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Pediatric emergency medicine trisk 482

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Clinical Recognition
A history of exposure in a closed space should heighten concern for smoke
inhalation. Need for CPR at the site implies significant carbon monoxide
poisoning and/or hypoxia secondary to decreased ambient oxygen concentration
or severe respiratory disease. The physician should also consider the types of
material involved to determine the risk of poisoning from carbon monoxide or
other toxins. Important elements from the patient’s history include the mechanism
of inhalation injury, duration of exposure, location, and pre-existing
comorbidities.
Physical examination that reveals facial burns, singed nasal hairs, pharyngeal
soot, or carbonaceous sputum justifies a presumption of smoke inhalation. Any
sign of neurologic dysfunction, including irritability or depression, should be
presumed related to tissue hypoxia until proven otherwise. Signs of respiratory
dysfunction, including tachypnea, cough, hoarseness, stridor, decreased breath
sounds, wheezing, rhonchi, or rales may be detected on presentation or may be
delayed for 12 to 24 hours, depending on the severity of the insult.
Auscultatory findings often precede chest radiograph abnormalities by 12 to 24
hours. Radiographic changes may include diffuse interstitial infiltration or local
areas of atelectasis and edema ( Fig. 90.3 ). Acute respiratory failure may occur at
any point. ABG analysis provides the ultimate assessment of effective respiratory
function. Fiberoptic bronchoscopy can document the extent and severity of injury
by assessing for the presence of hyperemia, edema and soot, and can help remove
debris. In general, it is respiratory function, not the appearance of surface lesions,
that guides supportive care; therefore, most patients can be treated effectively
without bronchoscopy.


FIGURE 90.3 Smoke inhalation in a 9-year-old girl. A: There is bilateral central alveolar
process consistent with acute smoke inhalation. B: A day later, the patient has been extubated



and there is marked improvement in the appearance of pulmonary edema. (Courtesy of Soroosh
Mahboubi, MD, The Children’s Hospital of Philadelphia.)

Triage Considerations
Initial assessment and resuscitation at the scene should proceed according to the
principles outlined in Chapter 7 A General Approach to the Ill or Injured Child .
Because of the likelihood of carbon monoxide exposure and the difficulty of
assessing hypoxemia clinically, all victims should receive the maximum
concentration of inspired oxygen possible in transport and in the ED until further
evaluation is complete ( Table 90.1 ).

Clinical Assessment
In the ED, assessment of airway and respiratory functions must proceed
simultaneously with cardiovascular stabilization. Supplemental oxygen at the
maximum concentration should be provided, and if there is concern for cyanide
toxicity (from burning plastic, vinyl, wool, or silk) then hydroxocobalamin IV
(Cyanokit) should be administered at a dose of 70 mg/kg (maximum 5 g).
Thermal injury to the nose, mouth, or face, or compromise of the upper airway
(stridor, hoarseness, barking cough, retractions, delayed inspiration, or difficulty
handling secretions) indicates the need for direct laryngoscopy. The presence of
significant pharyngeal, supraglottic, or glottic edema is an indication for
immediate elective endotracheal intubation because worsening edema may lead to
respiratory arrest and a difficult emergency intubation through a distorted airway.
Elective tracheostomy may be considered if placing or securing the endotracheal
tube will further traumatize an edematous airway or severe facial burns.


TABLE 90.1
MANAGEMENT OF SMOKE INHALATION




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