Current Clinical Management of Smoke Inhalation Injuries: a Reality Check
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Editorial Current Clinical Management of Smoke Inhalation Injuries. A
Editorial Current clinical management of smoke inhalation injuries. A reality check. Arietta Spinou1, Nikolaos G. Koulouris2 1. Health Sport and Bioscience, University of East London, London, UK 2. 1st Respiratory Medicine Department, National and Kapodistrian University of Athens Medical School, Athens, Greece Corresponding author: Dr Arietta Spinou Email: [email protected] Address: Stratford Campus, University of East London Health Sport and Bioscience Water Lane, Stratford, London E15 4LZ Words: 1502 References: 30 Keywords: burns, smoke inhalation injury, clinical management, physiotherapy To the Editor, A major disaster is happening at the moment, as the Camp Fire, Woolsey Fire and Hill Fire are burning in California. Camp Fire in Northern California has already burned 546.3 km2 and is the deadliest wildfire in the history of the state, with 48 fatalities and still counting (1). It was also only recently, in July 2018, when a fire entered the populated area of Mati, Greece, and created a wildland urban interface that caused 99 fatalities and numerous burns and smoke inhalation injuries. A few years ago, in August 2007, 67 people died in a megafire event in the Peloponnese region, Greece, which was created by 55 simultaneous large fires (based on size, intensity, environmental and socio-economic impact) (2). These and numerous other tragic incidents highlight the importance of our current clinical management in the victims of fire. Burns are categorised according to depth, and their severity depends on the extent (percentage of total body surface area), age of the individual and accompanied smoke inhalation. Essential treatment for the burn victims remains the resuscitation with intravenous fluids to maintain optimal fluid balance, nutrition optimisation, wound coverage, and pain control (3). -
Airway Pressures and Volutrauma
Airway Pressures and Volutrauma Airway Pressures and Volutrauma: Is Measuring Tracheal Pressure Worth the Hassle? Monitoring airway pressures during mechanical ventilation is a standard of care.1 Sequential recording of airway pressures not only provides information regarding changes in pulmonary impedance but also allows safety parameters to be set. Safety parameters include high- and low-pressure alarms during positive pressure breaths and disconnect alarms. These standards are, of course, based on our experience with volume control ventilation in adults. During pressure control ventilation, monitoring airway pressures remains important, but volume monitoring and alarms are also required. Airway pressures and work of breathing are also important components of derived variables, including airway resistance, static compliance, dynamic compliance, and intrinsic positive end-expiratory pressure (auto-PEEP), measured at the bedside.2 The requisite pressures for these variables include peak inspiratory pressure, inspiratory plateau pressure, expiratory plateau pressure, and change in airway pressure within a breath. Plateau pressures should be measured at periods of zero flow during both volume control and pressure control ventilation. Change in airway pressure should be measured relative to change in volume delivery to the lung (pressure-volume loop) to elucidate work of breathing. See the related study on Page 1179. Evidence that mechanical ventilation can cause and exacerbate acute lung injury has been steadily mounting.3-5 While most of this evidence has originated from laboratory animal studies, recent clinical reports appear to support this concept.6,7 Traditionally, ventilator-induced lung injury brings to mind the clinical picture of tension pneumothorax. Barotrauma (from the root word baro, which means pressure) is typically associated with excessive airway pressures. -
Wildland Firefighter Smoke Exposure
❑ United States Department of Agriculture Wildland Firefighter Smoke Exposure EST SERVIC FOR E Forest National Technology & 1351 1803 October 2013 D E E P R A U RTMENT OF AGRICULT Service Development Program 5100—Fire Management Wildland Firefighter Smoke Exposure By George Broyles Fire Project Leader Information contained in this document has been developed for the guidance of employees of the U.S. Department of Agriculture (USDA) Forest Service, its contractors, and cooperating Federal and State agencies. The USDA Forest Service assumes no responsibility for the interpretation or use of this information by other than its own employees. The use of trade, firm, or corporation names is for the information and convenience of the reader. Such use does not constitute an official evaluation, conclusion, recommendation, endorsement, or approval of any product or service to the exclusion of others that may be suitable. The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, age, disability, and where applicable, sex, marital status, familial status, parental status, religion, sexual orientation, genetic information, political beliefs, reprisal, or because all or part of an individual’s income is derived from any public assistance program. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication of program information (Braille, large print, audiotape, etc.) should contact USDA’s TARGET Center at (202) 720-2600 (voice and TDD). To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, S.W., Washington, D.C. -
