Medical Case File
Learn more about the medical cases the doctors of SGH have faced
Inhalation Injury
By Meg Marinis, Director of Research
Airway.
Breathing.
Circulation.
The ABCs of medicine. A.B.C. It's as simple as that.
This mnemonic exists as an aid to doctors and medical professionals to remember the most important things when assessing and treating patients. Without an open airway, a person will suffocate even if their heart is beating. Without oxygen, the heart will stop beating. Without the heart beating, life will cease to exist. Each one depends on the other. Each one needs to be assessed, in that order, whenever a doctor comes upon any patient—conscious or unconscious—before they proceed.
As we state in Episode 606, I Saw What I Saw, the ABCs come as a part of Med School 101. A part of Med School 101 that Dr. April Kempner did not follow this evening...
What exactly is an inhalation injury?
Unbeknownst to many people, smoke inhalation actually remains the number one cause of death from indoor fires. When victims breathe in smoky air, they actually ingest a combustive combination of hot gaseous products including carbon monoxide and cyanide. These products essentially equal poison to your lungs.
What are the main complications of smoke inhalation?
1.) Thermal damage – When these toxic and combustive gases reach your airway, they can cause burns to the mucosal surfaces, causing swelling of the throat. If it reaches a severe stage, respiratory failure may ensue because the airway will swell up so much it cuts off the breathing—thus, the "A" of the ABCs—(and, like the tragic case of Cathy Becker); and a medical team will need to follow with endotracheal intubation, unless the airway is too swollen already to pass a tube.
2.) Asphyxiation – When carbon monoxide and cyanide enter the airway, these combustive gases use up much-needed oxygen for the body's tissues and circulation—the "C." The victim needs to be treated with 100% oxygen until the imbalances have resolved. They can't breathe (thus, the "B").
3.) Pulmonary irritation (Chemical injury) – When the body inhales the chemicals from the smoke, they can cause extensive tissue damage to the lung. Symptoms such as, "A," bronchospasm (narrowing of the airway), difficulty or increased rate of breathing, "B," and an accelerated heart rate, "C."
How can you tell if someone has been affected?
Start with the ABCs of emergency protocol!
You want to check out the airway and maintain cervical immobilization if any injury to the neck or head might exist. Check the patient's breathing, the respiratory rate, and lung movement. Then, go ahead and continue with circulation by determining consciousness, pulse rate, strength of pulse, and blood pressure.
Like I said, the ABCs.
A neurological exam should also be conducted, and the victim's clothes, if affected by the fire, need to be removed to prevent further burn injury. (This is generally referred to as the "D" and "E"—the neuro exam as disability and the removal of clothes as exposure).
Doctors should carefully determine whether or not respiratory failure may occur. If the airway or breathing seems compromised at all, treat aggressively. The pace at which respiratory failure can cause a cascading effect of injuries is extremely quick (like we saw tonight with Cathy Becker). Signs that indicate potential respiratory problems include: difficulty swallowing, hoarseness in the voice, wheezing, rapid breath sounds, and complaints of pain in the throat.
Also, if the victim has suffered from facial burns, soot in the throat/mouth, or singed facial hair, the medical professional should also consider this as a possible symptom of any airway problem.
So, what exactly went wrong tonight?
In the episode, April missed an extremely important step—checking the throat (doing a physical examination of the airway). If she had checked the throat, she would have seen the soot that Cathy inhaled—knowing she immediately needed to intubate to prevent further swelling of her pharynx. Or, at the very least, they should keep a CLOSE eye on her, watching her very carefully to try and intubate before it's too late.
April's failure to intubate early basically led to Cathy's rapid descent. If she had intubated, Cathy's airway would not have become too swollen to intubate, the chemicals wouldn't have built up in her body, and her lungs would not have collapsed. They wouldn't have had to do the cricothyrotomy (the "crike"), and she wouldn't have soon descended into pulmonary edema and A.R.D.S. (acute respiratory distress syndrome). Her organs started to shut down, soon causing her to code. The doctors did everything they could, but Cathy then went into DIC—disseminated intravascular coagulation—when the body's blood is unable to clot.
Cathy was gone. It was too late.
For more information, please visit:
http://www.nlm.nih.gov/medlineplus/burns.html