Inhalation injuries

Alcohol and drug abuse in burn injuries

Two studies are described in this paper. In the first study 225 acutely, severely burned patients were retrospectively investigated as to admission blood alcohol level and history of chronic alcohol abuse. The influence of further risk factors, circumstances and therapeutic data was studied, in particular the influence of gender, full-thickness burns, smoke inhalation injury, smoking, length of total and ICU stay, and suicide attempt. The 70 patients with positive blood alcohol levels on admission had a significantly higher fatality rate (31.5 per cent) in comparison with the 18.1 per cent fatality rate of patients with a negative blood alcohol level. Both groups had nearly identical mean TBSA and mean age. Chronic alcohol abuse was noted in 59 patients. These patients were found to have a higher fatality rate (31.4 per cent, 22/70) compared with that of patients without a history of chronic alcohol abuse who had an overall fatality rate of 18.1 per cent (28/155). No significant difference was found between non-intoxicated and acutely intoxicated alcoholics (31.4 vs 29.3 per cent). Our conclusion is that intake of alcohol before burn injury represents an independent risk factor. The second study was a prospective study of 16 consecutively admitted burn patients, who were evaluated for both drug and alcohol intake. Five patients had positive drug levels and five had positive alcohol levels. Five patients had a history of chronic drug and/or alcohol abuse. This incidence of alcohol and drug abuse supports the findings of our retrospective study.

The admission chest radiograph after acute inhalation injury and burns

The admission chest radiographs of 29 patients admitted with acute inhalation injury and burns, who required ventilatory support, were analysed for signs of inhalation injury. Four were excluded because of a history of chronic bronchitis or cardiac failure. 13 had radiological signs of inhalation injury, which included oedema of a nodular, consolidatory and interstitial pattern, and linear opacities due to atelectasis. 12 chest radiographs were normal. Inhalation injury in burns cases often requires clinical, bronchoscopic and blood gas assessment. Although changes were noted on 13/25 chest radiographs, the admission chest radiograph is an insensitive indicator of airway and parenchymal lung damage following acute inhalation injury and burns. We draw attention to the fact that significant lung damage may be present even with a normal initial chest radiograph.

Smoke inhalation injury

Smoke inhalation injury in children still represents a significant cause of pulmonary disease and mortality. Carbon monoxide and other toxic products of combustion are major determinants of severity. Early hypoxemia is a contributor to over 50% of deaths. There are several clinical entities: upper airway obstruction, bronchospasm, consolidation, pulmonary edema, ARDS, and late pneumonia. Intensive care has improved outcome from burns, but pulmonary injury is still an important cause of mortality. New therapies such as high frequency ventilation may improve the outcome. Primary prevention is the most important way to reduce the poor outcome from significant exposure.

Carbon monoxide poisoning: an A&E perspective

Carbon monoxide (CO) is a colourless, odourless, tasteless and non-irritating gas and may therefore be inhaled in large quantities by the victim without his realizing it. The toxic effect of CO is not exclusively the result of the binding of haemoglobin; the primary mechanism appears to be inhibition of cellular respiration. Carboxyhaemoglobin (COHb) is excreted fairly rapidly from the body, therefore blood levels do not necessarily reflect the severity of CO poisoning. Airway support and adequate ventilation are the primary objectives of the nursing and medical team. Oxygen is the only antidote to CO. Continuous monitoring of the patient's neurological state is necessary; conscious level is the most important guide to the patient's progress. Nurses must be aware of the clinical indications and contraindications for HBO therapy to ensure that their patients receive optimal treatment.

Carbon monoxide poisoning. An occult epidemic

Carbon monoxide poisoning is a significant health threat in the United States. Smoke inhalation from fires is the most common source. History of carbon monoxide exposure and elevated carboxyhemoglobin levels should alert physicians to the diagnosis of acute poisoning. When there is no history of exposure, carbon monoxide poisoning must be considered when two or more patients are similarly or simultaneously sick. The diagnosis must be excluded by a directed history and physical examination. If suspicion remains, carboxyhemoglobin levels should be determined and oxygen therapy should be started empirically while laboratory results are pending. Prompt administration of hyperbaric oxygen may reduce the risk of death. If carbon monoxide poisoning is confirmed, the source must be identified and recommendations for correction or avoidance should be made.