Airway management for burn injury patients

| In Articles | 10th October 2020

AIRWAY MANAGEMENT FOR BURN INJURY PATIENTS

  • Maintain low threshold for intubation and high index of suspicion for airway injury
  • Swelling is rapid and progressive in the first 24 hours
  • Consider rapid sequence intubation RSI - cautious use of succinylcholine due to potassium increase!
  • Prior to intubation attempt - have smaller sizes of endotracheal tube
  • Prepare for cricothyrotomy or tracheostomy
  • Utilise end-tidal carbon dioxide ETCO2 monitoring as pulse oximetry may be inaccurate in burn injury patients

AIRWAY CONSIDERATION FOR BURN INJURIES

  • Upper airway injury (above the glottis) - area buffers the heat of smoke - thermal injuries are usually confined to the larynx and upper trachea
  • Lower airway/alveolar injury (below the glottis) - caused by the inhalation of steam or chemical smoke and often presents as acute respiratory distress syndrome ARDS after 24-72 hours

CRITERIA FOR INTUBATING PATIENTS WITH BURN INJURIES

  • Changes in voice
  • Wheezing/laboured respirations
  • Excessive, continuous cough
  • Altered mental status
  • Carbonaceous sputum
  • Singed facial or nasal hair
  • Facial burns, eyes swollen shut
  • Oropharyngeal oedema/stridor
  • Assume inhalation injury in any patient confined in a fire environment
  • Extensive face/neck burns
  • Burns 50% or greater of the total body surface area

AIRWAY/BREATHING ASSESSMENT IN BURN INJURIES

  1. Start oxygen if:
  • Moderate or critical burn
  • Decreased level of consciousness
  • Signs of respiratory involvement
  • Burn occurred in closed space
  • History of smoke or carbon monoxide exposure

2. Assisted ventilation if needed

CARBON MONOXIDE INTOXICATION

Carbon monoxide is a colourless, odourless, tasteless product of incomplete combustion. It has a binding affinity for haemoglobin 210-240 times greater than oxygen. Carbon monoxide intoxication results in decreased oxygen delivery to tissues, leading to cerebral and myocardial hypoxia. Cardiac arrhythmias are the most common fatal occurrence.

SIGNS AND SYMPTOMS OF CARBON MONOXIDE INTOXICATION

  • Usually symptoms do not appear until 15% of the haemoglobin is bound to carbon monoxide rather than to oxygen
  • Early symptoms are neurological in nature due to cerebral oxygenation impairment
  • Confused, irritable, restless
  • Headache, vomiting, incontinence
  • Dilated pupils
  • Tachycardia, arrhythmias or infarction
  • Pale or cyanotic complexion
  • Seizures
  • Overall cherry red colour - rarely seen
  • Death - when more than 50-60% of the haemoglobin is bound to carbon monoxide

MANAGEMENT OF CARBON MONOXIDE INTOXICATION

  • Remove the patient from the source of exposure
  • Administer 100% high flow oxygen

The half life of carboxyhemoglobin if the patient is breathing room air is 120-200 minutes and with 100% high flow oxygen it is 30 minutes.