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Adult Burn - Case Review - Part 2

BURN Part 2

We started off this second part to the burn case review with a history of what happened and a rapid trauma assessment.  Let’s take the management of this patient one system at a time. Like Klint had mentioned, and what you should know is, we are not moving past the airway until we come up with a plan of action. This patient is at a critical juncture and how you deal with it now can have grave consequences minutes, hours and days down the road in her anticipated clinical course. 

 Let’s talk about the pathophysiology of her airway burn. Coming out of the environment she was in, we know a few things that are potentially occurring. She likely either has lower airway damage, flame burn, smoke inhalation or a combination of all three. Each type has their own associated issue and one can actually perpetuate the others. There are many factors that go into determining the extent of the injury. Elements like exposure time, what was burning (wood versus carpet, furniture, etc.), the heat that was generated and of course the patient’s own existing and underlying medical problems. In the case of lower airway burns, the carbon particles adhere to the mucosa damaging the cilia. When that occurs, depending on the extent, the patient cannot clear foreign matter. As that continues, cell membrane damage occurs, followed by a cascade of inflammation and swelling which ultimately affects the patient’s ability to ventilate and oxygenate. In this case study, the patient was alert and to some extent was able to protect her lower airway, either by holding her breath (when she could) or by using a shirt or something else to cover her mouth and nose. Unconscious patients lose that ability...

 Another issue for this (and most burn patients) is exposure to carbon monoxide (CO). During the burning process and as a result of incomplete combustion of the materials burning, CO can be a major contributor in the mortality of a burn patient. Even a small amount of CO can inhibit the ability to offload oxygen. Since affinity of CO to hemoglobin is so great, the seats on the hemoglobin become fully occupied, which leads to less oxygen delivery. Remember, this patient was a 2-pack a day smoker, so she likely has an elevated CO level to begin with. Smokers can have a baseline SpCO reading of 10 PPM (parts per million) or more. 

Looking at her vital signs, we find the following:

  • BP: 160/70 mmHg
  • HR: 100 BPM
  • RR: 20 BPM
  • SpO2: 89% on a NRB
  • EtCO2: 50 mmHg
  • SpCO: 16 PPM

Based on these findings, it becomes clear that we need to perform a medication facilitated intubation. We are going to be transporting this patient to the burn center which is 20 minutes away. 

We inspect her airway by having her open her mouth wide and stick out her tongue. She is compliant, and you note a class 3 Mallampati score with associated soot and edema present.  You take out your rapid-sequence induction for intubation checklist and prepare your equipment. You ask how much she weighs, and she tells you 168 pounds. 

For the next article, we are going to discuss the medication selection for this intubation. In the meantime, think about your options as you have the following medications at your disposal:

  • Versed
  • Etomidate
  • Ketamine
  • Succinylcholine
  • Rocuronium
  • Nimbex
  • Vecuronium
  • Fentanyl

Check back for a continuation of this case on the Adult Burn, Part 3...

Peer Review #1:

 Mike explains a burn patient with definite airway priority. However, he reminds us that just getting a piece of plastic between the cords, doesn’t mean we are out of the woods. We also are concerned about lung injury and inflammation from the exposure. It is important that a lung protective strategy be used right from the beginning with ventilation. If you are forced to use a bag, be smart about it. Remember that cyclic opening and closing of the lungs is like tachycardia beating against the walls of an aneurysm. 

Always consider cyanide poisoning with all burn patients. We know cyanide interferes with oxygen binding to the last molecule in the electron transport chain. The symptoms of cyanide poisoning are very vague and mimic carbon monoxide exposure.

Airway Camouflage is very real complication of intubating a patient who has had significant heat and smoke exposure to the airway. This, plus laryngeal inflammation can make it very hard to identify landmarks. Slow and progressive laryngoscopy will be key!

It’s also important to realize engaging the hyoepiglottic ligament might not be enough to reveal the cords if the epiglottis is swollen. If confronted with this, I try to use the Mac as a Miller and lift the epiglottis out of the way. If using video laryngoscopy, I will make an intentional effort to go deep. A Bougie with cudae tip will be needed to deflect a more anterior angle that is needed.

Tyler Christifulli, CCP, NRP, FP-C

Peer Review #2:

This case nicely illustrates a classic dilemma in the prehospital care of burn patients.  We all know that the potential for evolving airway compromise justifies a more aggressive approach to airway management.  However, the past decade has taught us that intubation is not always the life saving procedure we assumed, with the increased morbidity and mortality forcing us to reconsider an aggressive ABC's approach.
This patient has a clear indication for intubation (hypoxemia following burn injury) but is awake and talking, suggesting a patent airway at the moment.  She is going to require bronchoscopy today to evaluate the extent of her airway damage.  Ideally, the decision regarding intubation could be made with the benefit of this additional information.  With a short transport time to a burn center, it would be reasonable to defer intubation until bronchoscopy.  That said, it would also be reasonable to be pre-emptive and intubate now while her airway is patent.
That's not to say that it would be an easy intubation, even with the current patent airway.  The significant hypoxemia will limit apnea time to only a few seconds.  Rather than rushing to paralyze her, it would be reasonable to use positive airway pressure therapy to improve SpO2 values before "pulling the trigger" and inducing paralysis.  Bilevel ventilation ("BiPAP"), continuous positive airway pressure ("CPAP"), or assisted ventilation using a bag-valve mask with the patient in a seated position are all reasonable pre-oxygenation strategies to correct hypoxemia and target SpO2 values above 93%.  And once paralysis is induced, intubation attempts should be brief, with optimal bag-valve-mask ventilation between attempts to "re-oxygenate".
Dr. Dan Davis, MD

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