Burn ICU Inhalational Injury Policy

Original Date: 09/2020
Purpose: To standardize the work up, classification, and treatment of burn inhalational injuries.

Admission Evaluation/Initial Management:

  1. Original Date: 09/2020
    Purpose: To standardize the work up, classification, and treatment of burn inhalational injuries.

    Admission Evaluation/Initial Management:

    1. History and physical to assess risk of inhalational injury
      1. Mechanism – exposure to smoke, blast injury, steam burns, exposure to caustic fumes
      2. Intensity and duration of exposure (e.g. patient trapped in enclosed space, found unconscious, etc…)
      3. Examination
        1. Carbonaceous sputum, stridor, hoarseness, drooling, and/or dysphagia are highly suggestive of inhalational injury.
        2. Facial burns, singed eyebrows or nasal hair, and/or soot deposits on face may also be present, though they alone do not necessarily connote the presence of an inhalational injury.
    2. Work up to assess risk of inhalational injury
      1. Pulse oximetry
      2. Arterial blood gas with lactate, methemoglobin, and carboxyhemoglobin (COHb) level
        1. Order “Arterial Blood Gas w/ COOX”
      3. Chest x ray
    3. Determine clinical concern for carbon monoxide (CO) poisoning:
      1. Remember that SpO2 levels can be falsely elevated in patients with significant CO exposure, so:
        1. While COHb lab is pending, leave patient on 100% FiO2.
        2. If not intubated, patient should be placed on humidified 100% FiO2 via a non-rebreather until COHb levels return.
      2. If COHb < 10%, wean FiO2 as tolerated
      3. If COHb > 10%, continue 100% FiO2 and repeat COHb every hour until the value is <10%.
    4. Determine clinical concern for cyanide poisoning for cyanide poisoning (enclosed fire, unexplained unconsciousness)
      1. Cyanide toxicity is difficult to identify in a timely fashion and should be treated empirically in patients who were in an enclosed structure or vehicle fire. The risk of treatment is low.
      2. Administer Hydroxocobalamin (Cyanokit 5g IV) if:
        1. Lactate levels > 10
        2. Persistent and unexplained acidosis
        3. Unexplained hemodynamic instability
        4. If given by prehospital personnel, do not give again unless directed by attending physician.
      3. The max dose of hydroxocobalamin is 10g (two doses max)
      4. Hydroxocobalamin can cause transient hypotension, will turn the urine dark red (not rhabdomyolysis), and may stain the skin red.
    5. Indications for intubation
      1. >GCS < 8
      2. COHb level > 20%
      3. Extensive face and neck burns
      4. Respiratory failure with hypoxia
      5. Signs and symptoms of airway obstruction by edema (e.g. hoarseness, stridor, labored breathing, difficulty swallowing)
      6. Other clinical concern for impending airway obstruction
    6. Fiberoptic bronchoscopy is the standard diagnostic test for identifying inhalational injury and should be performed within 2 hours of injury

    History and physical to assess risk of inhalational injury

    1. Mechanism – exposure to smoke, blast injury, steam burns, exposure to caustic fumes
    2. Intensity and duration of exposure (e.g. patient trapped in enclosed space, found unconscious, etc…)
    3. Examination
      1. Carbonaceous sputum, stridor, hoarseness, drooling, and/or dysphagia are highly suggestive of inhalational injury.
      2. Facial burns, singed eyebrows or nasal hair, and/or soot deposits on face may also be present, though they alone do not necessarily connote the presence of an inhalational injury.
  2. Work up to assess risk of inhalational injury
    1. Pulse oximetry
    2. Arterial blood gas with lactate, methemoglobin, and carboxyhemoglobin (COHb) level
      1. Order “Arterial Blood Gas w/ COOX”
    3. Chest x ray
  3. Determine clinical concern for carbon monoxide (CO) poisoning:
    1. Remember that SpO2 levels can be falsely elevated in patients with significant CO exposure, so:
      1. While COHb lab is pending, leave patient on 100% FiO2.
      2. If not intubated, patient should be placed on humidified 100% FiO2 via a non-rebreather until COHb levels return.
    2. If COHb < 10%, wean FiO2 as tolerated
    3. If COHb > 10%, continue 100% FiO2 and repeat COHb every hour until the value is <10%.
  4. Determine clinical concern for cyanide poisoning for cyanide poisoning (enclosed fire, unexplained unconsciousness)
    1. Cyanide toxicity is difficult to identify in a timely fashion and should be treated empirically in patients who were in an enclosed structure or vehicle fire. The risk of treatment is low.
    2. Administer Hydroxocobalamin (Cyanokit 5g IV) if:
      1. Lactate levels > 10
      2. Persistent and unexplained acidosis
      3. Unexplained hemodynamic instability
      4. If given by prehospital personnel, do not give again unless directed by attending physician.
    3. The max dose of hydroxocobalamin is 10g (two doses max)
    4. Hydroxocobalamin can cause transient hypotension, will turn the urine dark red (not rhabdomyolysis), and may stain the skin red.
  5. Indications for intubation
    1. >GCS < 8
    2. COHb level > 20%
    3. Extensive face and neck burns
    4. Respiratory failure with hypoxia
    5. Signs and symptoms of airway obstruction by edema (e.g. hoarseness, stridor, labored breathing, difficulty swallowing)
    6. Other clinical concern for impending airway obstruction
  6. Fiberoptic bronchoscopy is the standard diagnostic test for identifying inhalational injury and should be performed within 2 hours of injury
    Grade Class Description
    0 No injury No carbonaceous deposits, erythema, edema, bronchorrhea, or obstruction
    1 Mild injury Minor or patchy areas of erythema, carbonaceous deposits, bronchorrhea, or bronchial obstruction present
    2 Moderate injury Moderate erythema, carbonaceous deposits, bronchorrhea, or bronchial obstruction present
    3 Severe injury Severe inflammation with friability, copious carbonaceous deposits, bronchorrhea, or bronchial obstruction present
    4 Massive injury Mucosal sloughing, necrosis, or endoluminal obstruction

