1. 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.

2. 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: ̊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%

3. 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);

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

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

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

7. 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

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

9. 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);

10. Nebulized Anticoagulants
Miller AC , et al. Crit Care Med 2014;42:413-9.

11. 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

12. 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%

13. 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