Clinical Management of Severe Acute Respiratory Infections When Novel Coronavirus Is Suspected: What to Do and What Not to Do
INTERIM GUIDANCE DOCUMENT Clinical management of severe acute respiratory infections when novel coronavirus is suspected: What to do and what not to do Introduction 2 Section 1. Early recognition and management 3 Section 2. Management of severe respiratory distress, hypoxemia and ARDS 6 Section 3. Management of septic shock 8 Section 4. Prevention of complications 9 References 10 Acknowledgements 12 Introduction The emergence of novel coronavirus in 2012 (see http://www.who.int/csr/disease/coronavirus_infections/en/index. html for the latest updates) has presented challenges for clinical management. Pneumonia has been the most common clinical presentation; five patients developed Acute Respira- tory Distress Syndrome (ARDS). Renal failure, pericarditis and disseminated intravascular coagulation (DIC) have also occurred. Our knowledge of the clinical features of coronavirus infection is limited and no virus-specific preven- tion or treatment (e.g. vaccine or antiviral drugs) is available. Thus, this interim guidance document aims to help clinicians with supportive management of patients who have acute respiratory failure and septic shock as a consequence of severe infection. Because other complications have been seen (renal failure, pericarditis, DIC, as above) clinicians should monitor for the development of these and other complications of severe infection and treat them according to local management guidelines. As all confirmed cases reported to date have occurred in adults, this document focuses on the care of adolescents and adults. Paediatric considerations will be added later. This document will be updated as more information becomes available and after the revised Surviving Sepsis Campaign Guidelines are published later this year (1). This document is for clinicians taking care of critically ill patients with severe acute respiratory infec- tion (SARI). -
A Toxicological Review of the Products of Combustion
HPA-CHaPD-004 A Toxicological Review of the Products of Combustion J C Wakefield ABSTRACT The Chemical Hazards and Poisons Division (CHaPD) is frequently required to advise on the health effects arising from incidents due to fires. The purpose of this review is to consider the toxicity of combustion products. Following smoke inhalation, toxicity may result either from thermal injury, or from the toxic effects of substances present. This review considers only the latter, and not thermal injury, and aims to identify generalisations which may be made regarding the toxicity of common products present in fire smoke, with respect to the combustion conditions (temperature, oxygen availability, etc.), focusing largely on the adverse health effects to humans following acute exposure to these chemicals in smoke. The prediction of toxic combustion products is a complex area and there is the potential for generation of a huge range of pyrolysis products depending on the nature of the fire and the conditions of burning. Although each fire will have individual characteristics and will ultimately need to be considered on a case by case basis there are commonalities, particularly with regard to the most important components relating to toxicity. © Health Protection Agency Approval: February 2010 Centre for Radiation, Chemical and Environmental Hazards Publication: February 2010 Chemical Hazards and Poisons Division £15.00 Chilton, Didcot, Oxfordshire OX11 0RQ ISBN 978-0-85951- 663-1 This report from HPA Chemical Hazards and Poisons Division reflects understanding and evaluation of the current scientific evidence as presented and referenced in this document. EXECUTIVE SUMMARY The Chemical Hazards and Poisons Division (CHaPD) is frequently required to advise on the health effects arising from incidents due to fires. -
Respiratory Therapy Pocket Reference
Pulmonary Physiology Volume Control Pressure Control Pressure Support Respiratory Therapy “AC” Assist Control; AC-VC, ~CMV (controlled mandatory Measure of static lung compliance. If in AC-VC, perform a.k.a. a.k.a. AC-PC; Assist Control Pressure Control; ~CMV-PC a.k.a PS (~BiPAP). Spontaneous: Pressure-present inspiratory pause (when there is no flow, there is no effect ventilation = all modes with RR and fixed Ti) PPlateau of Resistance; Pplat@Palv); or set Pause Time ~0.5s; RR, Pinsp, PEEP, FiO2, Flow Trigger, rise time, I:E (set Pocket Reference RR, Vt, PEEP, FiO2, Flow Trigger, Flow pattern, I:E (either Settings Pinsp, PEEP, FiO2, Flow Trigger, Rise time Target: < 30, Optimal: ~ 25 Settings directly or by inspiratory time Ti) Settings directly or via peak flow, Ti settings) Decreasing Ramp (potentially more physiologic) PIP: Total inspiratory work by vent; Reflects resistance & - Decreasing Ramp (potentially more physiologic) Card design by Respiratory care providers from: Square wave/constant vs Decreasing Ramp (potentially Flow Determined by: 1) PS level, 2) R, Rise Time ( rise time ® PPeak inspiratory compliance; Normal ~20 cmH20 (@8cc/kg and adult ETT); - Peak Flow determined by 1) Pinsp level, 2) R, 3)Ti (shorter Flow more physiologic) ¯ peak flow and 3.) pt effort Resp failure 30-40 (low VT use); Concern if >40. Flow = more flow), 4) pressure rise time (¯ Rise Time ® Peak v 0.9 Flow), 5) pt effort ( effort ® peak flow) Pplat-PEEP: tidal stress (lung injury & mortality risk). Target Determined by set RR, Vt, & Flow Pattern (i.e. for any set I:E Determined by patient effort & flow termination (“Esens” – PDriving peak flow, Square (¯ Ti) & Ramp ( Ti); Normal Ti: 1-1.5s; see below “Breath Termination”) < 15 cmH2O. -
