Burn Case - General Discussion of Respiratory Care

From a respiratory care standpoint, some of the major problems associated with burned patients include:

• carbon monoxide poisoning
• smoke inhalation/upper airway obstruction
• restrictive defects

Carbon monoxide poisoning

In a closed space, the individual will develop cerebral hypoxia in 3 - 4 minutes.

Concentrations over 70% cause severe hypoxia and permanent brain damage.

Treatment

• For carboxyhemoglobin levels < 25% - 100% oxygen
100% oxygen will decrease blood CO levels by 50% in about 50 minutes.
• For carboxyhemoglobin levels > 25% - Hyperbaric Oxygen

Fortunately this patient didn't receive high levels of CO exposure, but 100% oxygen was administered initially as a precaution.

Smoke inhalation/upper airway obstruction

Patients with head and neck burns are likely to develop upper airway obstruction from the respiratory injuries sustained from smoke inhalation. Pulmonary abnormalities are not apparent in over 75% of all burn patients upon admission. It takes 8-24 hours before signs of airway obstruction appear.

Treatment

Treatment typically consists of humidified oxygen, bronchodilator therapy, suctioning, CPT, bronchoscopy, intubation, and mechanical ventilation.

This patient's degree of upper airway obstruction was underestimated. It soon became apparent after extubation on the 29th, that there was more airway obstruction than initially suspected. Over the course of 24 hours, the patient's ability to effectively ventilate deteriorated.

A similiar incident occurred 10 days later when the patient was again re-intubated following an extubation that only lasted 4 hours. The patient developed stridor, lots of secretions, and became lethargic.

Restrictive Defects

Burned skin (3rd degree) becomes tough, dry, and leathery. It loses its elasticity. A restrictive defect may occur anywhere on the body, but from a respiratory standpoint, chest and abdomen burns are the most life-threatening. The burned skin will restrict chest or abdomen movement, decrease chest wall compliance, and make it very difficult to ventilate the patient.

Treatment

escharotomy: incisions are made along the skin that allows the tissue to expand and decreases pressure on the underlying structures. Escharotomies are performed anywhere on the body where the burn eschar or swelling interfers with circulation.

Our patient received escharotomies on all ten fingers. The fingers were cold and poorly perfused before the escharotomy, but circulation returned after the incisions were made.