Airway stability should be assessed rapidly in burns involving facial or suspected inhalation injuries, particularly in the early period following injury when the airway is at risk of obstruction due to swelling of the oropharynx and soft tissues of the neck. It is important to identify early those who may require intubation as it becomes increasingly difficult with the development of oedema, especially once fluid resuscitation has commenced which cascades the swelling. Airway management manoeuvres such as intubation are not without risk with significant complications reported in the literature (29).
- ASSESS AIRWAY STABILITY
- ASSESS FOR INHALATION INJURY
- CONSIDER INTUBATION
- MAINTAIN SPINAL PRECAUTIONS IF INDICATED
ASSESS AIRWAY STABILITY:
- Does the patient respond appropriately to a question?
- Look for signs of airway obstruction (stridor, use of accessory muscles, paradoxical chest movements).
- Listen for any upper-airway noises and breath sounds.
ASSESS FOR INHALATION INJURY:
Suspect inhalation injury if:
- Exposure to fire and smoke in an enclosed setting;
- Hoarseness or change in voice;
- Harsh cough; stridor;
- Burns to the face; head and neck swelling; inflamed oropharynx
- Singed nasal hair, eyebrows or eyelashes;
- Soot in the saliva, sputum, nose or mouth.
A patient with a history or signs suggestive of inhalation injury requires repeated airway assessment over time if they are not intubated
Consider intubation if there are any signs of:
- Pending airway obstruction: stridor, hoarse voice; (requires urgent emergency intubation)
- Decreased level of consciousness;
- Unprotected airway;
- Airway is at risk in transit
- Uncooperative/combative patient leading to distress and further risk of injury
MAINTAIN FULL SPINAL PRECAUTIONS IF INDICATED
About Inhalation Injury
Inhalation injury has a wide spectrum of clinical consequence and has a significant impact on survival. It comprises in varying degrees of severity, upper and lower airway oedema, inflammation, epithelial sloughing, increased mucus production, atelectasis, respiratory failure, obstruction and carbon monoxide intoxication. The variable presentation and delayed onset of symptoms can lead to ambiguity in diagnosis and delayed management. Fibreoptic bronchoscopy is a simple, and safe method of assisting the diagnosis of acute inhalation injury; however, it often is not readily available in all EDs. Bronchoscopy is performed on all patients with suspected inhalation injury once they reach the Trauma Centre.
Intubation in cases of suspected Inhalation Injury
There is no definitive evidence available yet to determine which people with burn injury require intubation from those who do not. We advocate intubation in all cases with obvious inhalation injury, and also in cases where symptoms and the progression of airway compromise remains unclear, delaying the procedure makes it increasingly challenging as symptoms and swelling progress.
Nevertheless, several studies report a high incidence of likely unnecessary intubations, with high extubation rates (>40% – 65%) within the first 48 hours. These studies found that patients who had flame burn injuries were more likely to be intubated, and those cases which were extubated in <48 hours were more likely to have been burnt outside in an unenclosed space. Unfortunately, there are no evidence based guidelines available yet which can always be reliably used to determine which burn patients may require intubation or not. Romanowski et al. (28) recently proposed the following guidelines for intubation pf burn patients in the pre-hospital setting based on a 10 year retrospective review of intubations at one Burn Centre involving 416 cases:
- Patient safety should not be compromised, and patient status is the ultimate determinant of intubation need
- Standard indications for intubation should be followed including but not limited to shortness of breath, wheezing, stridor, hoarseness, combativeness, or decreased level of consciousness
- Contact should be made with the Burn Service as soon as is safely feasible to discuss the events surrounding the burn and need for intubation
- If patient is clinically stable with no signs or symptoms of a compromised airway they have a low likelihood of requiring intubation. The following types of burns also have a lower need for intubation before transfer:
√ Burns that occur from causes other than flame injury
√ Burns that do not occur in enclosed spaces
√ Burns less than 20% TBSA
√ Burns with no third degree burns to the face
√ Within a reasonable distance to a burn service (approximately 3 hr transfer time)