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RR: 28 bpm

HR: 128 bpm

BP: 130/78 mmHg

SpO₂: 97%

CO: 25 ppm

Blood glucose: not repeated

Temperature: not repeated

GCS: E3, V6, M5, 14/15

4 lead ECG: sinus tachycardia

1  Explain the significance of the soot in and around the mouth and nose. Soot in mouth and nose is suggestive of inhalation injury. The patient also has singed nasal hair and a hoarse voice, so there is the potential for airway burns that may lead to further complications as the airway starts to swell. The cough indicates the patient may have inhaled irritants, so be aware for signs of toxicity as well. Inhalation injury is the main cause of mortality in burn patients.

2  Why might SpO 2 monitoring be unreliable in this patient? What else could you measure?Pulse oximetry measures peripheral capillary oxygen saturation (SpO2) and the percentage of haemoglobin (oxygenated haemoglobin) compared to the total amount of haemoglobin. Carbon monoxide is one of the products of combustion and can affect patients exposed to smoke‐filled environments. CO diffuses across the alveoli in a similar way to oxygen, creating carboxyhaemoglobin, which has a much greater affinity with haemoglobin than oxygen (approx. 250 times greater). This reduces the ability of the haemoglobin to transport oxygen around the body. Pulse oximetry cannot distinguish between oxyhaemoglobin and carboxyhaemoglobin and SpO2 readings may be falsely elevated, making it challenging to accurately determine the severity of the patient. Some non‐invasive pulse oximetry devices can measure carboxyhaemoglobin saturation (SpCO) levels, although most are not validated and should be used as an adjunct to clinical decision making.End‐tidal carbon dioxide (EtCO2) would be another useful addition, as it would help detect any bronchospasm that may not be noted on auscultation.

3  What are the signs and symptoms of carbon monoxide poisoning? See Table 1.5.Table 1.5 Signs and symptoms related to carboxyhaemoglobin (COHb) level at time of exposure to carbon monoxideSource: Adapted from Curtis et al. (2019), p. 535.COHb level %Signs and symptoms0None10Frontal headache20Throbbing headache, shortness of breath on exertion30Impaired judgement, nausea, fatigue, visual disturbances, dizziness40Confusion, loss of consciousness50Seizures, coma60Hypotension, respiratory failure70Death

1  What additional questions might help you to determine the severity? Duration of time in the smoke‐filled room?Any prior history of respiratory problems, especially asthma?Any action taken to prevent inhalation (cloth or towel across mouth and nose, stayed low to floor to avoid fumes, etc.)?Any signs and symptoms associated with CO poisoning?Does patient smoke (smokers have a higher baseline reading of CO)?