Burns injury - PACT - ESICM

Singer AJ, Taira BR, Thode HC Jr, McCormack JE, Shapiro M, Aydin A, et al. The
association between hypothermia, prehospital cooling, and mortality in
burn victims. Acad Emerg Med 2010; 17(4): 456–459. PMID 20370787
Airway management on scene
If the patient has a facial burn or if there was a fire in a closed room, direct
inspection of the oropharynx should be performed, preferably by a physician
experienced in airway management. This procedure might be difficult to achieve in
the pre-hospital setting. Carbonaceous sputum, hypoxia and hoarseness indicate
inhalation injury (see the section on inhalation injury in Task 4, below) and most
experts will advocate tracheal intubation in this setting. If there is doubt about the
patency of the airway, intubation should be performed with a cuffed (endo)tracheal
tube (ETT) that has not been cut. Due to oedema formation, a smaller ETT may be
required. A selection of ETT sizes and intubation aids should be available, including
‘difficult airway trolley’ if a difficult intubation is expected (usually not available on
scene). Secure the tube properly after intubation. The indication to intubate should
be broad; it is easier to extubate a patient when significant airway injury has been
excluded than to intubate a patient with extensive airway burns which are identified
later. Note that signs and symptoms of airway oedema may only become apparent
when intravenous resuscitation is established - potentially during inter-hospital
transport.
See the PACT module on Airway management.
All (endo)tracheal tubes should be well secured, especially in patients with
facial and neck burns. The tracheal tube may be very difficult or impossible to
reinsert if accidentally dislodged.
Many use un-cut tracheal tubes to pre-emptively correct for anticipated
oedema. If the tube is to be cut, do not cut the ETT to a standard ‘oral length’ as
patients with facial and inhalational burns commonly develop marked oedema and a
cut tube may ultimately become too short and be difficult to secure and/or become
dislodged. [Images in interactive version]
Eastman AL, Arnoldo BA, Hunt JL, Purdue GF. Pre-burn center management of
the burned airway: do we know enough? J Burn Care Res 2010; 31(5):
701–705. PMID 20634705
4