Applicable to. Team Members Performing

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1 Protocol: Pediatric Burn Inhalation Injury Category Clinical Practice Protocol Number Approval Date November 1, 2016 Due for review November 1, 2018 Applicable to VUH Children s DOT VMG Off-site locations VMG VPH Other All faculty & staff Other: Faculty & staff providing direct patient care or contact Team Members Performing MD House Staff APRN/PA RN LPN Content Experts Richard J. Wendorf, M.D. Lead Author: Associate Professor of Pediatrics Division of Critical Care Department of Pediatrics Medical Director, Pediatric Intensive Care Unit Table of Contents I. Population:... 2 II. Definitions:... 2 III. Assessment:... 3 IV. Diagnosis:... 4 V. Intervention/Treatment:... 6 VII. References:...7 1

2 I. Population: This protocol is intended to provide recommendations of treatment plans for pediatric patients with inhalation injuries. All patients with confirmed or suspected inhalation injuries will be admitted to the PICU. II. Definitions: Inhalation injury consists of any respiratory injury resulting from inhalation of products of combustion. Injury can result either from chemical irritation of the lung tissue or from disruption of oxygen uptake at the cellular level due to carbon monoxide or cyanide Vanderbilt University. All rights reserved. Page 2 of 7

3 III. Assessment: All burn patients should be assessed for inhalation injury. It is important to know the circumstances of the burn injury enclosed vs non-enclosed. Patients trapped in enclosed spaces such as house fires and car fires with prolonged extrication are at greatest risk for inhalation injury. Patients should be examined for physical signs of smoke inhalation soot in mouth/nose/larynx, hoarseness, stridor, facial burns, singed nasal hairs or carbonaceous sputum. Not all patients present with the classic signs and symptoms of inhalation injury and presence or absence of these factors are not always a reliable indicator of presence or severity of inhalation injury Vanderbilt University. All rights reserved. Page 3 of 7

4 IV. Diagnosis Carbon Monoxide Poisoning- Carbon monoxide poisoning should be suspected in anyone who was burned in an enclosed space. The half-life of carboxyhemoglobinemia is around 60 minutes when breathing 100% oxygen 2 **Neither PaO2 nor bedside pulse oximetry is reliable to assess oxygenation** 3 CO-Hb, % Signs and symptoms of various concentrations of carboxyhemoglobin levels 0-10 None Tightness across forehead, slight headache, dilation of the cutaneous blood vessels Headache and throbbing in the temples Severe headache, weakness, dizziness, dimness of vision, nausea, vomiting, collapse Same as above, greater possibility of collapse; syncope, increased pulse and respiratory rates Syncope, increased RR and HR, coma, intermittent convulsions, Cheyne-Stokes respiration Coma, intermittent convulsions, depressed heart action and respiratory rate, possible death Weak pulse, slow respiration leading to death within hours Death in less than 1 hour >90 Death within minutes Cyanide Poisoning Cyanide poisoning is caused by the products of combustion of synthetic materials (such as couches, mattresses, etc.) and should be strongly suspected in patients who were trapped in enclosed spaces. Cyanide causes disruption to aerobic metabolism and will cause patients to develop a profound lactic acidosis even in the setting of adequate fluid resuscitation. Because this is a problem with oxygen uptake rather than delivery, pulse oximetry is unreliable because patients can be functionally hypoxic even with excellent oxygen saturations. Cyanide labs are performed externally and results will not be available for >24hrs. Due to the low risks associated with treatment, treatment of cyanide poisoning should be performed empirically if inhalation injury is suspected Vanderbilt University. All rights reserved. Page 4 of 7

5 Inhalation Injury The diagnosis of inhalation injury may be suspected based upon clinical findings in the setting of smoke exposure, but a definitive diagnosis relies upon direct examination of the airways. 1 Once the airway is secured, and the patient is hemodynamically stabilized, a suspected diagnosis of inhalation injury should be confirmed with visual inspection of the airways 4. Direct airway examination - Direct laryngoscopy can be used for a limited direct examination of the upper airways for obvious signs of smoke inhalation. However, fiberoptic bronchoscopy allows examination of the airways from the oropharynx to the lobar bronchi and is the standard for confirming a diagnosis of inhalation injury. 4,5,6 To accurately assess severity of injury, visual exam must occur within 24 hours. This can be coordinated with the burn surgeon. Injury severity scoring The Abbreviated Injury Score (AIS) correlates with mortality as well as gas exchange. AIS grading of inhalation injury by bronchoscopy is as follows. 7 Consideration should be given to sending BAL specimens to microbiology with 3 injuries. Grade Class Description 0 No injury Absence of carbonaceous deposits, erythema, edema, bronchorrhea or obstruction 1 Mild injury Minor or patchy areas of erythema, carbonaceous deposits in proximal or distal bronchi 2 Moderate injury Moderate degree of erythema, carbonaceous deposits, bronchorrhea, or bronchial obstruction 3 Severe injury Severe inflammation with friability, copious carbonaceous deposits, bronchorrhea or obstruction 4 Massive injury Evidence of mucosal sloughing, necrosis, endoluminal obliteration 2016 Vanderbilt University. All rights reserved. Page 5 of 7

