Severe Inhalation Injury Research Articles

Acute Lung Injury and Multiple Organ Dysfunction Syndrome Secondary to Intra-Abdominal Hypertension and Abdominal Decompression in Extensively Burned Patients

Secondary abdominal compartment syndrome (ACS) is a lethal complication after resuscitation from burn shock, even after abdominal decompression (AD) is performed. This study investigated increased susceptibility to multiple organ dysfunction syndrome (MODS) in extensively burned patients with ACS. Patients admitted to our burn unit between 2002 and 2005 with burns affecting 40% or more of the total body surface area without severe inhalation injury were analyzed. Hemodynamic parameters, blood gas analysis, and intrabladder pressure as intra-abdominal pressure were recorded. Serum interleukin (IL)-8 and IL-6 concentrations were measured in 20 of these patients. Lung injury score and Sequential Organ Failure Assessment scores were serially determined. Fourteen of 38 patients developed intra-abdominal hypertension in 22.9 +/- 8.9 hours postburn. Hemodynamic parameters in these 14 patients, including peak intra-abdominal pressure (46.6 +/- 11.2 to 19.8 +/- 9.9 cm H2O), peak inspiratory pressure (51.4 +/- 10.5 to 31.8 +/- 7.0 cm H2O), and abdominal perfusion pressure (51.3 +/- 18.3 to 73.9 +/- 13.6 mm Hg), were improved immediately after AD. Despite AD, lung injury score and Sequential Organ Failure Assessment scores increased significantly 2 and 3 days postburn in patients who required AD. Plasma concentration of IL-8 was elevated in intra-abdominal hypertension patients 3 days postburn. Intra-abdominal hypertension induced acute lung injury and MODS with IL-8 elevation, even though AD improved hemodynamic parameters in extensively burned patients.

Management of blast and inhalation injury

<h3>Key points</h3> All patients with facial burns may be suspected of having ‘difficult-to-control’ airways owing to smoke inhalation injury (SII). Many of them either have an incorrect diagnosis, or mild-to-moderate injury with unrecognised aggravating respiratory failure. For a diagnosis of inhalation injury, it is necessary to follow the patient closely for &gt;48 h. Inhalation injury is a condition with different clinical presentations. Clinical follow-up is necessary to improve patient care, to help guide treatment and to provide clues for therapeutic interventions. Notwithstanding intensive care treatment including airway intubation and mechanical ventilation, many patients with severe inhalation injury remain under-treated. <h3>Educational aims</h3> To discuss the initial approach and assessment of a patient with SII. To help the reader recognise different clinical pictures of inhalation injury. To outline management and discuss treatment. <h3>Summary</h3> “Inhalation injury” describes a variety of insults caused by the aspiration of superheated gases, steam or noxious products of incomplete combustion. Inhalation injury involves the entire respiratory system. Early diagnosis based on history and physical examination, in addition to careful monitoring for respiratory complications, is mandatory. As there is no specific treatment for inhalation injury, management involves providing the necessary degree of support required to compensate for upper airway swelling and impairment in gas exchange. Airway intubation and mechanical ventilation may be required while the endobronchial and alveolar mucosa are regenerating. Primary blast injury (BI) is caused by immediate pressure variations, which are the product of rapid sequences of compression and decompression. Secondary and tertiary BI include lesions caused when the subject is thrown against rigid structures or is hit by flying objects. Its diagnosis and therapy follows guidelines for emergency care.

Tissue injury by hot fluid containing nitrogen mustard

Nitrogen mustards are analogous to sulfur mustard and have similar toxic effects on tissues. With the recent surge in terror activity, mustard could be used by terrorists. Recently a group of patients suffered from skin injury caused by hot fluid containing nitrogen mustard were treated. All the patients displayed eye symptoms such as eye pain, photophobia, excessive tearing, and blurred vision. One patient suffered from severe inhalation injury. Laboratory examination showed the decrease of white blood cell count, which may result from the loss of neutrophils. At the same time, platelets were at lower level during the first 8 days and gamma-glutamyltransferase (gamma-GT), a marker of oxidative stress, was significantly increased.