Addressing Toxic Smoke Particulates in Fire Restoration
Addressing Toxic Smoke Particulates in Fire Restoration By: Sean M. Scott In the restoration industry today, a lot of attention testing laboratory or industrial hygienist provides an is given to the testing and abatement of air clearance test to certify that the abatement or microscopic hazardous materials. These include remediation process was successful. Upon receipt asbestos, lead, mold, bacteria, pathogens, and all of the clearance, people can then reenter the sorts of bio-hazards fall into this category. If these remediated area, rooms, or building. However, contaminants are disturbed, treated, or handled when the structural repairs are completed after a improperly, all of them can cause property fire, an air clearance test is rarely ever performed. damage and serious harm to the health and How then can consumers be assured or restoration welfare of those living or working in or near the companies guarantee that the billions of toxic areas where they’re present. However, there are particulates and volatile organic compounds other hazardous toxins that commonly present (VOCs) generated by the fire have been themselves in restoration projects, that seem to go removed? Is there cause for concern or is a simple unnoticed. These are the toxic smoke particulates “sniff” test or wiping a surface with a Chem-sponge created during structure fires. sufficient? Why is it so common to hear customers complain of smelling smoke long after the When a building is abated from asbestos, lead, or restoration is completed? What measures are mold, special care is given to be sure every being taken to protect workers and their families microscopic fiber, spore, and bacteria is removed. -
Hypoxic Brain Injury
Hypoxic brain injury Headway’s publications are all available to freely download from the information library on the charity’s website, while individuals and families can request hard copies of the booklets via the helpline. Please help us to continue to provide free information to people affected by brain injury by making a donation at www.headway.org.uk/donate. Thank you. Acknowledgements: Many thanks to Dr Steven White, Consultant Neurophysiologist at St. Mary’s Hospital, London, and Great Ormond Street Hospital, London, for co-authoring this factsheet. Introduction The brain needs a constant supply of oxygen to survive and function. Any interruption in this supply leads to a condition called hypoxia, which can cause brain injury. Hypoxic brain injuries can sometimes be overlooked due to the fact that the primary illness was unrelated to the brain, for example, a heart attack or smoke inhalation. This is especially true if the primary condition is successfully treated and the impact on the brain was relatively mild. It is very important to seek specialist support for the effects of the brain injury as soon as possible and to be aware that changes in functioning and behaviour after such an event may be related to brain injury. This factsheet is intended as an overview of the causes, effects, treatment and rehabilitation of hypoxic brain injury. The information will be particularly useful for the family members of people who have sustained such an injury and also provides a useful starting point for professionals who wish to improve their knowledge of the subject. What is hypoxic brain injury? The brain needs a continuous supply of oxygen to survive and it uses 20% of the body’s oxygen intake. -
Near Drowning
Near Drowning McHenry Western Lake County EMS Definition • Near drowning means the person almost died from not being able to breathe under water. Near Drownings • Defined as: Survival of Victim for more than 24* following submission in a fluid medium. • Leading cause of death in children 1-4 years of age. • Second leading cause of death in children 1-14 years of age. • 85 % are caused from falls into pools or natural bodies of water. • Male/Female ratio is 4-1 Near Drowning • Submersion injury occurs when a person is submerged in water, attempts to breathe, and either aspirates water (wet) or has laryngospasm (dry). Response • If a person has been rescued from a near drowning situation, quick first aid and medical attention are extremely important. Statistics • 6,000 to 8,000 people drown each year. Most of them are within a short distance of shore. • A person who is drowning can not shout for help. • Watch for uneven swimming motions that indicate swimmer is getting tired Statistics • Children can drown in only a few inches of water. • Suspect an accident if you see someone fully clothed • If the person is a cold water drowning, you may be able to revive them. Near Drowning Risk Factor by Age 600 500 400 300 Male Female 200 100 0 0-4 yr 5-9 yr 10-14 yr 15-19 Ref: Paul A. Checchia, MD - Loma Linda University Children’s Hospital Near Drowning • “Tragically 90% of all fatal submersion incidents occur within ten yards of safety.” Robinson, Ped Emer Care; 1987 Causes • Leaving small children unattended around bath tubs and pools • Drinking -
