A 65-year-old male is admitted to the hospital after he was found down in his kitchen during a house fire. On admission to the hospital, he was somnolent, had singed nasal hairs, and carbonaceous material in his mouth. He was hypoxic to the 80s and hoarse and was intubated for airway protection. His carboxyhemoglobin in the ED was 10%. He had no cutaneous burns identified. He was admitted to the ICU. On the ventilator, his settings are:
with last ABG:
On bronchoscopy, he had moderate erythema and carbonaceous deposits.
What is the BEST management of this patient’s inhalation injury?
Correct Answer: B
The bronchoscopy findings and clinical history suggest this patient has a moderate (Grade 2) inhalation injury. Some centers will obtain a CT chest for additional information about the extent of inhalation injury, in which increased interstitial markings and ground glass opacities correlate with a more severe injury. Early intubation has long been one of the tenets of managing inhalation injury, because of the risk of progressive upper airway edema and airway compromise in these patients. For patients on the ventilator, lung protective ventilation is generally recommended, with tidal volume goal less than 7 mL/kg, maintaining plateau pressures less than 30 with the minimum FiO2 necessary to effectively oxygenate. Providers often follow PO2 /FiO2 ratios to follow the progression of inhalation injury with these different methods. When a sufficient PO2 /FiO2 ratio cannot be maintained with the above guidelines, patients may need increased sedation, paralysis, less conventional ventilator settings, or even in severe cases ECMO to effectively oxygenate and ventilate, minimizing barotrauma.
Although inhalation injury does place this patient at higher risk of developing pneumonia, there is no indication that this patient has an active infection currently, so (A), broad-spectrum antibiotics are not indicated. (C) It would be inappropriate to extubate the patient in this situation, given that he is still on an assist-control setting on the ventilator with an FiO2 70%, and therefore requires considerable weaning on the ventilator before he will be ready for extubation. As described above, tidal volumes between 6 and 8 mL/kg are advised in accordance with lung protective guidelines, and (D) there is no indication to increase the tidal volume to 10 mL/kg.
Reference:
A 19-year-old male is brought in by ambulance to the ED after a near-drowning episode in which he was caught in a rip tide. Rescuers extracted him from the water within 20 minutes. On the scene, he was coughing and mildly confused. On arrival to the ED he is found to be awake and alert, with initial oxygen saturation 85% on room air. Supplemental oxygen is administered via aerosol face mask at 10 L/min, and after 30 minutes, his oxygen saturation rises to 90%. He remains awake and is in no distress.
What is the BEST next step in management?
Correct Answer: D
In a near-drowning situation, symptomatic patients can be hypoxic on arrival to the ED. In this case, supplemental oxygen should be administered in order to maintain the patient’s oxygen saturation greater than 94%, or greater than a PaO2 of 60. When initial supplemental oxygen is not sufficient, as long as the patient can maintain their airway and does not have another contraindication to noninvasive positive pressure ventilation, CPAP, BiPAP, or high-flow nasal cannula can be attempted prior to deciding to intubate the patient.
(A) An oxygen saturation of 90% is not sufficient. It is recommended to target an oxygen saturation of >94%, and it would not be appropriate to deescalate supplemental oxygen at this time. Although in the past, performing (B) the Heimlich maneuver was recommended in the prehospital setting to evacuate water from a patient’s lungs, it is no longer recommended, as it delays the assisted ventilation (rescue breaths) that should be initiated as soon as possible. It has no role in the hospital setting. (C) Intubation should be considered in near-drowning patients with depressed neurologic status and concern for ability to maintain an airway, and in patients who are persistently hypoxic with SpO2 <90% or PaO2<60.
References:
A 34-year-old woman female fell off a dam into a lake while intoxicated. She was extracted approximately 10 minutes after the incident. She is unresponsive at the scene, and rescue breathing was initiated by onlookers. On EMS arrival, she has a pulse and is her respiratory rate is 10. Supplemental oxygen is administered and she is brought to the ED. On arrival, her GCS is 8, and her oxygen saturation is 85% on 15L non-rebreather. She is intubated.