A case of severe smoke inhalation injury without cutaneous burn required massive fluid for resuscitation

A case of severe smoke inhalation injury without cutaneous burn required massive fluid for resuscitation

EFFECTS OF SEVERE SMOKE INHALATION INJURY AND SEPTIC SHOCK ON GLOBAL HEMODYNAMICS AND MICROVASCULAR BLOOD FLOW IN SHEEP

This prospective, randomized, controlled experimental study looks at the effects on global and regional microvascular blood flow (RMBF) in an ovine model of septic shock after severe smoke inhalation injury. Sixteen sheep were randomized into two groups, a control group (no injury, n = 8) and a smoke/sepsis (SS) group (n = 8), which received an insufflation of 4 sets of 12 breaths of cotton smoke (<40 degrees C) followed by instillation of live Pseudomonas aeruginosa into both lung lobes, according to an established protocol. All sheep were mechanically ventilated with 100% oxygen, and fluid resuscitated with lactated Ringer's solution for the entire duration of the 24-h experimental period to maintain hematocrit at baseline (BL) levels. Healthy control animals were not subjected to the injury and received only 4 x 12 breaths of room air and instillation of the vehicle (normal saline). Blood flow was analyzed using colored microspheres. Control animals remained hemodynamically stable and had no statistical changes from BL in visceral or cerebral blood flow during the entire experimental period. All SS animals developed a hypotensive, hyperdynamic circulation, characterized by a significant increase in heart rate and cardiac output with a simultaneous significant fall in mean arterial pressure, which, in combination, led to a fall in systemic vascular resistance index versus BL (P < 0.001, each). In visceral organs, the trachea showed a significant increase in RMBF (P < 0.001). In addition, skeletal muscle significantly increased versus BL and versus controls over time (P < 0.01). Whereas the pancreas displayed a significant drop in RMBF versus BL and controls (P < 0.05), no statistical differences occurred in the renal cortex, spleen, and ileum. All investigated cerebral structures, such as the cortex cerebri, basal ganglia, thalamus, hippocampus, pons, medulla oblongata, and cerebellum showed a significant increase in RMBF versus BL and versus control animals (P < 0.05, each). These data differ in areas of normal, increased, and decreased RMBF during septic shock after smoke inhalation injury and show differences to former studies of our group investigating RMBF in ovine models of either smoke inhalation or P. aeruginosa infusion. The results of this study reflect the complex pathophysiological variances of the combined injury and may provide a basis for future investigations for the treatment of this kind of injury.

Hypertonic Lactated Saline Resuscitation Reduces the Risk of Abdominal Compartment Syndrome in Severely Burned Patients

Secondary abdominal compartment syndrome is a lethal complication after resuscitation from burn shock. Hypertonic lactated saline (HLS) infusion reduces early fluid requirements in burn shock, but the effects of HLS on intraabdominal pressure have not been clarified. Patients admitted to our burn unit between 2002 and 2004 with burns > or =40% of the total body surface area without severe inhalation injury were entered into a fluid resuscitation protocol using HLS (n = 14) or lactated Ringer's solution (n = 22). Urine output was monitored hourly with a goal of 0.5 to 1.0 mL/kg per hour. Hemodynamic parameters, blood gas analysis, intrabladder pressure as an indicator of intraabdominal pressure (IAP), and the peak inspiratory pressure were recorded. Pulmonary compliance and the abdominal perfusion pressure were also calculated. In the HLS group, the amount of intravenous fluid volume needed to maintain adequate urine output was less at 3.1 +/- 0.9 versus 5.2 +/- 1.2 mL/24 h per kg per percentage of total body surface area, and the peak IAP and peak inspiratory pressure at 24 hours after injury were significantly lower than those in the lactated Ringer's group. Two of 14 patients (14%) in the HLS group and 11 of 22 patients (50%) developed IAH within 20.8 +/- 7.2 hours after injury. In patients with severe burn injury, a large intravenous fluid volume decreases abdominal perfusion during the resuscitative period because of increased IAP. Our data suggest that HLS resuscitation could reduce the risk of secondary abdominal compartment syndrome with lower fluid load in burn shock patients.

