Advanced Trauma Life Support ATLS Student Course Manual 2018

PRIMARY SURVEY AND RESUSCITATION OF PATIENTS WITH BURNS 171
edema and pose a greater risk for airway compromise.
Because their airways are smaller, children with burn
injuries are at higher risk for airway problems than
their adult counterparts.
A history of confinement in a burning environment or
early signs of airway injury on arrival in the emergency
department (ED) warrants evaluation of the patient’s
airway and definitive management. Pharyngeal thermal
injuries can produce marked upper airway edema, and
early protection of the airway is critical. The clinical
manifestations of inhalation injury may be subtle and
frequently do not appear in the first 24 hours. If the
provider waits for x-ray evidence of pulmonary injury
or changes in blood gas determinations, airway edema
can preclude intubation, and a surgical airway may
be required. When in doubt, examine the patient’s
oropharynx for signs of inflammation, mucosal injury,
soot in the pharynx, and edema, taking care not to injure
the area further.
Although the larynx protects the subglottic airway
from direct thermal injury, the airway is extremely susceptible
to obstruction resulting from exposure to heat.
American Burn Life Support (ABLS) indications for
early intubation include:
••
Signs of airway obstruction (hoarseness, stridor,
accessory respiratory muscle use, sternal
retraction)
••
Extent of the burn (total body surface area
burn > 40%–50%)
••
Extensive and deep facial burns
••
Burns inside the mouth
••
Significant edema or risk for edema
••
Difficulty swallowing
••
Signs of respiratory compromise: inability
to clear secretions, respiratory fatigue, poor
oxygenation or ventilation
••
Decreased level of consciousness where airway
protective reflexes are impaired
••
Anticipated patient transfer of large burn with
airway issue without qualified personnel to
intubate en route
A carboxyhemoglobin level greater than 10% in
a patient who was involved in a fire also suggests
inhalation injury. Transfer to a burn center is indicated
for patients suspected of experiencing inhalation injury;
however, if the transport time is prolonged, intubate
the patient before transport. Stridor may occur late
and indicates the need for immediate endotracheal
intubation. Circumferential burns of the neck
can lead to swelling of the tissues around the airway;
therefore, early intubation is also indicated for fullthickness
circumferential neck burns.
Pitfall
Airway obstruction
in a patient with burn
injury may not be
present immediately.
Ensure Adequate Ventilation
Direct thermal injury to the lower airway is very
rare and essentially occurs only after exposure to
superheated steam or ignition of inhaled flammable
gases. Breathing concerns arise from three general
causes: hypoxia, carbon monoxide poisoning, and
smoke inhalation injury.
Hypoxia may be related to inhalation injury, poor
compliance due to circumferential chest burns, or
thoracic trauma unrelated to the thermal injury. In
these situations, administer supplemental oxygen
with or without intubation.
Always assume carbon monoxide (CO) exposure
in patients who were burned in enclosed areas. The
diagnosis of CO poisoning is made primarily from
a history of exposure and direct measurement of
carboxyhemoglobin (HbCO). Patients with CO levels
of less than 20% usually have no physical symptoms.
Higher CO levels can result in:
••
headache and nausea (20%–30%)
••
confusion (30%–40%)
••
coma (40%–60%)
••
death (>60%)
prevention
• Recognize smoke inhalation
as a potential cause of airway
obstruction from particulate
and chemical injury.
• Evaluate the patient for
circumferential burns of
the neck and chest, which
can compromise the airway
and gas exchange.
• Patients with inhalation
injury are at risk for
bronchial obstruction
from secretions and
debris, and they may
require bronchoscopy.
Place an adequately sized
airway—preferably a size 8
mm internal diameter (ID)
endotracheal tube (minimum
7.5 mm ID in adults).
n BACK TO TABLE OF CONTENTS