We had a case a few months ago at Janus General–very sad and very scary. The patient came in after a house fire. He had some burns, but not enough to be the cause of his arrest. Instead, it had to be the asphyxia and possible toxicology of the smoke inhalation. I wanted to get a better idea of ideal care for these patients; for that I needed a toxicologist.
Few tox folks are smarter than Lewis Nelson, MD of the NYC Poison Center.
Note: In this episode we don’t deal with the thermal injury of smoke inhalation
- Empiric administration of Hydroxocobalamin 5 g rapid IV drip x 1
- Even better if this can be given at the scene as soon as the patient arrests or is profoundly hypotensive
- Messes with labs that use colorimetric probes (cooximetry, lactate, LFTs, etc.) Get blood for cooximetry before giving the med if at all possible
- Dr. Nelson doesn’t recommend giving sodium thiosulfate in addition to the Hydroxocobalamin
- An IM version is in the pipeline–this will be easier for EMS/emergency use
- Put the patient on 100% fiO2
- Not much to do beyond that until the patient stabilizes
- See LITFL for more on CO
- Caused by Hb oxidation from the heat of the fire
- Administer Methylene Blue 2 mg/kg x 1 IVP
- May be worthwhile to start a drip if patient has resistant hypotension, but this is an unproven therapy