KAMEDO Report No. 75 Fire Catastrophe in Gothenburg 29–30 October 1998

A fire developed in a facility being used as a discotheque that resulted in death for 63 young people. The rescue operations, ambulance responses, medical care provided at the scene, hospital operations, and psychosocial responses are described. Bodies blocked the exit and many survivors had to evacuate by leaping from windows. A total of 16 ambulances were used. Survivors and people not directly involved in the incident created disturbances and some even attacked responders. Many of those who escaped early suffered mild inhalation injuries and those who escaped later, sustained more severe inhalation injuries. High levels of both carbon-monoxide and cyanide were detected at autopsy. A total of 213 persons were transported to hospitals, 85 by ambulance. Most who died at the scene had severe burn injuries, were unconscious, or suffered from fire-gas injuries. A total of 150 victims were admitted to a hospital, of which 74 (49.3%) required intensive care. Only one of the four hospitals actuated a disaster alert. Psychosocial support was complicated due the multicultural characteristics of those involved. Support to the survivors and relatives of the victims was provided by representatives of various religious organization, non-profit organizations, and by the government of Gothenburg. Many recommendations are provided to better prepare for future events.

Successful Management of Adult Smoke Inhalation with Extracorporeal Membrane Oxygenation

Pulmonary complications remain one of the leading causes of mortality in patients with burns. We report two cases of adult patients with thermal and inhalation injuries who were placed on extracorporeal membrane oxygenation (ECMO) and survived. Patient 1 was a 42-year-old male who suffered 15% TBSA and a severe inhalation injury requiring intubation upon arrival to the emergency department. Patient 2 was a 24-year-old female in a house fire who received 20%TBSA and was noted to be in respiratory distress and intubated on the scene by the paramedic team. Three days after admission, patient 1 developed severe respiratory failure. He decompensated, despite maximum conventional management, and was placed on ECMO. After 300 hours of ECMO, his pulmonary function had improved, and he was decannulated. Patient 2 also developed severe refractory respiratory failure and was placed on ECMO. She was decannulated 288 hours later. Both patients were discharged home shortly afterwards and have managed well. ECMO should be considered when patients are facing a respiratory death from inhalation injury on conventional mechanical ventilation.

Cilinical Experience With Early Tracheotomy in Treating 69 cases of Moderate and Severe Inhalation Injury

目的 观察早期气管切开对中、重度吸入性损伤病人的治疗效果.方法对69例中重度吸入性损伤病人采取气管切开及综合治疗.结果全组死亡29例,病死率与吸入性损伤的程度有关.结论中、重度吸入性损伤宜尽早实行气管切开治疗(伤后6小时以内),并有预防意义。

Antithrombin (human) concentrate infusion in pediatric patients with >50% TBSA burns

Background: Antithrombin (human) [AT(H)] concentrate infusions have been safely utilized in adult burn patients to counteract subclinical disseminated intravascular coagulopathy and pulmonary complications. Objective: AT(H) concentrate was given to two thermally injured pediatric patients to evaluate safety and dosage requirements. Design: The first patient was a 2-year-old with 83% total burn surface area (TBSA) full thickness flame burn and severe inhalation injury. The second patient was a 14-month-old who sustained 56% TBSA deep partial and full thickness scald injury. Each child received 10 infusions of AT(H) concentrate (106 units/kg) in the first 4 days post-injury. Result: For these two patients, the plasma AT level (normal range: 100±20%) increased, respectively, from 25 and 66% on admission to 224 and 217% on day 1, 114 and 116% on day 2, and 193 and 171% on day 3. Both patients tolerated the infusions well. In one patient, the eschar on all four extremities easily peeled off the subcutaneous tissues along a natural demarcation between viable and non-viable tissue with only a 40 cc estimated blood loss (EBL). Conclusions: AT(H) concentrate is tolerated in the pediatric population in the acute phase of injury. Lack of bleeding during eschar removal may be of benefit to burn excision and grafting.

