PGY2 Critical Care Pharmacy Resident Management of Inhalation Injury: A Focus on Hydroxocobalamin and Nebulized Heparin Describe the pathophysiology of an inhalation injury (IHI) Discuss the role of hydroxocobalamin and nebulized heparin in patients suffering from IHI 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 Carboxy-hemoglobin 144 110 11 1.2 4.3 18 190 158 > 12 24.4%

Mechanism Thermal injury Chemical irritation Systemic toxicity Upper respiratory track Thermal injury Accumulation of particulates Chemical irritation Carbon monoxide Cyanide Systemic toxicity Rehberg S, et al. Expert Rev Respir Med 2009;3(3);283-97.

Pathophysiology 1 Hour 6 Hours 24 Hours 72 Hours Miller AC , et al. Crit Care Med 2014;42:413-9.

Management Administer 100% O2 Endotracheal intubation Pharmacologic interventions Collect laboratory data Stabilize patient Endotracheal intubation Administer 100% O2

Cyanide Poisoning Cyanokit (single 5-g vial) [package insert]. Columbia, MD: Meridian Medical Technologies, Inc.; 2011.

Hydroxocobalamin Protocol Victim of a fire in an enclosed space plus one of the following: Cardiac arrest 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 Rationale Bronchodilators Mucolytics Anticoagulants 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 Rehberg S, et al. Expert Rev Respir Med 2009;3(3);283-97.

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? Hydroxocobalamin IV Heparin neubulized Albuterol and NAC nebulized A and C All of the above Na Cl BUN Scr K CO2 BG EtOH Lactate Carboxy-hemoglobin 144 110 11 1.2 4.3 18 190 158 > 12 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