Pediatric Polytrauma Fire Victim Simulation.

Introduction: Pediatric trauma has long been one of the primary contributors to pediatric mortality. There are multiple cases in the literature involving cyanide (CN) toxicity, carbon monoxide (CO) toxicity, and smoke inhalation with thermal injury, but none in combination with mechanical trauma. Methods: In this 45-minute simulation case, emergency medicine residents and fellows were asked to manage a pediatric patient with multiple life-threatening traumatic and metabolic concerns after being extracted from a van accident with a resulting fire. Providers were expected to identify and manage the patient's airway, burns, hemoperitoneum, and CO and CN toxicities. Results: Forty learners participated in this simulation, the majority of whom had little prior clinical experience managing the concepts highlighted in it. All agreed or strongly agreed that the case was relevant to their work. After participation, learner confidence in the ability to manage each of the learning objectives was high. One hundred percent of learners felt confident or very confident in managing CO toxicity and completing primary and secondary surveys, while 97% were similarly confident in identifying smoke inhalation injury, preparing for a difficult airway, and managing CN toxicity. Discussion: This case was a well-received teaching tool for the management of pediatric trauma and metabolic derangements related to fire injuries. While this specific case represents a rare clinical experience, it is within the scope of expected knowledge for emergency medicine providers and offers the opportunity to practice managing multisystem trauma.

Exercise-induced myocardial ischemia presenting as exercise intolerance after carbon monoxide intoxication and smoke inhalation Injury: case report.

BACKGROUND: Carbon monoxide intoxication and smoke inhalation injury can lead to severe disorders, and the current literature has elaborated on the importance of major cardiopulmonary impairment. Exercise intolerance has seldom been discussed, particular in patient with low cardiovascular risk. CASE PRESENTATION: Two young male fire survivors who presented with exercise intolerance after CO intoxication and smoke inhalation injury. Both received bronchodilator and glucocorticoid therapy, high-flow oxygen therapy, and hyperbaric oxygen therapy for airway edema and CO intoxication during acute care. Serum carboxyhemoglobin levels improved after treatment (8.2-3.9% in Case A and 14.8-0.8% in Case B). However, subjective exercise intolerance was noted after discharge. Cardiopulmonary exercise testing revealed exercise-induced myocardial ischemia during peak exercise (significant ST-segment depression on exercise electrocardiogram). They were instructed to exercise with precaution by setting the intensity threshold according to the ischemic threshold. Their symptoms improved, and no cardiopulmonary events were reported in the 6-month follow-up. CONCLUSION: The present case report raised the attention that exercise intolerance after carbon monoxide intoxication and smoke inhalation injury in low cardiovascular risk population may be underestimated. Cardiopulmonary exercise testing help physician to discover exercise-induced myocardial ischemia and set up the cardiac rehabilitation program accordingly.

Smoke inhalation injury in a 2-year-old domestic fire victim.

Smoke inhalation injury is common in victims of domestic fires, among whom children are the most vulnerable. Cyanide poisoning may occur in addition to carbon monoxide poisoning and is challenging to diagnose. In France, the recommended antidotes are hydroxocobalamin for cyanide and hyperbaric oxygen for carbon monoxide. We managed a 26-month-old girl who sustained smoke inhalation injury with both carbon monoxide and cyanide poisoning during a house fire. Despite hydroxocobalamin and sodium thiosulfate therapy combined with hyperbaric oxygen, she had residual neurological impairments 3 months after the injury. The treatment challenges and detailed neurological follow-up data are described.

Impact of diagnostic bronchoscopy in burned adults with suspected inhalation injury.

