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Management of Inhalation Injury:
A Focus on Hydroxocobalamin and
Nebulized Heparin
Meagan Doolin, PharmD
PGY2 Critical Care Pharmacy Resident
September 2015
The speaker has no actual or potential conflict of interest in relation to this presentation.
Patient Case
BC is a 56 YOF who was found down and unconscious for
an unknown duration in a house fire. She was brought to
the ED by EMS and was subsequently determined to have
a 48% total body surface area (TBSA) burn.
• VS: 100.1 ̊F, 19, 111, 90/50, 94%
• PE: deep partial to full thickness burns on the face,
bilateral arms, torso, and bilateral legs below the knees
• Baseline lab values:
Na
Cl
BUN
Scr
K
CO2
BG
EtOH Lactate
144
110
11
1.2
4.3
18
190
158
> 12
Carboxyhemoglobin
24.4%
Mechanism
• Upper
respiratory
track
Thermal
injury
Rehberg S, et al. Expert Rev Respir Med 2009;3(3);283-97.
Chemical
irritation
• Accumulation
of particulates
• Carbon
monoxide
• Cyanide
Systemic
toxicity
Pathophysiology
1
Hour
Miller AC , et al. Crit Care Med 2014;42:413-9.
6
Hours
24
Hours
72
Hours
Management
Administer 100% O2
Endotracheal intubation
Stabilize patient
Collect laboratory data
Pharmacologic interventions
Cyanide Poisoning
Cyanokit (single 5-g vial) [package insert]. Columbia, MD: Meridian Medical Technologies, Inc.; 2011.
Hydroxocobalamin Protocol
Cardiac arrest
Victim of a fire
in an enclosed
space plus one
of the
following:
Glascow Coma Score < 8
Hypotension despite
oxygen administration and
fluid resuscitation
Lactate > 10 mmol/L
Cyanokit®
Cyanokit (single 5-g vial) [package insert]. Columbia, MD: Meridian Medical Technologies, Inc.; 2011.
Nebulized Treatments
Class
•
Bronchodilators
Mucolytics
Anticoagulants
Rehberg S, et al. Expert Rev Respir Med 2009;3(3);283-97.
•
•
•
•
Rationale
Improved lung compliance due to
decreased airway resistance
Improved airspace fluid clearance
Improved clearance of pulmonary
secretions due to decreased viscosity
Decrease fibrin deposition
Improve clearance of casts
Nebulized Anticoagulants
Miller AC , et al. Crit Care Med 2014;42:413-9.
Inhalation Injury Protocol
Heparin
• Heparin 10,000 units/mL nebulized Q4H
• Dilute with 2 mL NS for total volume 3 mL
Albuterol
+ NAC
• Albuterol 2.5 mg nebulized Q4H +
• NAC 3 mL nebulized Q4H
Frequency
• Alternate heparin with albuterol + NAC so a treatment is given Q2H
Duration
• Continue for 7 days or until extubation if sooner
Learning Assessment
• Which of the following therapies would you
recommend for BC?
A. Hydroxocobalamin IV
B. Heparin neubulized
C. Albuterol and NAC nebulized
D. A and C
E. All of the above
Na
Cl
BUN
Scr
K
CO2
BG
EtOH Lactate
144
110
11
1.2
4.3
18
190
158
> 12
Carboxyhemoglobin
24.4%
Summary
• IHI causes significant morbidity and mortality due
to both local and systemic effects
• Immediate treatment of systemic toxicities includes
oxygen administration and hydroxocobalamin
• Nebulized agents such as heparin, albuterol,
sodium bicarbonate, and NAC may be used to
improve lung function and decrease ventilator days