Respiratory Management of Trauma, Obesity, Near Drowning, and Burns

Effective respiratory management is a cornerstone of comprehensive medical care for patients suffering from trauma, obesity, near drowning, or burns.

These conditions present unique challenges for maintaining adequate oxygenation and ventilation, often necessitating specialized approaches and interventions.

While these conditions differ in their etiology and presentation, they all compromise respiratory function either directly or indirectly, escalating the risk of respiratory failure.

Understanding the underlying pathophysiology, as well as the appropriate diagnostic and therapeutic modalities for each case, is vital for optimizing patient outcomes.

This article provides a detailed analysis of the respiratory management techniques that are instrumental in addressing these challenges.

 

 

Respiratory Management in Trauma Patients

Trauma patients often present with injuries that can impede effective respiratory function. Rib fractures, pneumothorax, or hemothorax are just some conditions that could necessitate immediate respiratory intervention.

Initial management includes securing the airway and establishing adequate ventilation, often requiring endotracheal intubation for severe cases.

Monitoring through arterial blood gases (ABGs) helps clinicians adapt ventilatory settings to meet metabolic demands. Positive pressure ventilation may be employed to manage underlying conditions such as a flail chest.

Additionally, analgesia is crucial for managing pain, which otherwise could lead to hypoventilation and subsequent respiratory failure.

Respiratory Management in Obesity

Patients with obesity often have comorbidities like obstructive sleep apnea and obesity hypoventilation syndrome that compromise respiratory function.

Positioning, such as elevating the head of the bed, can alleviate some mechanical constraints on the lungs. Non-invasive ventilation (NIV) like continuous positive airway pressure (CPAP) or bi-level positive airway pressure (BiPAP) may be initially employed.

In severe cases, careful endotracheal intubation and ventilation with low tidal volumes are recommended, taking into account the possible need for higher positive end-expiratory pressures (PEEP) to maintain alveolar recruitment.

Respiratory Management in Near Drowning

Near drowning can cause aspiration pneumonia, acute respiratory distress syndrome (ARDS), or other conditions that demand rapid intervention.

Immediate management focuses on ensuring a patent airway and removing aspirated material if possible. Oxygen therapy is usually initiated, and mechanical ventilation may be needed depending on the severity of respiratory distress.

The application of positive end expiratory pressure (PEEP) may help to keep alveoli open in the presence of atelectasis or ARDS.

Respiratory Management in Burns

Burn patients are at risk of inhalation injury, which can cause airway edema and respiratory distress. Early endotracheal intubation may be warranted to secure the airway before significant edema develops.

Ventilatory support should be adjusted based on ABGs and other clinical indicators. Humidified air and nebulized treatments can help in mucosal hydration and clearance of secretions.

In cases of carbon monoxide poisoning associated with smoke inhalation, high concentrations of oxygen are used to displace carbon monoxide from hemoglobin.

Practice Questions About Trauma, Obesity, Near Drowning, and Burns

1. What is drowning?
A term that refers to the suffocation and death as a result of submersion in liquid

2. What is near-drowning?
A situation in which a victim survives a liquid submersion, at least temporarily

3. What is dry drowning?
A type of drowning where the glottic closes and prevents water from entering the lungs

4. What is wet drowning?
A type of drowning where the glottis doesn’t close, which allows water to enter the lungs

5. What clinical manifestations occur from drowning?
Atelectasis, alveolar consolidation, increased alveolar-capillary membrane thickness, and bronchospasm

6. When should temperature management be performed?
Temperature management is something that should be considered if the patient is submerged in cold water for a period of time.

7. What types of airway clearance therapy may be indicated for a near-drowning victim?
Bronchoscopy, lavage, and prone positioning

8. Most near-drowning victims experience what?
ARDS

9. Does drowning and near-drowning always lead to death?
Drowning always results in death. Many near-drowning victims survive, although death occurs in some cases.

10. What will the chest assessment of a near-drowning patient likely show?
Crackles and rhonchi

11. What will the arterial blood gas results of a near-drowning victim likely show?
Acute ventilatory failure with hypoxemia

12. What will the radiologic findings of a near-drowning patient likely show?
Fluffy infiltrates, pneumothorax, and pneumomediastinum

14. What is the primary goal during the transport of a near-drowning patient?
High-quality CPR with 100% oxygen

15. What do most near-drowning patients suffer from?
Hypoxemia, hypercapnia, and acidosis; it also often leads to ARDS

16. What anatomic alterations of the lung occur in near-drowning patients?
Laryngospasm/bronchoconstriction, interstitial edema, decreased levels of pulmonary surfactant, increased alveolar surface tension, atelectasis, and frothy white secretions.