Survival of severe ARDS with five-organ system failure following burns and inhalation injury in a 15-year-old patient

Objective: To show the effectiveness of an integrated therapeutical approach in a severe case of acute respiratory distress syndrome (ARDS) following burns, inhalation injury with therapy-refractory oxygenation under maximized ventilatory settings, and an overall complicated clinical course. Patient and methods: Case report of a patient with severe inhalation injury and burns in an intensive care unit setting, undergoing cardiopulmonary resuscitation (CPR), nitric oxide (NO)-inhalation, surfactant-, kinetic-, and urodilatin-therapy. Case report: A 15-year-old male presented with deep dermal and full thickness thermal injuries involving 25% of his total body surface area. Shortly after presentation, the patient developed therapy-refractory respiratory failure, cardiac arrest, and subsequently suffered five-organ system failure (lung, heart, gastrointestinal, liver, kidney), in addition to burn injury, and ischemia related cerebral lesions. The patient was successfully treated with cardiac resuscitation, extra corporeal membrane oxygenation (ECMO), NO, kinetic therapy, surfactant, urodilatin, and other standard intensive care regimens. Three months post-trauma the patient was discharged home, nearly fully recovered. Conclusions: In a patient with severe ARDS, oxygenation failure under maximized ventilatory settings, and subsequent five-organ system failure, an integrated therapeutical approach comprising ECMO, NO, kinetic therapy, surfactant, and urodilatin did cross-bridge respiratory and vital functions, enabling overall survival.

The deeply burned upper extremity: functional graft distribution concept with selective use of a synthetic dermal substitute (Integra) and split-thickness skin grafts

A 15-year-old boy sustained a severe inhalation injury and second/third degree burns following a flame burn involving the face, neck, upper thoracic regions, and upper extremities measuring 25% of his total body surface area. The right arm had a full-thickness burn, the left arm deep partial-thickness burns. Tangential excision and split-thickness skin grafting (STSG) were performed. Because of the full-thickness burns on the right arm, an epifascial excision was necessary on the left arm, sparing the venous tributaries. To reconstruct the epifascially excised extremity, a new concept was used. Split-thickness skin graftings were selectively distributed over the digits, and the remaining zones were covered with a synthetic dermal substitute (Integra). Unfortunately, the dressing changes and the definitive grafting of the synthetic dermal substitute had to be delayed until day 62 because of severe lung failure, acute respiratory distress syndrome (ARDS), the necessity for extracorporeal membrane oxygenation, multiple organ failure, and prolonged intensive care stay. Despite circulatory and ischemic complications, all grafts taken on both extremities after incorporation of the dermal substitute, both immediate and delayed, were complete. There was no infection or other complication. The functional range of motion of all involved joints and the skin surface quality and contour were remarkably good. It is emphasized that the considerations in this report should be considered as preliminary and that further investigations are required.

Continuous Albuterol Nebulization in Severe Inhalation Injury: An Effective Therapy for Children

Continuous Albuterol Nebulization in Severe Inhalation Injury: An Effective Therapy for Children

Acute Management of Exposure to Liquid Ammonia

Ammonia injury is an uncommon injury, but it is associated with high morbidity and mortality. This case report demonstrates the pathophysiology and treatment of both cutaneous burn wounds and inhalation injury caused by ammonia. Frequent bronchoscopy was used to attempt to avoid intubation and its associated morbidity. The patient remained extubated, but later he required skin grafts to close his wounds after healing of his pulmonary injury. A review of the management of inhalation injury is also discussed. Ammonia injury can cause a severe inhalation injury. Bronchoscopy can be a useful tool to avoid intubation.

Effects of an L-selectin antibody on the pulmonary and systemic manifestations of severe smoke inhalation injuries in sheep.

Sheep were treated with either lymphocyte adhesion molecule (LAM)1-3, an antibody against L-selectin, (40 mg 1 hour before smoke inhalation and 35 mg 24 hours after smoke inhalation; n = 6) or equivalent volumes of 0.9% saline solution (n = 6). After the smoke inhalation injuries, the PaO2/FIO2 ratio declined in both groups until 40 hours after the injuries, when a trend toward improvement was noted in the group that received LAM1-3. Lung lymph flow increased in both groups until 36 hours after the smoke inhalation injuries and then significantly decreased in the group that received LAM1-3. Forty-eight hours after the smoke inhalation injuries, there was a significant decrease in the ratio of wet-dry lung weight and in preservation of the reflection coefficient in the group that received LAM1-3 (P < .05). Histopathologic examination showed no differences between the groups in the pulmonary morphology associated with smoke inhalation. A reduction in splanchnic blood flow was noted in the control group (P < .05); this reduction was attenuated by treatment with LAM1-3. The delayed pulmonary effects and improved splanchnic blood flow suggested that LAM1-3 attenuated the development of a systemically induced secondary lung injury rather than of the primary lung injury associated with smoke inhalation.

