep matches out of reach n Lower Prevention n Smoke detectors that work n Keep matches out of reach n Lower the temp on hot water heaters n Cover electrical outlets n Buy flame resistant children’s clothing n Use fire-safe cigarettes

Mortality Rate n Highest when: n Burn n See exceeds 30% body surface area. Mortality Rate n Highest when: n Burn n See exceeds 30% body surface area. figure 39 -1 n Associated n Child with smoke inhalation younger than 4 years old

Pathophysiology n Disruption of the protection provided by skin: n Protects body from infection Pathophysiology n Disruption of the protection provided by skin: n Protects body from infection and injury n Prevents fluid loss n Regulates body temp n Provides sensory input from environment

Pathophysiology n Composed of 2 layers n Epidermis – thin outer layer n Dermis Pathophysiology n Composed of 2 layers n Epidermis – thin outer layer n Dermis – deeper, thick inner layer n Dermis contains: Hair follicles n Sweat glands n Sebaceous glands n Sensory fibers for touch, pain, pressure and temp n n Beneath n the dermis Subcutaneous tissue composed of connective tissue and fat

Classification of Burn n 1 st Degree n Superficial n Involves only the dermis Classification of Burn n 1 st Degree n Superficial n Involves only the dermis n Skin is red n No blisters n Painful and sensitive to touch

Classification of Burn n 2 nd Degree n Involve the epidermis and part of Classification of Burn n 2 nd Degree n Involve the epidermis and part of the dermis n Very painful due to nerve endings that survive the insult n Blistering is common n Healing occurs quickly

Classification of Burn n 3 rd Degree n “Full thickness” burns n Involve injury Classification of Burn n 3 rd Degree n “Full thickness” burns n Involve injury and necrosis below the hair follicles thru the entire thickness of skin and into subcutaneous tissue n Area swells slowly and appears blanched n Sensory nerves are destroyed causing local anesthesia

Management 1 st degree usually heals by itself n 2 nd and 3 rd Management 1 st degree usually heals by itself n 2 nd and 3 rd degree may require grafting, excision and antimicrobial therapy such as Silva dine n

Management n Important to initiate accurate fluid resuscitation ASAP n Careful: overaggressive fluid resuscitation Management n Important to initiate accurate fluid resuscitation ASAP n Careful: overaggressive fluid resuscitation may result in high extravascular hydrostatic pressure, pulmonary edema and soft tissue swelling n Urine output is a good indicator of hydration

Inhalation Injury Mortality from smoke injury alone is 0 -11% n Mortality from smoke Inhalation Injury Mortality from smoke injury alone is 0 -11% n Mortality from smoke injury and burns is 30 -90% n Smoke inhalation that results in pneumonia has a mortality rate of 60% n

Physiologic Consequences of Inhalation Injury n Box 39 -1 Physiologic Consequences of Inhalation Injury n Box 39 -1

Upper Airway Injury n Results in obstruction from: n Edema n Hemorrhage n Ulceration Upper Airway Injury n Results in obstruction from: n Edema n Hemorrhage n Ulceration of mucosa Mild pharyngeal edema can lead to complete upper airway obstruction and asphyxia in only a few hours n Inflammation can be the result of ammonia, hydrogen chloride and chemical irritants found in smoke n

Lung Parenchyma Injury Only steam is capable of overwhelming the upper airway defenses and Lung Parenchyma Injury Only steam is capable of overwhelming the upper airway defenses and transmitting heat to the subglottic airways n Direct cellular injury results in inflammatory response n n Leads to bronchoconstriction n Increase in tracheobronchial blood flow with edema n Leukocyte infiltration

Lung Parenchyma Injury n Sloughing of necrotic tissue plugs up the airways n Can Lung Parenchyma Injury n Sloughing of necrotic tissue plugs up the airways n Can cause partial or complete airway obstruction n Can be fatal

Lung Parenchyma Injury n Pulmonary parenchyma shows: n Varying degrees of congestion n Interstitial Lung Parenchyma Injury n Pulmonary parenchyma shows: n Varying degrees of congestion n Interstitial and alveolar edema n Hyaline membranes n Dense atelectasis