INTRODUCTION: Inhalation injury is a common complication of thermal trauma. Fiberoptic bronchoscopy (FOB) is regarded as current standard practice in diagnosing and grading inhalation injury. Nonetheless, its predictive value in terms of therapeutic decision-making and clinical outcome is controversial. METHODS: Adult burn patients with inhalation injury (InI) were selected from the National Burn Repository of the American Burn Association. Subjects were propensity score pair-matched based on injury severity and grouped based on whether or not FOB had been performed (FOB, CTR, respectively). Mortality, incidence of pneumonia, length of hospitalization, length of ICU stay and dependency on mechanical ventilation were compared between the two groups. RESULTS: 3014 patients were matched in two groups with a mean TBSA of 22.4%. There was no significant difference in carboxyhemoglobin fraction at admission. Patients, who underwent FOB on admission had a significantly increased incidence of pneumonia (p < 0.001), mortality (p < 0.05), length of hospitalization (p = 0.002), ICU stay (p < 0.001) and duration of mechanical ventilation (p = 0.006). In a subgroup analysis of patients with TBSA of at least 20%, incidence of pneumonia was significantly higher in the FOB group (p < 0.001) and longer mechanical ventilation was required (p = 0.036). DISCUSSION: Diagnosis and grading of InI through FOB is the current standard, although its predictive value regarding key outcome parameters and therapeutic decision-making, remains unclear. The potential procedural risk of FOB itself should be considered. This study demonstrates correlations of FOB with major clinical outcomes in both a general collective of burned adults as well as severely burned adults. Although these findings must be interpreted with caution, they may induce further research into potential harm of FOB and critical review of routine diagnostic FOB in suspected inhalation injury in thermally injured patients.

Circulating cell-free DNA as a potential marker in smoke inhalation injury.

Failure in evaluation of smoke inhalation injury (SII) is related to increased morbidity and mortality. Prognostic biomarkers that reflect the injury are undoubtedly needed. Cell-free DNA (CFD) concentrations are associated to the extent of tissue damage and inflammation in various pathologies. We have developed a simple assay for CFD quantification and previously found it prognostic in various pathologies including burns, lung disease, and sepsis. The aim of this study was to evaluate admission CFD as an injury severity marker in patients with SII.In a prospective study, we measured admission CFD levels in 18 SII patients and matched control subjects. Daily CFD levels were also performed in 4 hospitalized patients. Serum CFD levels were measured by our direct rapid fluorometric assay.Admission CFD levels of SII patients were significantly higher than those of healthy controls, 879 (236-3220) ng/mL vs. 339 (150-570) ng/mL, [median (range)], P < .0001. Admission CFD levels of hospitalized patients were significantly higher than those of nonhospitalized patients, 1517 (655-3220) ng/mL vs. 675 (236-1581) ng/mL, P < .05. Admission CFD positively correlated with hospitalization time (Rho = 0.578, P < .05) and was in linear correlation with CO poisoning (carboxyhemoglobin (COHb) levels, R = 0.621, P < .0001). Additionally, along with the recovery of hospitalized patients, we observed a matched reduction of CFD levels.CFD appears to be a potentially valuable marker for severity and follow-up of SII. We believe this rapid assay can help introduce the routine use of CFD measurement into daily practice.

[National experts consensus on clinical diagnosis and treatment of inhalation injury (2018 version)].

Inhalation injury is caused by inhalation of heat, toxic or irritating gases which lead to respiratory and pulmonary parenchyma damage. At present, the clinical understanding about it is still limited and lack of effective diagnosis and treatment standard. Based on the experience of diagnosis and treatment of domestic inhalation injury, combined with reports of international researches, criteria (expert consensus) for inhalation injury were systematically discussed from pathological and pathophysiological changes, clinical diagnosis and evaluation, and clinical treatment, which provides reference for clinical diagnosis and treatment of patients inflicted with inhalation injury.

[National experts consensus on clinical diagnosis and treatment of inhalation injury (2018 version)].

Inhalation injury is caused by inhalation of heat, toxic or irritating gases which lead to respiratory and pulmonary parenchyma damage. At present, the clinical understanding about it is still limited and lack of effective diagnosis and treatment standard. Based on the experience of diagnosis and treatment of domestic inhalation injury, combined with reports of international researches, criteria (expert consensus) for inhalation injury were systematically discussed from pathological and pathophysiological changes, clinical diagnosis and evaluation, and clinical treatment, which provides reference for clinical diagnosis and treatment of patients inflicted with inhalation injury.

Expression profile of microRNAs in bronchoalveolar lavage fluid of rats as predictors for smoke inhalation injury.

