Burns injury - PACT - ESICM

See the PACT module on Airway management
When inhalation injury is suspected, the indication to intubate should be
broad and intubation carried out promptly. Late intubation is sometimes impossible
leading to death by asphyxia, while extubating a patient without injury is simple and
can be done rapidly after confirmation of absence of inhalation injury.
Specific measures after inhalation injury
Lack of diagnostic criteria and large randomised trials make specific therapeutic
recommendations in patients with inhalation injury difficult. Since 100% oxygen
reduces the half-life of carbon monoxide (CO) it should be initiated as soon as
possible (see CO intoxication). Once carboxyhaemoglobin levels have normalised,
FiO 2 should be reduced. In a review article from 2011 on modern burn treatment,
Kasten suggests that aggressive pulmonary toilet, nitric oxide, nebulised heparin, N-
acetylcysteine, and/or bronchodilators may be considered in patients with inhalation
injury. However with the exception of for aggressive broncho-pulmonary toilet, these
measures are not standard care.
Colohan SM. Predicting prognosis in thermal burns with associated inhalational
injury: a systematic review of prognostic factors in adult burn victims. J
Burn Care Res 2010; 31(4): 529–539. PMID 20523229
Ikonomidis C, Lang F, Radu A, Berger MM. (2012) Standardizing the diagnosis of
inhalation injury using a descriptive score based on mucosal injury
criteria. Burns 2012; 38(4): 513–519. PMID 22348802
Palmieri TL. Inhalation injury consensus conference: conclusions. J Burn Care
Res 2009; 30(1): 209–210. PMID 19060761
Kasten KR, Makley AT, Kagan RJ. Update on the critical care management of
severe burns. J Intensive Care Med 2011; 26(4): 223–236. PMID 21764766
Carbon monoxide poisoning
A high index of suspicion should always be maintained for carbon monoxide (CO)
poisoning, particularly in high-risk injuries such as burns suffered in enclosed spaces
and in patients with associated injuries which may have altered the level of
consciousness. CO poisoning is responsible for many early deaths in burn victims due
to anoxic encephalopathy.
Diagnosis
Carbon monoxide poisoning requires blood gas analysis by CO-oximeter, which will
give accurate measurements of oxyhaemoglobin, carboxyhaemoglobin (COHb) and
methaemoglobin. Arterial or venous blood can be used. Arterial blood gas analysis
using the conventional blood gas machines may only demonstrate a metabolic
acidosis.
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