Lung Parenchyma Injury n Systemic effects: n Increase in RAW n V/Q mismatch n Lung Parenchyma Injury n Systemic effects: n Increase in RAW n V/Q mismatch n Increase in oxygen consumption n Decrease in compliance n Decrease in oxygenation n Decreased surfactant production

Carbon Monoxide Poisoning Smoke inhalation from all types of fires result in significant CO Carbon Monoxide Poisoning Smoke inhalation from all types of fires result in significant CO exposure. n Pulse oximeter do not reflect the true oxygen saturation in the presence of COHB. n Symptoms- Table 39 -1 n

Clinical Manifestations n Smoke inhalation injury more likely in individuals with: n History of Clinical Manifestations n Smoke inhalation injury more likely in individuals with: n History of burn injury in an enclosed space n Appearance of facial burns n Singed nose and facial hair n Erythema of the oropharynx n Carbonaceous sputum n Debris around the nose, mouth and pharynx

Bronchoscopy Gold standard for diagnosis of inhalation injury n Provides direct visualization of airway Bronchoscopy Gold standard for diagnosis of inhalation injury n Provides direct visualization of airway n n Soot n Charring n Mucosal erythema n Ulceration n Hemorrhage n Edema n inflammation

Management Oxygen Therapy n Airway Maintenance n Bronchial Hygiene Therapy n Pharmacologic Management n Management Oxygen Therapy n Airway Maintenance n Bronchial Hygiene Therapy n Pharmacologic Management n Mechanical Ventilation n n Conventional n High frequency

Management n Oxygen Therapy n Initially n Wean give 100% by blood gas values Management n Oxygen Therapy n Initially n Wean give 100% by blood gas values n Analyze COHB with co-ox

Management n Airway maintenance n Intubation by most skilled clinician n Nasal intubation is Management n Airway maintenance n Intubation by most skilled clinician n Nasal intubation is easier for securing a tube to a burned face n Burns to the neck can cause tightening of the tissue causing restriction to the airway n Escharotomies to reduce the pressure exerted to the area

Management n Bronchial Hygiene Therapy n Retained n Early secretions can be life threatening Management n Bronchial Hygiene Therapy n Retained n Early secretions can be life threatening ambulation n Therapeutic n Chest coughing PT n Airway suctioning n Therapeutic bronchoscopy n Pharmacologic agents for retained secretions

Management n Pharmacological Management n Inhalation injury creates intense bronchospasm and wheezing n Manage Management n Pharmacological Management n Inhalation injury creates intense bronchospasm and wheezing n Manage with B 2 – agonists n Racemic epinephrine to promote vasoconstriction (trx edema), bronchodilation, and breaking up of secretions n Mucomyst to break down mucus in the airway n Heparin/mucomyst nebulizer may reduce pts mortality

Management n Mechanical Ventilation n For resp failure associated with inhalation injury n Pts Management n Mechanical Ventilation n For resp failure associated with inhalation injury n Pts with this type of injury are at increased risk of ventilator associated injury

Management n Conventional Mechanical Ventilation n Start with Vt of 12 -15 ml/kg n Management n Conventional Mechanical Ventilation n Start with Vt of 12 -15 ml/kg n Better outcomes with non conventional modes of ventilation such as: n Pressure limited ventilation n Reduced rate of death with this type of injury

High Frequency Ventilation Provides o 2 at lower concentrations and adequate ventilation at reduced High Frequency Ventilation Provides o 2 at lower concentrations and adequate ventilation at reduced airway pressures. n Reduces barotrauma n Less incidence of pneumonia n Improved Pa. O 2/Fi. O 2 ratio n

Complications Most common complications are infection and resp failure n Barotrauma due to MV Complications Most common complications are infection and resp failure n Barotrauma due to MV n Late complications due to inflammatory responses of the body n n Bronchiectasis n Bronchial stenosis n ETT cuffs erosion

Long Term Outcomes Most patients have normal lung parenchyma return within 5 months n Long Term Outcomes Most patients have normal lung parenchyma return within 5 months n Children heal slowly n n PFT changes for up to 8 years n Altered lung mechanics n Impaired gas exchange n Chest wall scarring n Weak resp muscles n Some children never regain normal lung function