6 V. Intervention/Treatment Recommended Labs 1 1. ABG RESP stat x1 +LACTATE, WHOLE BLOOD RESP stat x1 +METHEMOGLOBIN RESP stat x1 +CARBOXYHEMOGLOBIN RESP stat x1 +LACTATE, WHOLE BLOOD RESP stat x1 2. Burn admission labs Tests: 1. Baseline Chest X-ray 2. Spontaneous Awakening Trials per unit protocol 3. Spontaneous Breathing Trials per unit protocol A CYANOKIT SHOULD BE ADMINISTERED EMPIRICALLY BEFORE THE CYANIDE LEVEL IS KNOWN **Cyanokit will turn the urine a magenta/pink color and will also cause wound exudate to develop a pink hue. CYANOKIT Hydroxocobalamin IV Initial Dose: 70 mg/kg Additional Dose*: 35mg/kg Max Dose: 5g *may be given depending upon the severity of poisoning or the clinical response to treatment. Medication: 1. All patients should receive humidified oxygen 2. All intubated patients with suspected inhalation injury should receive the burn cocktail Q4hr Q4hr Inhalation Injury Treatment Protocol for intubated and non-intubated patients Nebulizers- burn cocktail 1ml of 2.25% racemic epinephrine + 3ml 20% N-acetylcysteine Heparin 5000 units + 3ml of NS *The protocol is continued for 7 days or until extubated EXTUBATION CRITERIA: Patients often appear stable and meet extubation criteria during the first 24 hours. Strong consideration should be given to the following when discussing extubation: delayed mucosal sloughing is often seen with inhalation injuries 9 and patients with 2 inhalation injuries are at increased risk for hypoxemia up to 72 hours post injury Vanderbilt University. All rights reserved. Page 6 of 7

7 VENTILATORY STRATEGY: If patient has either Grade 0 or Grade 1, conventional ventilator strategies are preferred If patient has Grade 2 inhalational injury, consider either conventional ventilator strategies or VDR If patient has Grades 3 or 4 inhalational injury, consideration should be given to using the VDR as the initial ventilator strategy. This is a decision for the BICU Attending. FLUID MANAGEMENT: The presence of an inhalational injury can significantly impact the fluid requirements as part of the ongoing resuscitation. Expect the requirements to be greater than those predicted by the skin burn alone. VI. References: 1. Marion, DW. Diaphragmatic pacing. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed on November 25, 2013.) 2. Weaver LK, Howe S, Hopkins R, Chan KJ. Carboxyhemoglobin half-life in carbon monoxide-poisoned patients treated with 100% oxygen at atmospheric pressure. Chest 2000;117: Einhorn IN. Physiological and toxicological aspects of smoke produced during the combustion of polymeric materials. Environ Health Perspect 1975; 11: Woodson CL. Diagnosis and treatment of inhalation injury. In: Total Burn Care, 4 ed, Herndon DN (Ed), Dries DJ, Endorf FW. Inhalation injury: epidemiology, pathology, treatment strategies. Scand J Trauma Resusc Emerg Med 2013; 21: emedicine.medscape.com/article/ overview (Accessed on November 23, 2015). (from up to date reference) 7. Albright JM, Davis CS, Bird MD, et al. The acute pulmonary inflammatory response to the graded severity of smoke inhalation injury. Crit Care Med 2012; 40: Ronald P. Mlcaka, Oscar E. Suman, David N. Herndonc 9. Harkins HN. Springfield, Ill: Thomas Publisher; The treatment of burns. 10. MacIntyre NR, Cook DJ, Ely Jr EW, et al. Evidence-based guidelines for weaning and discontinuing ventilatory support: a collective task force facilitated by the American College of Chest Physicians; the American Association for Respiratory Care; and the American College of Critical Care Medicine. Chest 2001;120(6 Suppl.):375S 95S Vanderbilt University. All rights reserved. Page 7 of 7

8 2016 Vanderbilt University. All rights reserved. Page 8 of 7