This case is written by Dr. Kyla Caners. She is a staff emergency physician in Hamilton, Ontario and the Simulation Director of McMaster University’s FRCP-EM program. She is also one of the Editors-in-Chief here at EmSimCases.
Why it Matters
The management of patients with significant burns obtained in an enclosed space involves several important components. This case nicely highlights three key management considerations:
- The need to intubate early in anticipation of airway edema that may develop
- The possibility of cyanide toxicity in the context of hypotension and a high lactate, and the need to treat early with hydroxycobalamin
- The importance of recognizing and testing for possible CO toxicity (and initiating 100% oxygen upon patient arrival)
Clinical Vignette
A 33-year-old female has just been brought into your tertiary care ED. She was dragged out of a house fire and is unresponsive. The etiology of the fire is unclear, but the home was severely damaged. The EMS crew that transported her noted significant burns across her chest, abdomen, arm, and leg.
Case Summary
A 33 year-old female is dragged out of a burning house and presents to the ED unresponsive. She has soot on her face, singed eyebrows, and burns to her entire chest, the front of her right arm, and part of her right leg. She is hypotensive and tachycardic with a GCS of 3. The team should proceed to intubate and fluid resuscitate. After this, the team will receive a critical VBG result that reveals profound metabolic acidosis, carboxyhemoglobin of 25 and a lactate of 11. If the potential for cyanide toxicity is recognized and treated, the case will end. If it is not, the patient will proceed to VT arrest.
Download the case here: Burn CO CN Case
ECG for the case found here:
ECG source: https://lifeinthefastlane.com/ecg-library/sinus-tachycardia/
CXR for the case found here:
CXR source: https://emcow.files.wordpress.com/2012/11/normal-intubation2.jpg
EM Sim Cases 