Effects of an L-Selectin Antibody on the Pulmonary and Systemic Manifestations of Severe Smoke Inhalation Injuries in Sheep

Effects of an L-Selectin Antibody on the Pulmonary and Systemic Manifestations of Severe Smoke Inhalation Injuries in Sheep

Current Status Of Burn Resuscitation

Rapid assessment and management of airway and breathing problems are required in the patient with severe burns complicated by significant facial burns and inhalation injury. A policy that results in intubation of all patients at potential risk for airway compromise can be both foolish and dangerous. At the same time, it is recognized that intubation of patients who are likely to develop unstable airways is necessary if transport times to burn centers are long and if i.v. resuscitation is initiated during transport. The ideal burn resuscitation formula does not exist. Whichever formula is used, patients must be monitored closely and the fluid resuscitation individualized according to their responses. Patients with delay in resuscitation, associated trauma, inhalation injury, or alcohol abuse may require fluid resuscitations greater than those predicted. The goal is to maintain urine outputs in the range of 0.5 to 1 mL/kg/hr for adults and 1 to 1.5 mL/kg/hr in children. In patients with fluid requirements greater than 150% of that predicted by formula, the addition of colloid at 12 hours can reduce total fluid requirements and burn edema. Early placement of pulmonary artery catheters can be useful in patients with known myocardial dysfunction, age greater than 65 years, severe inhalation injury, or fluid requirements greater than 150% of that predicted by formula.

Inhalation injury treated with extracorporeal CO 2 elimination

A 38-year-old male was admitted to the intensive care unit with a full-thickness burn involving 30 per cent of his total body surface area (TBSA) and severe inhalation injury. Respiratory failure developed within 54 h and CO 2 could not be eliminated, even by very invasive mechanical ventilation. Because of the patient's age and the minor extent of the burned TBSA, we started extracorporeal CO 2 elimination (ECCO 2-R) and continued ECCO 2-R for 30 days, when the patient was weaned from ECC. The clinical course during ECCO 2-R was complicated by major bleeding from a thoracotomy tube, from the site of tangential excision and by four septic episodes. Lung biopsy was performed twice on day 29 (during ECCO 2-R) and day 58 (after ECCO 2-R) after admission and revealed bronchiolitis obliterans without tendency to recovery. The patient died of sepsis with multiorgan failure on day 81 after trauma.

高度の気管・気管支病変を来した重症気道熱傷のｌ例

We report a case of severe airway sequelae following inhalation injury. A 52 years old male was transferred to our hospital because of severe inhalation injury. Acute respiratory failure was treated by frequent tracheobronchial lavage using bronchofiberscope (BFS) under Pressure Support Ventilation with PEEP and superimposed high frequency jet ventilation. Severe tracheal stenosis and endobronchial multiple granuloma (polyposis) developed after one month. Life-threatening tracheal stenosis was treated by Nd-YAG Laser coagulation, and a silicone stent was inserted against recurrent stenosis up to the 693rd day. Endobronchial multiple granuloma subsided spontaneously following cicatrizational stenosis. After about one year from his admission, an ectatic change gradually developed in the peripheral bronchus and pulmonary fibrosis. The etiology of these airway sequelae were considered to be related to the destroyed basal membrane of the airways, and to the prolonged accompanying inflammation. The frequency of the sequelaelike cicatrizaional stenosis, inflammatory granuloma, peripheral bronchoectasia, pulmonary fibrosis will increase, as treatment in the acute phase improves. In cases of severe inhalation injury, it is important to investigate airway sequelae over a long follow-up period, and BFS is the most valuable means not only for treatment but also for investigation.

Burns with inhalation injury and petrol aspiration in adolescents seeking euphoria through hydrocarbon inhalation

We have recently managed four adolescent boys severely injured while aspirating petrol to achieve euphoria. This is a practice that occurs sporadically in this group in which alcohol and drugs are more difficult to procure by reason of their age and fiscal resources. The injuries sustained included extensive burns all with associated severe inhalation injury secondary to smoke and products of combustion, complicated by hydrocarbon pneumonitis.