    *There will be patients for whom you have a clinical suspicion for inhalational injury but who do not meet the above criteria. Use discretion when deciding on whether to intubate that patient or consider nasopharyngeal endoscopy.*

  7. Inhalational injury treatments
    1. All grade injuries:
      1. Supplemental humidified oxygen
      2. Nebulized 0.083% albuterol inhalational solution 2.49mg q4 hours inhaled (order under Nebulizer Treatment Orders Adult MPP)
    2. For Grade 2 and higher injuries, also order:
      1. Nebulized heparin 10,000 units q4 hours inhaled
    3. Nebulized 3% sodium chloride 3 mL q4 hours inhaled (order under Nebulizer Treatment Orders Adult MPP)
  8. Ventilator management
    1. Settings:
      1. No mode of ventilation has been shown to be superior in the setting of inhalational injuries.
      2. Conventional ventilation (lung protective ventilation)
        1. − 6 cc/kg predicted body weight tidal volumes
        2. − Plateau pressure < 30 cm H2O
        3. − Driving pressure (Pplat–PEEP) goal <15 cm H2O
      3. Volumetric Diffusive Respirator (VDR)
        1. − FiO2 95% and titrate to maintain SpO2> 90%. This includes the Fi02 setting on the Vapotherm that is teed in (Vapotherm should be set to 42C and 12-20 lpm of flow).
        2. − Peak inspiratory Pressure (PIP) sufficient to cause apical chest “wiggle” (usually 22 –32 cmH20).
        3. − Pulse Frequency/Percussive (High Rate) 550 bpm
        4. − Sinusoidal/Convective (Low) Rate 10-12 bpm
        5. − Inspiratory to Expiratory (I:E) ratio – 1:1
        6. − Oscillatory PEEP 7-11 cm H20. Set this value such that it is sufficient to maintain slight chest wiggle.
        7. − Demand PEEP 3 cm H2O (arrow on dial is set at the 3 o’clock position).
        8. − Convective rise is off
        9. − Initial I:E ratio is 1:1. High rate (i:e) ratio is also 1:1 (“arrows up”).
        10. − Endotracheal tube cuff can be partially deflated to assist with CO2 removal
      4. Airway Pressure Release Ventilation (APRV)
        1. − Pressure high (Phigh) – 2 cm H2O above plateau pressure
        2. − Pressure low (Plow) – 3 cm H2O
        3. − Time high (Thigh)
          1.  Start at 5.2
          2.  Shorten as needed to improve ventilation
          3.  The ideal Thigh is as a patient can tolerate without inadequate ventilation
        4. − Time low (Tlow)
          1.  Set at 0.8 seconds and watch the volume flow curve
          2. Decrease Tlow until you cut off the expiratory flow rate at 50-75%* More information available in the Acute Respiratory Distress Syndrome Algorithm***ARDS Algorithm
    2. Repeat bronchoscopy:
      1. For inhalational injuries Grade 2 or higher, consider repeat daily bronchoscopy to assess progression of inhalational injury prior to extubation.
      2. Utilize the Olympus bronchoscopes for repeat bronchoscopies as they allow improved suction capabilities compared to the disposable bronchoscopes.
    3. Extubation:
      1. Extubate as indicated, including presence of an adequate cuff leak
    4. If the patient does not tolerate these ventilator strategies, consider:
      1. Consultation of the ECMO team