CASE NO.2SMOKE INHALATION AND CYANIDE POISONINGAt 3:15 AM fire department crews were dispatched to a dwelling fire. A brick row home was found fully engulfed in flames. A second alarm was sounded. Neighbors believed that George Johnson was at home when the fire started. At 3:40 A M the rescue crew exited the home with a middle-aged black male, unconscious with nasal respirations. The paramedic crew that had been standing by began treating the patient by ventilating him with positive pressure oxygen. George had a pulse and had no apparent bleeding, so the crew quickly moved him into the ambulance to complete the secondary survey.George was unresponsive to deep pain: his pupils were dilated and reacted sluggishly to light. His mustache and nasal hair were singed. His entire body was covered with soot. and his sputum was carbonaceous. George’s skin was warm and dry. his capillary refill time delayed, color dusky, and mucous membranes gray.The rescue officer reported that George was found in a third-floor smoke-filled bedroom with no open fire near him. It appeared that the source of the fire was the living room couch on the first floor.As the paramedic attempted intubation, George gagged on the tube and aroused slightly. Therefore, oxygen was applied at 15 liters/min via a non-rebreather mask. George’s vital signs currently were BP 160/100. pulse 110. and respirations 28. Breath sounds were heard bilaterally. with coarse rhonchi throughout all lung fields. The ECG showed that George was in a sinus tachycardia with occasional unifocal PVCs. An intravenous line was established with an 18-gauge catheter and D-, W solution infused slowly. En route to the hospital the paramedic notified the ED of George’s condition, field assessment, treatment, and estimated time of arrival. The paramedic also requested and was granted an order from the ED physician for 2 mg intravenous Narcan and 25 g intravenous D50 W, to be administered en route.Triage Assessment, Acuity Level IV: Inhalation injury, hair singed: color pale. dusky: severe pulmonary congestion.Based on the field report, the paramedics bypassed the triage area and immediately brought George to the resuscitation area. Upon arrival George is noted to be approximately 60 years old, weighing 80 kg. George is somewhat combative, pulling at his oxygen mask and attempting to sit up on the stretcher. He is not comprehending instructions given by the resuscitation team, and he is nonverbal. George appears healthy and is ventilating spontaneously, though mildly tachypneic. George’s physical exam remains the same as that reported by the paramedics, and all other systems are clear of injury.Among the initial treatments/or George in the ED are intubation, mechanical ventilation with oxygen at 100%, positive end expiratory pressure (PEEP) 5cm and a second intravenous line. Blood samples are drawn for routine analysis. The ABG sample as well as the venous sample drawn at the scene are both sent to the lab for carboxyhemoglobin levels for comparison. A Foley catheter is inserted.Alupent nebulization is initiated. The team leader then uses a fiber-optic bronchoscope to visualize the damage to the lower airway. Bronchial inflammation and mucosal ulceration are noted.George’s updated ABG results are Pa02 62, PaCO2 56, and pH 7.28. The field COHb is 36% and ED COHb is 24%. Three-hundred milligrams of sodium nitrate is administered intravenously followed by 12.5 g of sodium thiosulfate intravenously.Throughout the resuscitation George’s vital signs remained stable. Hyperbaric oxygenation therapy is considered, and transportation arrangements are made for u helicopter to fly George to the closest chamber, located at a naval hospital 100 mile-away. QUESTIONS What is the etiology and complications of smoke inhalation?What assessment parameters can be used to determine the risk of airway compromise?What is the risk of cyanide toxicity, and how is it treated?What is hyperbaric oxygen therapy, and why is it used for CO inhalation?What nursing diagnoses are applicable to this situation?  Health Science Science NursingNURSING NR708

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