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Case: 57 year old female was transferred to your ICU from an OSH after a house fire for carbon monoxide poisoning, possible cyanide toxicity, and inhalational injury. Â She was found in her house unresponsive at the time of the fire. Â She was intubated at the OSH for airway protection. Â Her carbon monoxide level was 35%. Â She was given cyanide treatment and transferred for hyperbaric oxygen treatment.
She arrives in your ICU hypoxic after her hyperbaric treatment. Â You are able to suction minimal thick, concrete, black, carbonaceous secretions. Â What are you treatment options?
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Inhalational Injury Facts
- Inhalational injury occurs in ~20% of all burn patients
- Mortality is 30%.
- Caused by temperature, particulates that can travel down to the alveolar level, oxins such as carbon monoxide and cyanide, respiratory irritants such as nitrogens, phosgenes, ammonia, and chlorides
- Airway edema peaks at 24-48 hoursÂ
The role of bronchoscopy in inhalational injury
- Considered the gold standard in diagnosis of inhalational injury.
- However, bronchoscopy may contribute to further airway trauma in an already irritable and friable airway.
- Patients with severe hypoxia may not tolerate bronchoscopy.
 Emerging use of Nebulized heparin, NAC, and albuterol
- Dosing: Nebulized heparin can be used at 10,000IU every 4 hours, followed by nebulized NAC & albuterol 2 hours later for a total of 7 days.
- The nebulized heparin helps to prevent formation of airways casts.
- Together with the NAC, they have a mucolytic effect, and believed to help scavenge free radicals.
- May however cause bronchospasm, so albuterol is added to the regimen.
- Alternating nebulized heparin and NAC have been shown to:
- Improve P/F ratio
- Decrease ventilator days
- Reduce the development of acute lung injury
Back to the Case: In our patient, this combination relieved her hypoxia and allowed significantly better secretion clearance. Â Unfortunately, she still ultimately required a tracheostomy.
References
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