Guideline - UNM Health Sciences Center

Document Sample
Guideline - UNM Health Sciences Center Powered By Docstoc
					Applies To: UNMH Component(s): Responsible Department: Trauma Surgical Burn ICU

Burn Patient with Inhalation Injury
Patient Age Group: ( ) N/A ( ) All Ages ( ) Newborns

(x ) Pediatric (x) Adult

DESCRIPTION/OVERVIEW This collaborative guideline describes care of the burn patient with inhalation injury in the adult critical care unit. Abnormalities of ventilation and oxygenation are a common finding in the immediate post-burn period. Pulmonary insufficiency caused by the inhalation of smoke and heat is the major cause of death in the burn patient. The critical variables of inhalation injury are the physical properties and amount of smoke and/or toxins inhaled, duration of exposure and the patient’s physical condition prior to the injury. “Patient’s who inhale smoke, dust, fumes, steam, aerosols, or toxic gases either directly or during a fire are at risk for one or more of these four types of injury: asphyxiation, direct topical injury, systemic injury, and injury from the body’s own defense mechanism-the stress and inflammatory responses”. 1. Asphyxiation occurs when there is interference with or obstruction of oxygen transport.  Carbon monoxide (CO) (a gas produced during combustion) is the leading cause of death from asphyxiation. Signs and symptoms of carbon monoxide poisoning present when carboxyhemoglobin levels exceed 15%.  Cyanide is another gas produced during fires from the burning of products made of plastic, polyurethane, silk, nylon, rubber, or paper. Heat produces an immediate injury to the airway mucosa resulting in erythema and edema. “The brain and heart are the organs most affected by cyanide”.

2. Topical Injury is the result of direct contact with heat or chemical irritants. Symptoms may be immediate or delayed. 3. Systemic injury occurs when inhaled toxins cross the alveolar-capillary membranes and damage other organs. REFERENCES   L- Weibelhaus, Pam, Hansen, Sean, Hill, Heidi. Helping patients survive inhalation injuries. RN. 2001; 64 (10): 28-32 L- McQuillan Karen A., Von Reuden, Kathrn Truter, Hartstock, Robbi Lynn, Flynn, Mary Beth, Whalen, Eileen: Trauma Nursing from Resuscitation through Rehabilitation, 3rd edition, 2002, W.B Saunders Company.

_________________________________________________________________________________________________________________ Title: Owner: Effective Date: Doc. #

Page 1 of 2

 

NS-Johnson, Mario, Bulecheck, Gloria, Dochterman, Joanne M., Maas, Meridean, Moorhead, Sue: Nursing Diagnoses, Outcomes, & Interventions, NANDA, NOC, and NIC Linkage, St. Louis, MO. 2001, Mosby, Inc. L-Urden, LindaD. Stacy, MStacy, Lough, MaryE, Thelan’s Critical Care Nursing: Diagnosis and Management, 4th edition, 2002, Mosby, Inc.

AREAS OF RESPONSIBILITY TSICU, BICU, all physicians and physician assistants assigned to the care of the inhalation patient. GUIDELINE PROCEDURES EQUIPMENT 1. 2. 3. 4. 5. 6. Humidified oxygen supply Face mask if indicated Suction equipment Emergency intubation and/or tracheotomy equipment Ventilator, if indicated Bronchoscope

1. Assessment A. Admission Obtain a history from patient and/or police and pre-hospital care givers.  Was the patient in an enclosed space with the fire?  Was there an explosion?  Details about the color and odor of the smoke can help determine the causative agent(s) involved  Does the patient have a history of airway problems or disease?  Assess all items on Adult or Pediatric ICU Critical Care Flowsheet with initial focus on airway, breathing, and circulation.  Vital signs Q1 hour or more frequently as necessary until stable.  Look for soot around mouth or nose, signed or absence of facial or nasal hairs, lacrimation, and presence of carbonaceous sputum.  Observe for facial and neck edema  Crackles on auscultation  Pulse oximetry (inaccurate in the presence of carboxyhemoglobin)  Baseline arterial blood gas  Voice quality and changes  Tachypnea, dyspnea, wheezing, stridor  Substernal pain or chest tightness  Use of accessory muscles  Facial swelling or difficulty in swallowing  Disorientation progressing to obtundation and coma B. Ongoing
_________________________________________________________________________________________________________________ Title: Owner: Effective Date: Doc. #