Smoke inhalation injury (SII) is an independent risk factor for morbidity and mortality in patients with severe burns, however, the underlying mechanisms of SII are still not fully understood. In our study, we established an advanced rat model of SII based on the previous work, and explored the dynamic changes of pathophysiology and inflammatory factors during 28days post SII. We also measured the different expressions of miRNAs in bronchoalveolar lavage fluid (BALF) between SII and normal control rats by miRNA microarray. At 1day after smoke inhalation, the histopathological results exhibited inflammatory exudates in the lung tissue with significant edema. As time went on, the lung injuries gradually appeared at alveolar septum thickening and alveolar collapse, which suggested that it further induced damage to lung parenchyma by smoke inhalation. Particularly, the collagen deposition indicating pulmonary fibrosis happened at 28days post-injury. Plasma IL-6 and TNF-a were significantly increased after 1day of smoke inhalation. Plasma IL-10, BALF TNF-α and IL-10 were significantly increased after 2days of smoke inhalation. By extending the observation time, the levels of plasma IL-6, BALF TNF-a and IL-10 appeared a second peak again after 14days of injury. Compared with the normal control group, there were 23 upregulated miRNAs and 2 downregulated miRNAs in BALF of SII group at 1day post-injury. RT-qPCR validation assay confirmed that the changes of miR-34c-5p, miR-92b-3p, miR-205, miR-34b-3p, miR-92a-3p, let-7b-5p, let-7c-5p in BALF were consistent with the conclusion of the miRNA microarray. In summary, we showed the dynamic changes of pathologic changes and inflammatory factors in rats with SII, and a subset of seven miRNAs changed in BALF after SII which may be used for diagnosis and potential therapeutic targets.

Emergency department management of smoke inhalation injury in adults.

Smoke inhalation injury portends increased morbidity and mortality in fire-exposed patients. Upper airway thermal burns, inflammation from lower airway irritants, and systemic effects of carbon monoxide and cyanide can contribute to injury. A standardized diagnostic protocol for inhalation injury is lacking, and management remains mostly supportive. Clinicians should maintain a high index of suspicion for concomitant traumatic injuries. Diagnosis is mostly clinical, aided by bronchoscopy and other supplementary tests. Treatment includes airway and respiratory support, lung protective ventilation, 100% oxygen or hyperbaric oxygen therapy for carbon monoxide poisoning, and hydroxocobalamin for cyanide toxicity. Due to its progressive nature, many patients with smoke inhalation injury warrant close monitoring for development of airway compromise.

The diagnosis and management of inhalation injury: An evidence based approach.

INTRODUCTION: Smoke inhalation injury (II) is an independent risk factor for mortality in burns and its management is inherently complex. We aim to make recommendations for best practice in managing II and its sequelae by reviewing all available current evidence in order to provide an evidence-based approach. METHODS: We conducted a systematic search of the Cochrane database and Embase using PRISMA guidelines with no patient population exclusion criteria. Published work was reviewed and evidence levels graded. RESULTS: We identified 521 abstracts for inclusion. Of the 84 articles identified for secondary review, 28 papers were excluded leaving 56 papers suitable for final inclusion. CONCLUSIONS: We are able to identify a number of strategies in both diagnosis and treatment of II that have support in the published literature, including the role of bronchoscopy, permissive hypercapnia, nebulized heparin and hydroxycobalamin. Other strategies have not been shown to be harmful, but their efficacy is also not firmly established, such as high frequency oscillatory ventilation and exogenous surfactant. Prophylactic antibiotics and corticosteroids are not recommended. In general, published evidence for II is mostly Level 3 or below, due to a noticeable lack of large-scale human studies. This represents a challenge for evidence-based burns practice as a whole.

Proposal for an algorithm for the management of the patient's airway after smoke inhalation. / Propuesta de algoritmo para el manejo de la vía aérea del paciente tras inhalación de humo.

Smoke inhalation represents the leading cause of mortality and morbidity in burns patients. Given the injuries that can occur in the airway after this exposure, it is imperative to evaluate the need for orotracheal intubation in the emergency department and even in the place of first assistance by healthcare workers. Since the clinical signs are poor predictors of the severity of the lesion, in selected cases, it is advisable to perform a diagnostic fibroscopy. We present a case report of a patient with a smoke inhalation lesion in which the fibroscopy was determinant to proceed to intubation, and we propose an algorithm of action for the management of the airway in this type of patients.

