Case of the Month
August 2006

19-year-old female — exposure to structure fire

Dispatch

"Aid 9, with units responding, residential structure fire with victim trapped."

En route your crew discusses the following considerations:

• Heat exposure/burn trauma
• Smoke inhalation
• Appropriate transport destination for burn trauma/hyperbaric medicine

While responding the Incident Commander assigns you to Medical Group under MSO 5. Just after switching to the Rescue and Medical talk group you are told that you will have a 19-year-old female located at MSO 5’s apparatus, the patient was removed from a second story window by the first arriving engine company.

Scene Size-up
You arrive at MSO 5’s apparatus to find the female victim being attended to by the MSO and a firefighter. You are told that the patient was in the second story window of the house when the first arriving company went on location.  A large amount of smoke was issuing from the window. When they took her down the ladder she was very weak and near collapse. The victim was carried to where she is now and has shown some mild improvement.

Initial Assessment
The patient appears lethargic and has a large amount of mucus coming from her nose. She is wearing a night gown. You take the patient to the back of your aid car for further evaluation. She has singed hair around her face and she appears somewhat flushed. There is soot around her nose and mouth.  She is confused and lethargic. She coughs frequently, with a light barking cough.

Your partner completes an initial assessment:

SICK or NOT SICK?
Based on what you see so far, would you consider this patient SICK or NOT SICK? What steps will you take based on the direction you choose?

• Types of treatment needed for this patient?
• Further steps for evaluation?
• Need for ALS care?
• Transport destination?

Initial Treatment
You decide that the patient is SICK based on her decreased level of consciousness, rapid heart rate and exposure history.

You apply a partial non-rebreather mask at 10 liters per minute, and perform a neck-head to toe exam.  You find that she has soot around and inside her nose and mouth.  The interior of her mouth and back of her throat appear abnormally red.  When she speaks, her voice is hoarse.

Physical Exam
Your partner gives you the following information:

SAMPLE

Second Set of Vital Signs

The patient was immediately classified as SICK and high flow oxygen initiated. She showed signs of close contact with heat and smoke so she is quickly prepared for transport. Despite the high readings with the pulse oximeter it is suspected that she is oxygen deficient due to carbon monoxide poisoning. 

Because of this, the burn center is immediately contacted to discuss the need for hyperbaric treatment. Although your crew suspects her lethargy and confusion is secondary to smoke inhalation, an extensive trauma exam is performed during transport to evaluate for head trauma or other contributing factors concerning her decreased level of consciousness.

Your crew also continually looks into the patient’s mouth and closely monitors the patient’s face and neck for swelling and airway compromise. En route to the burn center your aid unit meets a medic unit. The medic crew transfer to the BLS unit to facilitate rapid transport. The ALS crew starts an IV line en route and performs endotracheal intubation. During intubation it is discovered that the patient’s vocal cords are beginning to swell.

At the hospital an arterial blood gas test is drawn and the patient is found to have a carboxyhemoglobin level of 32 (in some systems a measure of 25 or greater with neurological deficits is suggestive of treatment with hyperbaric oxygen).

The patient is stabilized and sent to a local hyperbaric chamber for further treatment. Over the course of several days the patient’s condition continues to improve and she is released from the hospital. She does suffer long term damage due to the exposure to her vocal cords.

Presentation of Smoke Inhalation
The number one cause of death related to fires is smoke inhalation. Up to 80% of fire deaths are due to smoke inhalation, not burns. Smoke inhalation damages the body in three ways:

1. Simple asphyxiants
2. Irritant compounds
3. Chemical asphyxiants

Simple Asphyxiants
Simple asphyxiants displace the oxygen in an environment and replace it with the products of combustion. As the oxygen level drops the patient’s level of consciousness drops also. Soon the patient is no longer able to think well and coordination is impacted, making escape difficult. If the oxygen level drops too far, death occurs.

Irritant Compounds
Irritant compounds are a major component of smoke. These irritants are both fire gasses and floating particles. For this reason the irritants have both chemical and physical effects on the body. To make matters worse, these gasses and particles may be heated, creating thermal injuries to the airways. Some of the major irritant gasses commonly found in smoke include sulfur dioxide, hydrogen chloride, chlorine, and ammonia.

Chemical Asphyxiants
Chemical asphyxiants are some of the most lethal products of combustion. Carbon monoxide, hydrogen cyanide, and hydrogen sulfide all interfere with the body’s ability to use oxygen. Although all three of these gasses are bad, carbon monoxide is particularly wicked. When red blood cells flow through the capillary beds of the alveoli your hope is that they will pick up fresh oxygen. However if carbon monoxide is present the red cells are up to 250 times more likely to capture the CO than the oxygen. For this reason, you could be in an oxygen rich atmosphere and if a moderate amount of carbon monoxide were present you could still suffocate chemically.

Treatment of Smoke Inhalation
The treatment for smoke inhalation is fairly simple and includes the following steps:

1. Remove the patient from the hazardous atmosphere.
2. Establish the ABCs.
3. Initiate high flow oxygen.
4. Treat for shock.
5. Evaluate for burn trauma.
6. Rapid transport to a burn center.
7. Consider the need for hyperbaric oxygen.

The first four steps are very straight forward; however the next three deserve some conversation:

Evaluate for Burn Trauma
Evaluate for burn trauma any patient who is taken from a fire environment or areas close to one. Of immediate concern are burns to the face, neck, or airway. Since the effects of burns can continue to worsen even after the heat is removed, the areas listed must be closely monitors as swelling can lead to airway compromise. Any patient with singed facial hair, soot in or near the mouth and nose, redness inside of the mouth, or hoarse voice must be considered at extreme risk of present or future airway swelling until proven otherwise at a hospital.

Rapid Transport to a Burn Center
Rapid transport to a burn center goes hand in hand with the potential for airway compromise. If the need for advanced airway techniques, such as a surgical airway, are required, it best if the patient is already at the hospital when the need arises.

Consider the Need for Hyperbaric Oxygen
Consider the need for hyperbaric oxygen if carbon monoxide poisoning is suspected. This is a procedure that is ordered by the emergency department physician, however as a transporting entity you should be aware of where this resource is in case you are requested to take the patient there for an emergency dive. Hyperbaric oxygen causes the hemoglobin to shed carbon monoxide more rapidly than its normal 4 to 6 hour half life to around 30 minutes.

Carbon Monoxide
Carbon monoxide has been sited as the number one cause of poisoning death in the United States. It occurs frequently in structural fires; however it often occurs as the result of faulty heating equipment, faulty cooking equipment, and poorly vented controlled fires. Early signs of CO poisoning include:

1. Nausea/vomiting
2. Headache
3. Decreased level of consciousness
4. Weakness
5. Dizziness

Unfortunately the suspicion of CO poisoning is largely reliant on the events surrounding the patient’s signs and symptoms. Many pulse oximetry units used by first responders do not differentiate between oxygen saturated hemoglobin and carbon monoxide saturated hemoglobin, therefore any readings from these devices should be met with suspicion.

If suspected, treat the patient for CO poisoning until an arterial blood gas can be evaluated. If you have the proper gas meter, and you can proceed safely ( i.e. utilizing self contained breathing apparatus), attempt to get a reading of the atmosphere to which the patient was exposed.

What ever you do, operate safely!