17. Interstitial edema in near-drowning includes what?
It includes engorgement of the perivascular and peribronchial spaces, alveolar walls, and interstitial spaces.

18. Decreased surfactant causes what?
It causes increased venous admixture.

19. When can ARDS occur after a near-drowning incident?
It usually shows up 24-48 hours after the incident.

20. What is dry drowning?
It occurs when the victim passes out before inhaling any water so the fluid doesn’t get into the distal airways.

21. How many people drown each year in the United States?
Between 6,000 and 8,000 people

22. Children under the age of five account for what percentage of drowning deaths in the United States per year?
40%

23. What percent of drowning deaths occur in persons between 5 and 20 years old?
20%

24. About how many victims of near-drowning are hospitalized annually?
About 8,000 each year

25. Describe the drowning or near-drowning sequence?
(1) Panic or violent struggle to return to the surface, (2) Period of calmness and apnea, (3) Swallowing fluid and vomiting, (4) Gasping inspirations and aspiration, (5) Convulsing, (6) Coma, and (7) Death

26. What is the mammalian dive reflex?
It optimizes respiration to allow staying underwater for extended periods of time and is more apparent in young children.

27. What clinical data is often obtained at the bedside of a near-drowning victim?
Increased respiratory rate, heart rate, cardiac output, blood pressure; cyanosis; cough/ frothy secretions; crackles and rhonchi

28. What would the ABG results show for a near-drowning victim?
Acute ventilatory failure with hypoxemia; there would be combined acidosis with a decreased pH, increased PaCO2, decreased HCO3, and a decreased PaO2

29. What would a chest x-ray show on a near-drowning victim?
It would likely show fluffy infiltrates, pneumothorax, and pneumomediastinum.

30. What occurs during the management of a near-drowning patient?
CPR should be performed by the first responder during transport and at the hospital.

31. What are the two types of chest trauma?
Blunt trauma and penetrating trauma

32. What are the assessment findings of chest trauma?
Dyspnea, respiratory distress, cough with or without hemoptysis, cyanosis, tracheal deviation, decreased breath sounds on the side of the injury, decreased oxygen saturation, and frothy secretions

33. What are the cardiovascular findings of chest trauma?
A rapid thready pulse, decreased blood pressure, narrowed pulse pressure, asymmetric blood pressure values in the arms, distended neck veins, muffled heart sounds, chest pain, crunching heart sounds, and dysrhythmias

34. What are the surface findings of chest trauma?
Bruising, abrasions, open chest wound, and subcutaneous emphysema

35. What should you do first when someone has a chest wound?
Ensure that there is a patent airway, provide oxygen, ensure that there is IV access, and remove clothing to assess the injury

36. What side do you put the patient on?
Place the patient on the injured side

37. What is a pneumothorax?
A term that refers to air in the pleural space

38. What are the signs and symptoms of pneumothorax?
Dyspnea, decreased movement of the involved chest wall, diminished or absent breath sounds on the affected side, and hyperresonance to percussion

39. What is the treatment for a pneumothorax?
It may resolve on its own, or it may require the insertion of a chest tube insertion with a drainage system.

40. What is a hemothorax?
A term that refers to blood in the pleural space

41. What are the signs and symptoms of a hemothorax?
Dyspnea, diminished or absent breath sounds, dullness to percussion, decreased Hgb, and shock

42. What is the treatment for a hemothorax?
Chest tube insertion with a drainage system

43. What is a tension pneumothorax?
A term that refers to air in the pleural space that does not escape, which increases intrathoracic pressure and causes the organs to shift

44. What is a flail chest?
A term that refers to a fracture of two or more adjacent ribs in two or more places, with a loss of chest wall stability

45. What are the signs and symptoms of flail chest?
Paradoxical movement of the chest wall and respiratory distress

46. What is cardiac tamponade?
A condition where blood rapidly collects in the pericardial sac, compresses the myocardium, and prevents ventricular filling

47. What are the signs and symptoms of cardiac tamponade?
Muffled heart sounds, decreased output, hypotension, JVD, and increased central venous pressure

48. What is the treatment for cardiac tamponade?
It is a medical emergency that requires pericardiocentesis.

49. What is the most common type of injury that occurs from blunt trauma?
Rib fractures

50. What are the clinical manifestations of rib fractures?
Pain, shallow breaths, atelectasis, and pneumonia

51. What are the clinical manifestations of a flail chest?
Tachypnea, tachycardia, asymmetric and uncoordinated movement of the thorax, and paradoxical chest movement

52. What does a chest tube do?
It drains the pleural space, drains air and fluid from the mediastinal space, and reestablishes negative air pressure.

