Breathing can be compromised following flame burn injury if people inhale smoke, especially in enclosed spaces. This can be life threatening as it can cause damage to the lungs and toxic poisoning from substances such as carbon monoxide or cyanide. Deep circumferential burns of the chest or abdominal skin may also restrict chest expansion and compromise ventilation. Early assessment of breathing is mandatory to identify any life threatening concerns that can be managed promptly.
- Administer High Flow 100% Oxygen
- Assess Breathing
- Assess for Circumferential Chest Burns
- Assess for COHb Poisoning
1. Administer High Flow 100% Oxygen
Administer 100% high flow (15 L/min) humidified oxygen via a mask or endotracheal tube.
2. Assess Breathing
A patient who is not breathing should be intubated and ventilated.
Assess respiratory rate, effort, breath sounds and O2 saturation. Look for signs and symptoms of inhalation injury and signs of deterioration.
Expose the chest and ensure that chest expansion is adequate and bilaterally equal.
3. Assess for Deep Circumferential Chest Burns
Deep circumferential burns of the chest or abdomen can restrict chest expansion, limiting respiratory excursion and compromising ventilation. Burnt skin loses its elasticity quickly in deep burns, which can have a tourniquet effect when combined with rapidly accumulating underlying burn oedema. Respiratory insufficiency or ischemia of an extremity are a risk.
An escharotomy may be required. Escharotomy is a high risk procedure and should only be performed after consultation and advice from ARV and the appropriate Burn Service.
4. Assess for COHb Poisoning
Consider carbon monoxide poisoning in patients who sustain burns in an enclosed area. Carbon monoxide has a 280 times greater affinity for hemoglobin than oxygen does.
Oxygen administration is pivotal increasing the gradient for oxygen binding to hemoglobin, so that unbound CO can be exhaled through the lungs. Oxygen saturation is an unreliable oxygenation parameter in patients with carbon monoxide poisoning. The machines interpret carbon monoxide as oxygen giving a false positive reading when the patient can be profoundly hypoxic, so oxygen should be given regardless of the oxygen saturation.
Assess for symptoms of high COHb levels which include a history of altered consciousness associated with the accident, the presence of neuropsychiatric abnormalities, the presence of cardiac abnormalities and a cherry pink appearance to the skin. COHb blood levels should be taken in the secondary survey.