Determining the role of nasolaryngoscopy in the initial evaluation for upper airway injury in patients with facial burns.

BACKGROUND: Upper airway injuries can be fatal in burn patients if not recognized, a scenario that causes a significant amount of anxiety for physicians providing initial assessment of burn patients. Early elective intubation is often performed; sometimes unnecessarily. However, some providers employ nasolaryngoscopy for patients presenting with facial burns or signs/symptoms of upper airway injury in order to assess the need for intubation, but this practice is not considered standard of care and may also be unnecessary. Evidence is currently lacking about the utility of nasolaryngoscopy as an adjuvant assessment during evaluation of potential upper airway burn injuries. The objective of this study was to determine if nasolaryngoscopy provides additional information to the history and physical in making the decision to electively intubate patients with facial burns. METHODS: This study was a retrospective analysis of all patients who underwent fiberoptic nasolaryngoscopy after facial burn injury to evaluate for upper airway injury associated with burns over a 2 year period at a regional burn center. During this time period, all patients who presented with facial burns, soot, or carbonaceous sputum underwent nasolaryngoscopy to look for upper airway injury regardless of mechanism of injury. Patients intubated prior to arrival were excluded from the study. Patients were considered to have signs/symptoms of airway injury (symptomatic) if they presented with dyspnea, tachypnea, hypoxia, or significant burns to buccal mucosa. Procedure notes were used to determine if supraglottic/glottic injury (erythema or edema) was present on nasolaryngoscopy. Presence of pathologic changes and whether they led to intubation were evaluated in the asymptomatic and the symptomatic groups of patients. Select individual records were inspected further to help determine if the nasolaryngoscopy findings altered management plans and if intubation was ultimately necessary based upon the presence or absence of a cuff leak and the duration of intubation. RESULTS: Twenty-two patients were symptomatic upon presentation, 14 of which had positive findings on laryngoscopy and 7 (50%) were intubated. One-hundred and eighty-eight patients were asymptomatic, 58 (31%) of which had either erythema or edema or carbonaceous debris on nasolaryngoscopy, and only 2 (1%) were intubated. These patients were both extubated within two days. None of the 130 asymptomatic patients with negative nasolaryngoscopy were intubated. CONCLUSIONS: This study showed disparity between signs and symptoms of airway injury and nasolaryngoscopy findings. Asymptomatic patients showed pathologic changes in 30% of scopes, but this finding only changed management 1% of the time. Furthermore, the two patients in this group were extubated quickly, suggesting they may have been suitable for observation without intubation. These results indicate that the presence of erythema or edema is of questionable clinical significance in asymptomatic patients and nasolaryngoscopy is of limited benefit in this group. Only 50% of the symptomatic patients with airway injury evident on nasolaryngoscopy were actually intubated, also bringing into question the significance of the pathologic changes in this group. However, negative nasolaryngoscopy may have had some benefit in preventing intubation in a few, select symptomatic patients. This study suggests that a thorough history and physical is the best tool to identify patients at higher risk of upper airway injury who need intubation, but this should be further studied in prospective trials to determine the definitive role of nasolaryngoscopy.

Prognostic value of serum zinc levels in patients with acute HC/zinc chloride smoke inhalation.

Hexachloroethane (HC)/zinc chloride (ZnCl, smoke bomb) exposure in the military setting results in lung injury which is uncommon and has been rarely described in previous studies. The aim of this study is to investigate the correlation between the serum zinc in patients with HC/ZnCl smoke inhalation lung injury and disease severity. A total of 15 patients with HC/ZnCl-related conditions were recruited in this study. The serum zinc level and the pulmonary function tests and liver function tests including total lung capacity (TLC), forced vital capacity (FVC), forced expiratory pressure in 1 second (FEV1), alanine aminotransferase (ALT), and aspartate transaminase (AST) were analyzed. Eleven cases had mild clinical manifestations. Four cases rapidly developed features typical of severe adult respiratory distress syndrome. The level of serum zinc was increased, but FVC, FEV1, and TLC was decreased significantly in the moderate and severe cases. In addition, the serum zinc level correlated well with the TLC, FVC, and FEV1 (r = -0.587, -0.626, -0.617, respectively; P = .027, .017, .019, respectively). The 4 cases in moderate and severe group had delayed impairment of liver functions after the accident. This study suggested that the serum zinc level may be associated with the severity of lung and liver injuries after HC/ZnCl smoke inhalation.