53. What is a pleural effusion?
An abnormal collection of fluid in the pleural space

54. What are the clinical manifestations of a pleural effusion?
Muffled heart sounds, distant, trouble breathing, diminished breath sounds, and sharp chest pain that worsens with inhalation

55. What metabolic dysfunction is seen in obese patients?
Insulin resistance, hyperglycemia, dyslipidemia (increased triglycerides, decreased HDL), hypertension, pro-inflammatory state (increased cytokinesis), vascular disruption (increased VEGF), and increased leptin

56. What is the link between obesity and asthma?
Obese patients are twice as likely to have asthma than overweight patients.

57. What is obesity hypoventilation syndrome?
It is a type of severe obesity that is linked to hypoventilation during both waking and sleeping hours. It is also known as Pickwickian syndrome and is characterized by hypoventilation that leads to acidosis and hypoxemia.

58. What is more prevalent in obese patients?
Hypoxemia, asthma, and sleep apnea

59. What is different about performing intubation in obese patients?
It is more difficult.

60. The severity of burns is based on what?
The depth (degree) of the burn, percent of body surface area involved, location of the burn on the body, association with other injuries, patient’s age, causative agent, respiratory involvement, and overall health of the patient

61. How does the body respond to moderate or major burns?
Sympathetic nervous system manifestations, tachycardia, increased respiratory rate, decreased gastrointestinal motility, and increased blood glucose levels

62. What is needed for infection protection with moderate or major burns?
Maintain a protective environment, restrict plants and flowers due to the risk of contact with pseudomonas, restrict the consumption of fresh fruits and vegetables, limit visitors, monitor for manifestations of infection and report them to the provider, administer tetanus toxoids, administer antibiotics to treat the infection, monitor peak and trough levels, and use strict asepsis with wound care

63. What airway injuries can occur with burns?
They can result from steam or chemical inhalation, aspiration of scalding liquid, and external explosions while breathing. Their effects might not manifest for 24 to 48 hours. It includes progressive hoarseness, brassy cough, difficulty swallowing, drooling, copious secretions, adventitious breath sounds, and expiratory sounds that include audible wheezes, crowing, and stridor.

64. What should the respiratory therapist do to treat airway injuries that occur with burn victims?
They should provide support for the airway to maintain ventilation and administer supplemental oxygen. They should also educate the patient and family about airway management, such as deep breathing, coughing, and elevating the head of the bed.

65. What are the types of burn injuries that can occur?
Thermal burns, chemical burns, smoke inhalation, metabolic asphyxiation, and electrical burns

66. What is a secondary complication of burns that may occur 12-24 hours later?
Pulmonary edema due to inflammation of the airways

67. What are the three classifications of burns?
1) Superficial (1st degree), 2) Deep (2nd degree), and 3) Full thickness (3rd and 4th degree)

68. What are we concerned about with burns to the face, neck, and chest?
Burns may interfere with breathing, so you should be concerned with an obstructed airway.

69. What are we concerned about with burns to the ears and nose?
The patient is at an increased risk for infection due to low blood supply to those areas.

70. How do you manage a burn victim at the scene of the incident?
Remove the patient from the source of the burning, stop the burning process, assess the patient’s ventilation status, and don’t put ice or cold water on the burns.

71. How should a patient with carbon monoxide poisoning be treated?
They should be treated with the highest possible FiO2 that is available. A nonrebreathing mask can be used to administer up to 100% oxygen, but the goal should be to place the patient in a hyperbaric oxygen chamber.

72. Patients with smoke inhalation may also experience what?
They may experience pulmonary burns within their airways, which may require intubation and mechanical ventilation.

73. The respiratory assessment of burns patients focuses on what?
The percentage of TBSA

74. What toxic gases are commonly inhaled in burn patients?
Carbon monoxide and cyanide

75. Burn victims can rapidly develop what?
ARDS

Final Thoughts

Respiratory management is a critical aspect of treating patients with trauma, obesity, near drowning, or burns. While each condition presents its own set of complexities, they all necessitate vigilant respiratory support to prevent life-threatening complications.

A multidisciplinary approach that includes early recognition, appropriate ventilatory strategies, and specialized interventions tailored to the unique challenges of each condition is crucial for optimal patient care.

Medical practitioners must stay abreast of current best practices and guidelines to ensure that patients receive the highest standard of care during their critical moments of need.