Transcript Chapter 7 Body Systems - Kingwood Application Server

Chapter 43
Smoke Inhalation and
Thermal Injures
ME
AB
TS
SM
FWS
Figure 43-1. Smoke inhalation and thermal injuries. TS, Thick secretions; BL, airway blister;
ME, mucosal edema; SM, smoke (toxic gas); FWS, frothy white secretions (pulmonary edema).
Slide 1
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Anatomic Alterations of the Lungs:
Thermal Injury
Slide 2

Injury caused by the inhalation of hot gases

Usually confined to upper airway

Nasal cavity

Oral cavity

Nasopharynx

Oropharynx

Laryngopharynx
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Anatomic Alterations of the Lungs:
Thermal Injury

Slide 3
Distal airways—usually spared because of:

Ability of upper airways to cool hot gases

Reflex laryngospasm

Glottic closure
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Anatomic Alterations of the Lungs:
Thermal Injury
Slide 4

Except for the rare instance of steam
inhalation, direct thermal injuries do not
usually occur below the level of the larynx

Distal airway damage is usually caused by
the harmful products found in SMOKE
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Anatomic Alterations of the Lungs:
Smoke Inhalation Injury
Early Stage (0 to 24 Hours Postinhalation)
Slide 5

Injuries not apparent right away

Pulmonary status changes over first 24 hours

Tracheobronchial tree becomes inflamed

Excessive airway secretions develop

Bronchospasms develop
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Anatomic Alterations of the Lungs:
Smoke Inhalation Injury
Intermediate Stage (2 to 5 Days Postinhalation)
Slide 6

Upper airways begin to improve, but the effects
of smoke inhalation peak

Excessive airway secretions

Mucosa sloughing occurs

Mucus plugging and atelectasis develop
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Anatomic Alterations of the Lungs:
Smoke Inhalation Injury
Intermediate Stage (2 to 5 Days Postinhalation)

Slide 7
Bronchial colonization, bronchitis, and
pneumonia frequently develop

Gram-positive
• Staphylococcus aureus

Gram-negative
• Klebsiella
• Enterobacter
• Escherichia coli
• Pseudomonas
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Anatomic Alterations of the Lungs:
Smoke Inhalation Injury
Intermediate Stage (2 to 5 Days Postinhalation)

If not already present, the following may develop:



Noncardiogenic pulmonary edema
Acute respiratory distress syndrome
When chest wall burns are present, the patient may
not be able to breathe deeply and cough due to:

Pain
 The use of narcotics
 Immobility
 Increased airway resistance
 Decreased lung and chest compliance
Slide 8
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Anatomic Alterations of the Lungs:
Smoke Inhalation Injury
Late Stage (5 or More Days Postinhalation)
Slide 9

Infections resulting from burn wounds are the
major concern during this period

Sepsis-induced multiorgan failure is the
primary cause of death during this stage

Pneumonia continues to be a major problem

Pulmonary embolism may develop
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Anatomic Alterations of the Lungs:
Smoke Inhalation Injury
Slide 10

Late Stage (5 or More Days Postinhalation)

Finally, the long-term effects of smoke inhalation
can result in either a restrictive or obstructive lung
disorder

Restrictive lung disorder
• Alveolar fibrosis
• Chronic atelectasis

Obstructive lung disorder
• Chronic bronchial secretions
• Bronchial stenosis
• Bronchial polyps
• Bronchiectasis
• Bronchiolitis
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Anatomic Alterations of the Lungs:
Thermal Injury
Slide 11

Blistering

Mucosal edema

Vascular congestion

Epithelial sloughing

Thick secretions

Acute upper airway obstruction
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Anatomic Alterations of the Lungs:
Smoke Inhalation Injury
Slide 12

Inflammation of the bronchial airways

Bronchospasm

Excessive bronchial secretions and mucus
plugging

Decreased mucosal ciliary transport

Atelectasis

Alveolar edema (pulmonary edema)
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Anatomic Alterations of the Lungs:
Smoke Inhalation Injury
Slide 13

ARDS (severe cases)

Bronchiolitis obliterans with organizing
pneumonia (BOOP)

Alveolar fibrosis, bronchial stenosis,
bronchial polyps, and bronchiectasis
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Etiology

Fire-related death is the third most common
cause of accidental death in the United States

It is estimated that thermal injury results in about
60,000 hospitalizations and about 6000 deaths
annually

Children account for about 50% of these deaths

Slide 14
Scalding burns account for up to 80% of thermal
injuries among children
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Etiology
The prognosis of fire victims usually is
determined by the:
1. Extent and duration of smoke exposure
2. Chemical composition of the smoke
3. Size and depth of body surface burns
4. Temperature of gases inhaled
5. Age (prognosis worsens in the very young
and old)
6. Preexisting health status
Slide 15
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Table 43-1.
Slide 16
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Table 43-1., cont.
Slide 17
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Table 43-1., cont.
Slide 18
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Table 43-1., cont.
Slide 19
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Table 43-2.
Slide 20
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Etiology

Slide 21
The severity and depth of burns usually are
defined as follows:

First degree
• Minimal depth in skin

Second degree
• Superficial to deep thickness of skin

Third degree
• Full thickness of skin including tissue beneath skin
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Overview of the Cardiopulmonary
Clinical Manifestations Associated
with SMOKE INHALATION AND
THERMAL INJURIES
The following clinical manifestations result from
the pathophysiologic mechanisms caused
(or activated) by Atelectasis (see Figure 9-7),
Alveolar Consolidation (see Figure 9-8),
Increased Alveolar-Capillary Membrane
Thickness (see Figure 9-9), Bronchospasm (see
Figure 9-10), and Excessive Airway Secretions
(see Figure 9-11)—the major anatomic alterations
of the lungs associated with smoke inhalation and
thermal injuries (see Figure 43-1)
Slide 22
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Figure 9-7. Atelectasis clinical scenario.
Slide 23
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Figure 9-8. Alveolar consolidation clinical scenario.
Slide 24
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Figure 9-9. Increased alveolar-capillary membrane thickness clinical scenario.
Slide 25
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Figure 9-10. Bronchospasm clinical scenario (e.g., asthma).
Slide 26
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Figure 9-11. Excessive bronchial secretions clinical scenario.
Slide 27
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Clinical Data Obtained at the
Patient’s Bedside
Vital signs
Slide 28

Increased respiratory rate

Increased heart rate, cardiac output,
blood pressure
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Clinical Data Obtained at the
Patient’s Bedside

Slide 29
Assessment of acute upper airway
obstruction (thermal injury)

Obvious pharyngeal edema and swelling

Inspiratory stridor

Hoarseness

Altered voice

Painful swallowing
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Clinical Data Obtained at the
Patient’s Bedside
Slide 30

Cyanosis

Cough and sputum production

Chest assessment findings

Usually normal breath sounds (early stage)

Wheezing

Crackles

Rhonchi
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Clinical Data Obtained from
Laboratory Tests and Special
Procedures
Slide 31
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Pulmonary Function Study:
Expiratory Maneuver Findings
FVC

FEVT
N or 
FEF25%-75%
N or 
FEF200-1200
N
PEFR
MVV
FEF50%
FEV1%
N
Slide 32
N or 
N
N or 
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Pulmonary Function Study:
Lung Volume and Capacity Findings
VT
N or 
VC

RV*
FRC*
TLC



ERV

RV/TLC%
N
IC

* When airways are partially obstructed.
Slide 33
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Decreased Diffusion Capacity
(DLCO)
Slide 34
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Arterial Blood Gases
Early Stages of Smoke Inhalation

pH

Slide 35
Acute alveolar hyperventilation with
hypoxemia
PaCO2

HCO3 (Slightly)
PaO2
/Normal
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Time and Progression of Disease
Disease Onset
Alveolar Hyperventilation
100
90
PaO2 or PaCO2
80
Point at which PaO2
declines enough to
stimulate peripheral
oxygen receptors
70
60
PaO2
50
40
30
20
10
0
Figure 4-2. PaO2 and PaCO2 trends during acute alveolar hyperventilation.
Slide 36
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Arterial Blood Gases
Severe Smoke Inhalation and Burns with
Metabolic Acidosis

When carbon monoxide or cyanide poisoning is
present, the patient may demonstrate the
following:
COHB

pH*
PacO2


HCO3
PaO2 
Normal
* Lactic acidemia.
† But patient has tissue hypoxia.
Slide 37
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Arterial Blood Gases
Late Stages of Smoke Inhalation

Slide 38
Acute ventilatory failure with hypoxemia
pH
PaCO2


HCO3 (Slightly)
PaO2

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Oxygenation Indices
Early and
Intermediate Stages
Late Stage
DO2


VO2


_
C(a-v)O2


O2ER


SvO2


.
_
Slide 39
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Hemodynamic Indices
(Cardiogenic Pulmonary Edema)
Early
Stage
Intermediate
Stage
Late
Stage
CVP

Normal

RAP

Normal

PA

Normal

PCWP

Normal

CO

Normal

SV

Normal

SVI

Normal

CI

Normal

__
Slide 40
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Hemodynamic Indices, cont.
Slide 41
Early
Stage
Intermediate
Stage
Late
Stage
RVSWI

Normal

LVSWI

Normal

PVR
Normal
Normal

SVR

Normal

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Carbon Monoxide Poisoning
Slide 42
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Table 43-3.
Slide 43
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Table 43-3., cont.
Slide 44
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Cyanide Poisoning
Slide 45
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Radiologic Findings
Chest radiograph
Slide 46

Usually normal (early stage)

Pulmonary edema/ARDS (intermediate stage)

Patchy or segmental infiltrates (late stage)
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Figure 43-2. A, Radiograph of a young man admitted after accidentally setting his kitchen on fire while
intoxicated. B, Prompt recovery after 72 hours. (Courtesy Dr. K. Simpkins, Leeds, England. From
Armstrong P et al: Imaging of diseases of the chest, ed 2, St. Louis, 1995, Mosby.)
Slide 47
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General Management of
Hot Gas and Smoke Inhalation
Slide 48

General emergency care

Airway management

Bronchoscopy

Hyperbaric oxygen

Treatment for cyanide poisoning

Antibiotic agents

Expectorants

Analgesic agents

Prophylactic anticoagulants
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General Management of
Hot Gas and Smoke Inhalation
Respiratory care treatment protocols
Slide 49

Oxygen therapy protocol

Bronchopulmonary hygiene therapy protocol

Hyperinflation therapy protocol

Aerosolized medication protocol

Mechanical ventilation protocol
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Classroom Discussion
Case Study:
Smoke Inhalation and Thermal Injury
Slide 50
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