Which of the following is TRUE regarding freshwater versus saltwater drowning?
Correct Answer: A
Near-drowning in saltwater versus freshwater was previously thought to cause different effects on the lung parenchyma, but it has now been demonstrated that (A) there is unlikely to be a significant difference between salt- and freshwater ingestion, and therefore the two groups should be managed similarly. It was previously thought that ingesting saltwater resulted in a hyperosmolar load to the lung parenchyma, not only increasing the amount of pulmonary edema but also contributing increased osmolarity to the plasma. It has since been demonstrated that the amount of water usually ingested during a near-drowning incident is not generally enough to confer this type of effect, whether that water is hyperosmolar or hypoosmolar (in the case of freshwater ingestion). Therefore, neither (B) desmopressin administration nor (C) furosemide administration is indicated in the acute setting. Although there are different organisms that tend to reside in salt- versus freshwater, (D) ingestion of one or the other is not particularly associated with increased risk of pneumonia.
A 45-year-old male ascends to 16 000 feet on an ice climbing expedition. He initially develops some headaches, and then becomes increasingly confused. Two days into the trip, he becomes unable to walk straight and trips over his feet. His climbing partners become increasingly concerned and administer supplemental oxygen and dexamethasone they have with them. They assist him with descent to a safe location where he is transported by helicopter to the local emergency department, where he is found to be interactive with improved mental status and only mild ataxia.
Which of the following is the MOST appropriate management for this patient?
Correct Answer: C
This patient is presenting with high-altitude cerebral edema (HACE), as defined by altered mental status in the setting of high altitude exposure. HACE is on the spectrum with acute mountain sickness, which can start with headaches and light-headedness, ataxia, and severe confusion are an indication that the patient has progressed to HACE. Initial management involves descending to a lower-altitude location, supplemental oxygen, and if available dexamethasone administration as well. If symptoms are severe and the ability to descend is limited, portable hyperbaric chambers can be helpful if they are available. This patient, while improving, would not be appropriate for (D) discharge with outpatient follow-up. Instead, because this patient is still ataxic and confused, (C) supplemental oxygen should be administered along with continuation of dexamethasone therapy. (B) Acetazolamide is generally used as prophylaxis to help with acclimatization to high altitude, as opposed to treatment for acute mountain sickness or HACE. Finally, there is no indication this patient has a CNS infection, so (A) lumbar puncture and administration of empiric antibiotics would not be indicated.
A 28-year-old painter is working on an aluminum ladder when the ladder he is working on comes in contact with high-voltage power lines (∼14 000 V). He has immediate pain to his bilateral hands, forearms, and feet but is able to lower himself to the ground. He presents to the ED, where he has a normal ECG, but continues to complain of arm and foot pain. He has superficial partial-thickness burns to his bilateral hands, but full sensation and range of motion. Volume resuscitation with 150 mL/h of LR (lactated Ringer’s) is initiated. Three hours later, the patient is complaining of bilateral forearm swelling, hand numbness, and limited ability to move his fingers.
Which of the following is the BEST next step in management of this patient?
This patient has sustained a high-voltage electrical injury, as defined by voltage greater than 1000 V. These patients are at high risk of extensive tissue damage, often which is not immediately visible. They will often present with relatively small cutaneous burns like this patient, but extension through the tissue can result in tissue breakdown beyond the site of injury. Volume resuscitation is indicated in these patients, and it is imperative to pay close attention to affected extremities given the risk of compartment syndrome. This patient has loss of sensation and motor capacity in the hands, indicating a compartment syndrome of the forearms, and likely the carpal tunnel, and therefore (C) should go to the OR for forearm fasciotomies and carpal tunnel release. In a patient with this degree of neurovascular compromise, the answer is compartment release, and there is never an indication for purely (A) elevation or (B) wrapping the bilateral arms. We have enough clinical suspicion for compartment syndrome that there is no role for further workup including (D) CTA.
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