Diagnosis and management of inhalation injury
Approximately 10–20 % of patients admitted to burn centers in the U. S. are diagnosed with inhalation injury, and the incidence of inhalation injury is directly related to burn size [1]. Inhalation injury, along with age and total body surface area (TBSA)
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University of California Davis Regional Medical Center; Shriners Hospital for Children Northern California, USA Stritch School of Medicine;The Robert J. Freeark Professor Department of Surgery; Burn and Shock Trauma Institute; Burn Center; Loyola University Medical Center, USA
Introduction Approximately 10 – 20 % of patients admitted to burn centers in the U. S. are diagnosed with inhalation injury, and the incidence of inhalation injury is directly related to burn size [1]. Inhalation injury, along with age and total body surface area (TBSA) burn, is also one of the factors contributing to the morbidity and mortality of patients with burn injury; inhalation injury has been reported to increase mortality two-fold [2 – 5]. The accurate and timely diagnosis of inhalation injury is key to predicting and improving outcomes for the patient with burn injury. One of the major challenges in the diagnosis of inhalation injury is that exposure to smoke and heat result in nonhomogeneous injuries that vary by location and type of insult. Hence, inhalation injury is a term used to define multiple different types of airway injury, each of which has unique diagnostic and treatment implications. The purpose of this article is to describe the pathophysiology, diagnosis, and treatment of the different forms of inhalation injury. In general, there are three different types of airway injury that occur after exposure to fire and smoke: 1. effects of inhaled gases, 2. upper airway injury, and 3. lower airway injury [6]. Each of the different types of smoke inhalation injury has a different cause, pathophysiology, treatment, and prognosis. As such, it is important to distinguish
among the three types of injury during the initial evaluation of the patient with suspected inhalation injury.
Effects of inhaled gases Inhalation of toxic byproducts of combustion account for 80 % of fire-related deaths [7]. Several changes in the composition of gases in the environment occur as the result of combustion of flammable objects, and the person exposed to these gases is subject to their effects. When flames engulf a room, they consume oxygen. This decreases the fraction of inspired oxygen in the room to below 10 %, which results in asphyxia and tissue hypoxia. Hence, the leading cause of death at the scene of a fire is due to hypoxia, not burns.
Carbon monoxide CO is one of the leading causes of poisoning deaths in the U. S., accounting for an estimated 15,000 emergency room visits and 500 unintentional deaths yearly [8]. CO has an affinity with hemoglobin 200 – 250 times that of oxygen, which decreases both the oxygen-carrying capacity and the delivery of oxygen to tissue [9]. As such, CO shifts the oxyhemoglobin disassociation curve to the left. The morbidity and mortality associated with CO toxici-
163 Marc G. Jeschke et al. (eds.), Handbook of Burns © Springer-Verlag/Wien 2012
T. L. Palmieri, R. L. Gamelli
ty are caused by interference of oxygen transport at the cellular level and the impairment of electron transport with in the cells, re
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