2005 OPEN FORUM Abstracts
HIGH FREQUENCY PERCUSSIVE VENTILATION (HFPV) IN THE MANAGEMENT OF 80% TOTAL BODY SURFACE AREA (TBSA) BURNS WITH INHALATION INJURY SECONDARY TO METHAMPHETAMINE LAB EXPLOSION - CASE REPORT
Brent Kenney BSRT, RRT, Martin Tyson DO, Bill Haire RRT, Mercy St. John's Health System, Springfield, MO.
Introduction: Traditionally, predicting mortality from burn injury has considered age, total body surface area burned, percent full thickness burn and inhalation injury. Mortality rates of burn patients with concomitant inhalation injury have been reported to be significantly higher than with burns alone. Methamphetamine is a central nervous system stimulant that acts on dopamine and norepinephrine receptors in the brain and may be snorted, smoked, or injected. Methamphetamine production is illegal and is endemic in certain areas of the United States. Missouri leads the nation in numbers of illegal methamphetamine labs as compiled by the United States Drug Enforcement Agency. Methamphetamine lab explosions may correspond to increased incidence of inhalation injury and may require more aggressive fluid resuscitation. Methamphetamine lab explosions with > 40% TBSA are not likely to survive. High Frequency Percussive Ventilation (HFPV) has been used successfully in burn patients of all age groups with or without inhalation injury. Burn patient with inhalation injuries are at increased risk for pneumonia, sepsis and Acute Respiratory Distress Syndrome. The incidence of methamphetamine lab explosions with burns and inhalation injuries appear to be on the rise.
Case Summary: The patient was 47 y/o male involved in a methamphetamine lab explosion. He suffered approximately 80% third degree burns as well as severe inhalation injury noted on bronchoscopy. Bronchoscopy revealed a large amount of soot and sloughing of the mucosa extending well into the segmental bronchi. The patient was placed on the Percussionaire VDR-4 with the following settings per Respiratory Care Protocol: Percussive rate 500, Convective rate 15, Proximal airway pressure (PAP) 40, Oscillatory/Demand CPAP 10, FIO2 1.0. Initial ABGs were pH 7.61, PCO2 21, PO2 412 with P/F ratio 412, Mean airway pressure (MAP) 14 cmH2O. Racemic Epinephrine 2.25 % (11.25 mg) and Heparin 5000 units were delivered via small volume nebulizer in line with the VDR-4 Q 8 hours till day 20. Patient went to surgery on day 1 for excision of burn and debridement with application of Integra to neck, chest, abdomen, arms and hands. Subsequent surgeries for excision, debridement, and application of Integra took place on days 3 and 6. Sputum cultures grew Enterobacter cloace and Stenotrophomonas maltophilia on day 5. Blood cultures grew Enterobacter cloace on day 5. Tracheostomy was performed on day 11. Sputum cultures grew Pseudomonas aeruginosa and Serratia marcescens on day 13. Blood cultures grew Candida albicans on day 13. Skin grafting was done on days 27 and 40. The FIO2 was reduced to 0.30 on day 5 on the VDR and remained there till transition to conventional ventilation. Proximal airway pressures remained in the mid twenties to upper teens till transition to the Drager Evita 4. The patient was transitioned to conventional ventilation (CV) on the Drager Evita 4 on day 21. Initial settings were CMV+AF, f 16, VT 700, Peep 5, MAP 13 cmH2O. Initial ABGs were pH 7.38, PCO2 38, PO2 86, with P/F ratio 287. The ventilator was weaned to CPAP/PS mode with Peep 7 cmH2O, automatic tubing compensation with PS off, FIO2 0.35. ABGs on CPAP/PS were pH 7.41, PCO2 28, PO2 153 with P/F ratio 437. Patient was placed on T-tube on day 32 on FIO2 0.40. ABGs on T-tube were pH 7.38, PCO2 38, PO2 124 with P/F ratio 310. The tracheostomy tube was removed on day 52 with SPO2 > 98%. Patient was ordered for rehabilitation evaluation on day 54.
Conclusion: Aggressive fluid resuscitation, early debridement, early grafting, aggressive pulmonary management (bronchcoscopy, VDR-4), and avoidance of sepsis and ARDS likely contributed to the survival of this patient. Higher PO2s and P/F ratios were obtained with the VDR-4 than with CV and similar MAP. The percussive effect of the VDR-4 helped to facilitate movement of carbonaceous debris and sloughed mucosa in the peripheral airways and may have contributed to the surprising pulmonary status of this patient throughout his hospitalization.