Treating Lung Injuries in Burn Cases

Sometimes, particularly with flame and fire burns to the body, the respiratory tract, from the mouth to the lungs, can become injured.  This can be associated with second degree burns or third degree burns of the face.  It can also be associated with no burns and only inhalation of hot fumes from a fire.  The degree of injury to the lungs depends on the following criteria:
  • The intensity of the exposure
  • The temperatures reached
  • The chemical composition of the fumes inhaled
  • Pre-existing conditions of the burned individual
The actual heat-related injury is usually confined to the mouth and upper throat with smoke inhalation the only issue below the vocal cords.  There can also be total body effects if the fumes contain a noxious substance or chemical that enters the bloodstream by means of the lungs.
When a person is burned, about 15-20 percent of the time, a respiratory injury is also sustained, which can add to the morbidity and mortality of the burned person.  Burn victims who sustain these types of injuries need special care beyond the treatment of their burns.
 
There are several complications that stem from inhalation injuries in burn victims.  These include:
  • A greater risk of death
  • Poor air exchange into and out of the bloodstream
  • Adult respiratory distress syndrome (RDS)
  • Pneumonia
  • Increased fluid requirements
  • Pulmonary fibrosis
  • Permanent lung damage
The treatment of lung injuries in burn patients is difficult.  In fact, it has been found to be harder to treat the lung injuries than it is to treat the cutaneous burn itself.  It is important, even when the patient seems fine, to recognize early on that an inhalation injury has occurred based on the factors surrounding the injury.  The longer the exposure time to the fire or flames, the greater is the chance that an inhalation injury occurred.
 
Suspecting an Inhalation Injury in Burn Victims
 
An inhalation injury is possible or even likely under the following circumstances:
  • Singed eyebrows or nose hairs
  • Prolonged exposure to the fire due to intoxication, being elderly or being trapped in a fire
  • Scald injuries in the mouth
  • Black sputum
  • Hoarseness or difficulty eating      

One way of looking to see if there should be rapid intervention is to do a bronchoscopic evaluation of the trachea and upper bronchi.  This involves using a camera at the end of a long tube and inserting it into the airway.  If there is soot or redness and swelling of the tissues in the mouth, trachea or bronchi, it means that things may get worse and intubation may be necessary before that happens.
 
Inhalation injury is worse if there are chemicals in the inhaled gases.  The chemicals can be caustic to the lungs or can poison the body, depending on what chemicals are inhaled.  When an inhalation injury happens, the mucosa of the membranes can slough off, causing fluid, also called exudate, to stream out of the tissue into the air passages.  This eventually dries to become thick fibrin casts that adhere to the mucosa, interfering with air flow. 
 
When to Intubate Early
 
As mentioned, there may be a need to place the patient on a ventilator earlier rather than later. These reasons include:
  • Much burning of the face and neck
  • Signs of airway blockage
  • Respiratory failure
  • Carbon monoxide or cyanide toxicity
  • Burns greater than 40 percent body surface area
  • The need to protect the airway from aspiration of stomach contents
  • Blood pressure instability
  • Intubation and management of the airway is the best and first measure to be taken in the event of inhalation injury.  It can, however, be done prematurely or unnecessarily.  The risks of doing this are the following:
  • You have an inability to communicate with the burn victim.
  • Too much sedation may be necessary
  • Injury to the airway
Carbon Monoxide and Cyanide Poisoning in Burn Injuries

Carbon monoxide poisoning can occur from smoke inhalation in a burn victim.  Carbon monoxide can bind to hemoglobin and will stay on, preventing oxygen from binding to hemoglobin.  The amount of carbon monoxide on the hemoglobin can be measured to gauge treatment.  The best way to manage high levels of carbon monoxide or CO is to provide 100 percent oxygen or even to use hyperbaric oxygen chambers where they are available.

Cyanide poisoning can occur especially in situations where plastic is burned. The oxygen saturation will look normal but the patient is still in respiratory distress. Doctors can also pick up on metabolic acidosis as a sign of cyanide toxicity.  Treatment is best done as early as possible using oxygen and inhalation of amyl nitrate and/or dimethylaminophenol. Other agents can be used to bind cyanide directly from the bloodstream.

Other Considerations

While it is tempting to withhold fluids in inhalation injury so as to avoid excess fluid on the lungs, this is actually the wrong choice.  Burn victims with inhalation injury get worse if they are not given enough fluid.  It is better to sit the patient up at about a 45 degree angle to keep fluid pooling in the deeper parts of the lungs instead of all over the lungs, to provide adequate fluid and to give the patient 100 percent humidified oxygen as part of inhalation injuries.

Ventilation is often necessary with burn victims who have lung injuries.  Many with deeper injuries require PEEP or positive end-expiratory pressure ventilation, which keeps the tiny air-exchanging alveoli in the lungs from collapsing with each breath.

Some patients with severe lung injury need ECMO, which stands for extracorporeal membrane oxygenation.  Blood is oxygenated outside of the body through a semi-permeable membrane so that the lungs have a chance to rest and heal after a burn injury.

A patient can have the endotracheal tube removed once they are alert and show little evidence of having fluid on the lungs.  Weaning off the ventilator should be a gradual process.  If the patient needs prolonged ventilation, a tracheostomy tube should be considered. 

A serious burn is a catastrophe. Anyone who has a serious burn thru the negligence of another should contact an experienced catastrophic injury lawyer.
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