Cases reported • Smoke Inhalation Injury; Inhalation Injury, Smoke

1/5. Early and late fatal complications of inhalation injury.

Severe inhalation injury causes a substantial deterioration in the prognosis and increases the general mortality of patients with extensive burns. Recently, in particular due to the development of invasive monitoring of patients and effective treatment of acute burn shock, we encounter with increasing frequency patients who survive the acute stage, including complications such as ARDS, and reach the stage of late complications. The latter include tracheooesophageal fistulas that develop on the basis of pressure ulcers and chondromalacia, usually at the site of the balloon of the tracheostomic cannula, and the overproduction of fibrous tissue in the area of the airways which leads to the development of stenosis, pulmonary fibrosis and bronchiectasia. Frequently, different early and late complications combine.

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2/5. Successful management of adult smoke inhalation with extracorporeal membrane oxygenation.

Pulmonary complications remain one of the leading causes of mortality in patients with burns. We report two cases of adult patients with thermal and inhalation injuries who were placed on extracorporeal membrane oxygenation (ECMO) and survived. Patient 1 was a 42-year-old male who suffered 15% TBSA and a severe inhalation injury requiring intubation upon arrival to the emergency department. Patient 2 was a 24-year-old female in a house fire who received 20%TBSA and was noted to be in respiratory distress and intubated on the scene by the paramedic team. Three days after admission, patient 1 developed severe respiratory failure. He decompensated, despite maximum conventional management, and was placed on ECMO. After 300 hours of ECMO, his pulmonary function had improved, and he was decannulated. Patient 2 also developed severe refractory respiratory failure and was placed on ECMO. She was decannulated 288 hours later. Both patients were discharged home shortly afterwards and have managed well. ECMO should be considered when patients are facing a respiratory death from inhalation injury on conventional mechanical ventilation.

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3/5. bronchiectasis and progressive respiratory failure following smoke inhalation.

A 49-year-old man who sustained inhalational injury in a fire 23 years ago developed bronchiectasis 12 years later and hypercapnic respiratory failure with cor pulmonale 20 years following the injury. Delayed onset of chronic respiratory failure should be considered among the long-term complications of inhalational injury.

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4/5. Suspected cyanide poisoning in smoke inhalation: complications of sodium nitrite therapy.

A 78 year old man was found comatose, apneic, and asystolic after closed-space smoke inhalation. He was successfully resuscitated to pulse and blood pressure at the scene. A cyanide component to the poisoning was suspected and two 300 mg doses of sodium nitrite were administered, resulting in significant hypotension. Although high methemoglobin levels were not induced, when added to simultaneously obtained carboxyhemoglobin levels, the total amount of non-oxygen transporting hemoglobin remained nearly constant for about 4-1/2 hours before hyperbaric oxygen (HBO) therapy could be administered. The patient later died in multi-organ system failure. Admission whole blood cyanide level was only 0.34 mcg/mL. These sodium nitrite adverse effects can be avoided by slow intravenous infusion and by administering only recommended doses. In smoke inhalation victims with suspected cyanide poisoning, sodium thiosulfate should be administered first, and sodium nitrite withheld until after the patient is receiving HBO therapy. When available, hydroxocobalamin (which neither induces methemoglobinemia nor causes hypotension) may be the specific cyanide antidote of choice for victims of smoke inhalation.

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5/5. Long-term course of bronchiectasis and bronchiolitis obliterans as late complication of smoke inhalation.

We describe the long-term course of a patient with bronchiectasis and bronchiolitis obliterans, both of which developed as late complications of a smoke inhalation injury. Sequential chest x-rays obtained during the observation period showed gradual progression of bronchiectasis from the saccular to the cystic type. Symptoms, spirometry and blood gas analysis, however, remained stable for 15 years. We believe that symptoms and physiological derangement were due mainly to bronchiolitis obliterans, and that once the pathophysiological condition had been established following the initial injury, it could be maintained by conservative medical management.

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