Page 2 of 2

Phase One (1st 36 hours)-Patients are at greatest risk of dying from asphyxia from either CO toxicity or airway obstruction.  Arterial blood gases as ordered  Continuous pulse oximetry  Breath sounds Q 1-2 hours or as indicated  Vital signs at least Q 2 hours or as needed  Auscultate breath sounds Q 1-2 hours as needed  Carboxyhemoglobin levels as ordered Phase Two (48-96 hours)-Upper airway and facial edema begin to resolve and pulmonary edema begins to emerge. This is caused by the massive amounts of fluid resuscitation given and by inflammatory mediators.  Assess breath sounds frequently  Note any changes in color, character or amount of secretionsdebris that sloughs off, thickens secretions  Monitor the patient for signs of infection Damaged mucosa is likely to overproduce secretions and the Oropharynx may become colonized. Phase Three (3-10 days post-insult)-Over 50% of inhalation-injured patients develop and die from pneumonia. Patients may also develop acute respiratory distress syndrome.  Frequently assess breath sounds  Watch for signs of hypoxemia (Pa02 < 60 mmHg) 2. Interventions Phase 1    

 

Maintain airway, breathing, and circulation as set forth in Basic Life support, Advanced Cardiac Life Support and Pediatric Advanced Life support Oxygen Therapy Mandatory for all patients with inhalation injury Patient should be placed on humidified oxygen Assist physician with bronchoscopy to clear patients airway of debris and visually inspect airway. Monitor arterial blood gases and carboxyhemoglobin levels (should be < 7%) CO is reduced by 50% for every 30 minutes of 90-100% oxygen therapy If cyanide exposure is suspected, sodium nitrate 300 mg IV bolus may be ordered as an antidote Patients may be intubated as a precaution if airway patency is questionable When in doubt, the patient should be intubated. You can always discontinue the endotracheal tube, but it may not always be possible to place one. Try to use soft tracheostomy ties instead of tape as this could produce further tissue damage.

_________________________________________________________________________________________________________________ Title: Owner: Effective Date: Doc. #

Page 3 of 2

Endotracheal tube should not be removed unless there is an air leak noted when the cuff is deflated (a sign that laryngeal edema has subsided) Keep the head of the bed ≥30 degrees to promote resolution of edema. Phase 2  Monitor for signs of pneumonia/ARDS Increased oxygen requirement Increased work of breathing Impaired gas exchange Provide meticulous oral care with toothbrush and toothpaste to reduce the possibility of the patient aspirating infective oral flora Head of bed ≥30 degrees promotes postural drainage out of secretions Turn patient Q2 hours to promote good pulmonary toilet Arterial blood gases as ordered Monitor for signs of increasing peak airway pressures/ventilator only Aggressive pulmonary toilet to decrease risk of pneumonia

   Phase 3    DOCUMENTATION: 1. 2. 3. 4. 5.

Adult or Pediatric ICU Critical Care Flowsheet or Nursing Care Flowsheet Any changes in respiratory status and physician notification All interventions and response to those interventions Outcomes criteria Teaching: Individual and Discharge (should address outcomes criteria that have not been met during hospitalization)

DEFINITIONS: Ventilation: The exchange of air between the lungs and the atmosphere so that oxygen can be exchanged for C02 in the alveoli. Oxygenation: The amount of oxygen carried in the blood. ARDS: A lung condition in which trauma to the lungs leads to inflammation of the lungs, accumulation of fluid in the alveolar air sacs, low blood oxygen and respiratory distress.

_________________________________________________________________________________________________________________ Title: Owner: Effective Date: Doc. #

Page 4 of 2

RESOURCES/TRAINING All nurses caring for the inhalation patient will be competent in ACLS and airway management. Nurses in the ICU are required to take annual competencies and be signed off in these areas.



Item Owner Consultant(s) Committee(s) Nursing Officer Medical Director/Officer Human Resources Finance Legal Official Approver Official Signature 2nd Approver (Optional) Signature Effective Date Origination Date Issue Date Catherine Beckmann, RN TSBICU Unit Director Jonathan Marinaro, MD Y Y N/A N/A N/A Contact Adrienne Costello, RN Supervisor TSBICU Date 11/08 Approval

ATTACHMENTS No Attachments

_________________________________________________________________________________________________________________ Title: Owner: Effective Date: Doc. #

Page 5 of 2

Shared By: