Copyright © 2006 by Mosby, Inc. Slide 1 Chapter 43 Smoke Inhalation and Thermal Injures Figure 43-1. Smoke inhalation and thermal injuries. TS, Thick secretions;

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Presentation on theme: "Copyright © 2006 by Mosby, Inc. Slide 1 Chapter 43 Smoke Inhalation and Thermal Injures Figure 43-1. Smoke inhalation and thermal injuries. TS, Thick secretions;"— Presentation transcript:

1 Copyright © 2006 by Mosby, Inc. Slide 1 Chapter 43 Smoke Inhalation and Thermal Injures 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). AB FWS SM TS ME

2 Copyright © 2006 by Mosby, Inc. Slide 2 Anatomic Alterations of the Lungs: Thermal Injury  Injury caused by the inhalation of hot gases  Usually confined to upper airway  Nasal cavity  Oral cavity  Nasopharynx  Oropharynx  Laryngopharynx

3 Copyright © 2006 by Mosby, Inc. Slide 3 Anatomic Alterations of the Lungs: Thermal Injury  Distal airways—usually spared because of:  Ability of upper airways to cool hot gases  Reflex laryngospasm  Glottic closure

4 Copyright © 2006 by Mosby, Inc. Slide 4 Anatomic Alterations of the Lungs: Thermal Injury  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

5 Copyright © 2006 by Mosby, Inc. Slide 5 Anatomic Alterations of the Lungs: Smoke Inhalation Injury Early Stage (0 to 24 Hours Postinhalation)  Injuries not apparent right away  Pulmonary status changes over first 24 hours  Tracheobronchial tree becomes inflamed  Excessive airway secretions develop  Bronchospasms develop

6 Copyright © 2006 by Mosby, Inc. Slide 6 Anatomic Alterations of the Lungs: Smoke Inhalation Injury Intermediate Stage (2 to 5 Days Postinhalation)  Upper airways begin to improve, but the effects of smoke inhalation peak  Excessive airway secretions  Mucosa sloughing occurs  Mucus plugging and atelectasis develop

7 Copyright © 2006 by Mosby, Inc. Slide 7 Anatomic Alterations of the Lungs: Smoke Inhalation Injury Intermediate Stage (2 to 5 Days Postinhalation)  Bronchial colonization, bronchitis, and pneumonia frequently develop  Gram-positive Staphylococcus aureus Staphylococcus aureus  Gram-negative Klebsiella Klebsiella Enterobacter Enterobacter Escherichia coli Escherichia coli Pseudomonas Pseudomonas

8 Copyright © 2006 by Mosby, Inc. Slide 8 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

9 Copyright © 2006 by Mosby, Inc. Slide 9 Anatomic Alterations of the Lungs: Smoke Inhalation Injury Late Stage (5 or More Days Postinhalation)  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

10 Copyright © 2006 by Mosby, Inc. Slide 10 Anatomic Alterations of the Lungs: Smoke Inhalation Injury  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 Alveolar fibrosis Chronic atelectasis Chronic atelectasis  Obstructive lung disorder Chronic bronchial secretions Chronic bronchial secretions Bronchial stenosis Bronchial stenosis Bronchial polyps Bronchial polyps Bronchiectasis Bronchiectasis Bronchiolitis Bronchiolitis

11 Copyright © 2006 by Mosby, Inc. Slide 11 Anatomic Alterations of the Lungs: Thermal Injury  Blistering  Mucosal edema  Vascular congestion  Epithelial sloughing  Thick secretions  Acute upper airway obstruction

12 Copyright © 2006 by Mosby, Inc. Slide 12 Anatomic Alterations of the Lungs: Smoke Inhalation Injury  Inflammation of the bronchial airways  Bronchospasm  Excessive bronchial secretions and mucus plugging  Decreased mucosal ciliary transport  Atelectasis  Alveolar edema (pulmonary edema)

13 Copyright © 2006 by Mosby, Inc. Slide 13 Anatomic Alterations of the Lungs: Smoke Inhalation Injury  ARDS (severe cases)  Bronchiolitis obliterans with organizing pneumonia (BOOP)  Alveolar fibrosis, bronchial stenosis, bronchial polyps, and bronchiectasis

14 Copyright © 2006 by Mosby, Inc. Slide 14 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  Scalding burns account for up to 80% of thermal injuries among children

15 Copyright © 2006 by Mosby, Inc. Slide 15 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

16 Copyright © 2006 by Mosby, Inc. Slide 16 Table 43-1.

17 Copyright © 2006 by Mosby, Inc. Slide 17 Table 43-1., cont.

18 Copyright © 2006 by Mosby, Inc. Slide 18 Table 43-1., cont.

19 Copyright © 2006 by Mosby, Inc. Slide 19 Table 43-1., cont.

20 Copyright © 2006 by Mosby, Inc. Slide 20 Table 43-2.

21 Copyright © 2006 by Mosby, Inc. Slide 21 Etiology  The severity and depth of burns usually are defined as follows:  First degree Minimal depth in skin Minimal depth in skin  Second degree Superficial to deep thickness of skin Superficial to deep thickness of skin  Third degree Full thickness of skin including tissue beneath skin Full thickness of skin including tissue beneath skin

22 Copyright © 2006 by Mosby, Inc. Slide 22 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)

23 Copyright © 2006 by Mosby, Inc. Slide 23 Figure 9-7. Atelectasis clinical scenario.

24 Copyright © 2006 by Mosby, Inc. Slide 24 Figure 9-8. Alveolar consolidation clinical scenario.

25 Copyright © 2006 by Mosby, Inc. Slide 25 Figure 9-9. Increased alveolar-capillary membrane thickness clinical scenario.

26 Copyright © 2006 by Mosby, Inc. Slide 26 Figure 9-10. Bronchospasm clinical scenario (e.g., asthma).

27 Copyright © 2006 by Mosby, Inc. Slide 27 Figure 9-11. Excessive bronchial secretions clinical scenario.

28 Copyright © 2006 by Mosby, Inc. Slide 28 Clinical Data Obtained at the Patient’s Bedside Vital signs  Increased respiratory rate  Increased heart rate, cardiac output, blood pressure

29 Copyright © 2006 by Mosby, Inc. Slide 29 Clinical Data Obtained at the Patient’s Bedside  Assessment of acute upper airway obstruction (thermal injury)  Obvious pharyngeal edema and swelling  Inspiratory stridor  Hoarseness  Altered voice  Painful swallowing

30 Copyright © 2006 by Mosby, Inc. Slide 30 Clinical Data Obtained at the Patient’s Bedside  Cyanosis  Cough and sputum production  Chest assessment findings  Usually normal breath sounds (early stage)  Wheezing  Crackles  Rhonchi

31 Copyright © 2006 by Mosby, Inc. Slide 31 Clinical Data Obtained from Laboratory Tests and Special Procedures

32 Copyright © 2006 by Mosby, Inc. Slide 32 Pulmonary Function Study: Expiratory Maneuver Findings FVC FEV T FEF 25%-75% FEF 200-1200  N or  N or  N PEFR MVV FEF 50% FEV 1% N N or  N N or  FVC FEV T FEF 25%-75% FEF 200-1200  N or  N or  N PEFR MVV FEF 50% FEV 1% N N or  N N or 

33 Copyright © 2006 by Mosby, Inc. Slide 33 Pulmonary Function Study: Lung Volume and Capacity Findings V T RV* FRC* TLC N or     VC IC ERV RV/TLC%    N V T RV* FRC* TLC N or     VC IC ERV RV/TLC%    N *  When airways are partially obstructed.

34 Copyright © 2006 by Mosby, Inc. Slide 34 Decreased Diffusion Capacity (DL CO )

35 Copyright © 2006 by Mosby, Inc. Slide 35 Arterial Blood Gases Early Stages of Smoke Inhalation  Acute alveolar hyperventilation with hypoxemia pH Pa CO 2 HCO 3 - Pa O 2    (Slightly)  /Normal pH Pa CO 2 HCO 3 - Pa O 2    (Slightly)  /Normal

36 Copyright © 2006 by Mosby, Inc. Slide 36 Time and Progression of Disease 100 50 30 80 0 0 Pa CO 2 10 20 40 Alveolar Hyperventilation 60 70 90 Point at which PaO 2 declines enough to stimulate peripheral oxygen receptors Pa O 2 Disease Onset Pa O 2 or Pa CO 2 Figure 4-2. PaO 2 and PaCO 2 trends during acute alveolar hyperventilation.

37 Copyright © 2006 by Mosby, Inc. Slide 37 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* Pac O 2 HCO 3 - Pa O 2      Normal * Lactic acidemia. † But patient has tissue hypoxia.

38 Copyright © 2006 by Mosby, Inc. Slide 38 Arterial Blood Gases Late Stages of Smoke Inhalation  Acute ventilatory failure with hypoxemia pH Pa CO 2 HCO 3 - Pa O 2    (Slightly) 

39 Copyright © 2006 by Mosby, Inc. Slide 39 Oxygenation Indices DO 2  VO 2  C(a-v)O 2  O 2 ER  SvO 2  Early and Intermediate Stages Late Stage. _ _

40 Copyright © 2006 by Mosby, Inc. Slide 40 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  __

41 Copyright © 2006 by Mosby, Inc. Slide 41 Hemodynamic Indices, cont. RVSWI  Normal  LVSWI  Normal  PVRNormalNormal  SVR  Normal  Early Stage Intermediate Stage Late Stage

42 Copyright © 2006 by Mosby, Inc. Slide 42 Carbon Monoxide Poisoning

43 Copyright © 2006 by Mosby, Inc. Slide 43 Table 43-3.

44 Copyright © 2006 by Mosby, Inc. Slide 44 Table 43-3., cont.

45 Copyright © 2006 by Mosby, Inc. Slide 45 Cyanide Poisoning

46 Copyright © 2006 by Mosby, Inc. Slide 46 Radiologic Findings Chest radiograph  Usually normal (early stage)  Pulmonary edema/ARDS (intermediate stage)  Patchy or segmental infiltrates (late stage)

47 Copyright © 2006 by Mosby, Inc. Slide 47 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.)

48 Copyright © 2006 by Mosby, Inc. Slide 48 General Management of Hot Gas and Smoke Inhalation  General emergency care  Airway management  Bronchoscopy  Hyperbaric oxygen  Treatment for cyanide poisoning  Antibiotic agents  Expectorants  Analgesic agents  Prophylactic anticoagulants

49 Copyright © 2006 by Mosby, Inc. Slide 49 General Management of Hot Gas and Smoke Inhalation Respiratory care treatment protocols  Oxygen therapy protocol  Bronchopulmonary hygiene therapy protocol  Hyperinflation therapy protocol  Aerosolized medication protocol  Mechanical ventilation protocol

50 Copyright © 2006 by Mosby, Inc. Slide 50 Classroom Discussion Case Study: Smoke Inhalation and Thermal Injury


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