Health Concerns from Smoke Released by Fires
Health Concerns from Smoke Released by Fires Key Points The materials released by a fire vary from one fire to another, depending on the items burning, the availability of oxygen and fresh air, and the temperature of the fire itself. Even within a fire covering a large area, the materials released may vary from location to location. Inhaling the smoke from a fire can cause injury from the heat of the smoke, the chemicals within the smoke, and the particles of soot. " The heat can cause burns to the nasal passages, airways and lungs. " The chemicals can poison the body, depending on the amount of carbon monoxide, cyanide, and other chemicals produced by the burning. " Soot particles and other substances can irritate the airways. Inhaling smoke can cause asthma and other lung conditions to worsen for hours to days after breathing the smoky air. The best course of action is to leave the smoky air as soon as possible. Staying indoors with closed windows is better than being outdoors when smoke is widespread. If symptoms occur after smoke inhalation, seek medical care for further evaluation and treatment as needed. Fire Chemistry and Toxicology The products of combustion from a fire are a complex mixture. Carbon monoxide is produced in every fire. In general, more carbon monoxide is produced from fires occurring indoors. Carbon monoxide is important to health because it interferes with a person’s ability to use oxygen to maintain body functions. As carbon monoxide levels rise, the amount of impairment also rises. Carbon monoxide levels above 10% typically cause symptoms. -
The Future of Mechanical Ventilation: Lessons from the Present and the Past Luciano Gattinoni1*, John J
Gattinoni et al. Critical Care (2017) 21:183 DOI 10.1186/s13054-017-1750-x REVIEW Open Access The future of mechanical ventilation: lessons from the present and the past Luciano Gattinoni1*, John J. Marini2, Francesca Collino1, Giorgia Maiolo1, Francesca Rapetti1, Tommaso Tonetti1, Francesco Vasques1 and Michael Quintel1 Abstract The adverse effects of mechanical ventilation in acute respiratory distress syndrome (ARDS) arise from two main causes: unphysiological increases of transpulmonary pressure and unphysiological increases/decreases of pleural pressure during positive or negative pressure ventilation. The transpulmonary pressure-related side effects primarily account for ventilator-induced lung injury (VILI) while the pleural pressure-related side effects primarily account for hemodynamic alterations. The changes of transpulmonary pressure and pleural pressure resulting from a given applied driving pressure depend on the relative elastances of the lung and chest wall. The term ‘volutrauma’ should refer to excessive strain, while ‘barotrauma’ should refer to excessive stress. Strains exceeding 1.5, corresponding to a stress above ~20 cmH2O in humans, are severely damaging in experimental animals. Apart from high tidal volumes and high transpulmonary pressures, the respiratory rate and inspiratory flow may also play roles in the genesis of VILI. We do not know which fraction of mortality is attributable to VILI with ventilation comparable to that reported in recent clinical practice surveys (tidal volume ~7.5 ml/kg, positive end-expiratory pressure (PEEP) ~8 cmH2O, rate ~20 bpm, associated mortality ~35%). Therefore, a more complete and individually personalized understanding of ARDS lung mechanics and its interaction with the ventilator is needed to improve future care. -
Simulator Measurement of the Work of Breathing for Underwater
SIMULATOP REASUREBEMT OF THE RORK OF BRIiAPHING FOB UNDEEWATER BREATHING APPARATUS Durcan Moir fliln~ E. Sc. Mar ire Science Stockton stat^ Colfege, New Jers~y,1973 A THESIS SUBEITTED IN PARTIAL PULPILLEEBT OF THE PEQUIREHENTS FOR THE DEGREE OF MASTER OF SCIENCE (KfNES IOLOGY) in the Department of Kicesiology a GUNCAN ROIB BILNE 1977 SIBOH FRASER UNIVERSITY December, 1977 All rights reserved, This thesis may nct t>f reproduced in whole or ir part, by photocopy or cthor means, without permission of tho author. NAYE: Duncan noir flllni TITLE OF THESIS: Hespiration Simulator' Htlasur+m~n* , of the Wark of Bre3thi11y far Und2rwater Breathinq A ppara tus EXhnINING COMnITTEE: Chairman: Dr. E. W. R;inister 'DL. J. n. aorrison Senior Sup:.r visor Dr, T, W. ialv.?rt Dr. A. E. Zhaprssry Ext +rnal Examin~r Prof -.ssor SLlncn Praser IJniv~rsity - at A,,,,,.,: .....................Jet, , V7r PART lAL COPYR lGHT L lCENSE I hereby grant to Simon Fraser University the right to lend my thesis, project or extended essay (the title of which is shown below) to users of the Simon Fraser University Library, and to make partial or single copies only for such users or in response to a request from the library of any other university, or other educational institution, on its own behalf or for one of its users. I further agree that permission for multiple copying of this work for scholarly purposes may be granted by me or the Dean of Graduate Studies. It is understood that copying or publication of this work for financial gain shall not be allowed without my written permission.