Severity of Inhalation Injury is Predictive of Alterations in Gas Exchange and Worsened Clinical Outcomes.

Inhalation injury (INH) is present in one third of large burn injuries and increases oxygenation and fluid resuscitation requirements, incidences of pulmonary complications, risk for multiple organ dysfunction syndrome (MODS), and overall mortality. Previous studies have demonstrated inconsistent correlation between bronchoscopic evaluation and clinical outcomes. The authors reviewed 161 patients admitted with a diagnosis of INH or underwent diagnostic bronchoscopy for suspected INH over a period of 8.5 years. One hundred one patients had concomitant burn injury and 60 had isolated INH. Seventeen patients had abbreviated injury score (AIS) 0, 81 patients had low-grade injury (AIS 1 and 2), and 63 patients had high-grade injury (AIS 3 and 4). Patients with high-grade INH had worse pulmonary dysfunction, worse oxygenation indices (P = 0.01) and plasma carboxyhemoglobin (COHgb; P < 0.01) on admission, increased fluid requirements (P < 0.01 at 24 hours; P = 0.04 at 48 hours), MODS (P = 0.04), pneumonia (P < 0.01), acute respiratory distress syndrome (P = 0.01 at 48 hours), fewer 28-day ventilator-free days (P < 0.01), greater ventilator dependence (P = 0.03), and longer length of stay (P < 0.01). Multivariate analyses demonstrated increased risk of MODS (P = 0.03), acute respiratory distress syndrome at 48 hours (P < 0.01), pneumonia (P = 0.01), prolonged ventilator dependence (P = 0.03), and a trend toward mortality (P = 0.08) with higher AIS groups. More severe INH correlates with early oxygenation impairments and is associated with more complicated hospitalization, fluid resuscitation requirements, and ventilation demands. Severe INH is associated with and predictive of increased morbidity and mortality.

The accuracy of burn diagnosis codes in health administrative data: A validation study.

BACKGROUND: Health administrative databases may provide rich sources of data for the study of outcomes following burn. We aimed to determine the accuracy of International Classification of Diseases diagnoses codes for burn in a population-based administrative database. METHODS: Data from a regional burn center's clinical registry of patients admitted between 2006-2013 were linked to administrative databases. Burn total body surface area (TBSA), depth, mechanism, and inhalation injury were compared between the registry and administrative records. The sensitivity, specificity, and positive and negative predictive values were determined, and coding agreement was assessed with the kappa statistic. RESULTS: 1215 burn center patients were linked to administrative records. TBSA codes were highly sensitive and specific for ≥10 and ≥20% TBSA (89/93% sensitive and 95/97% specific), with excellent agreement (κ, 0.85/κ, 0.88). Codes were weakly sensitive (68%) in identifying ≥10% TBSA full-thickness burn, though highly specific (86%) with moderate agreement (κ, 0.46). Codes for inhalation injury had limited sensitivity (43%) but high specificity (99%) with moderate agreement (κ, 0.54). Burn mechanism had excellent coding agreement (κ, 0.84). CONCLUSIONS: Administrative data diagnosis codes accurately identify burn by burn size and mechanism, while identification of inhalation injury or full-thickness burns is less sensitive but highly specific.

Fibrobroncoscopia negra en el contexto de un incendio / Black fiberoptic bronchoscopy after a fire

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Pathophysiology, research challenges, and clinical management of smoke inhalation injury.

Smoke inhalation injury is a serious medical problem that increases morbidity and mortality after severe burns. However, relatively little attention has been paid to this devastating condition, and the bulk of research is limited to preclinical basic science studies. Moreover, no worldwide consensus criteria exist for its diagnosis, severity grading, and prognosis. Therapeutic approaches are highly variable depending on the country and burn centre or hospital. In this Series paper, we discuss understanding of the pathophysiology of smoke inhalation injury, the best evidence-based treatments, and challenges and future directions in diagnostics and management.