CASE 33
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Incident
A 40-year-old mining worker has been involved in a gas explosion and subsequent fire. He has sustained burns to the face and circumferentially to both lower limbs (totalling 25% burn surface area [BSA]). He was intubated and ventilated on arrival at a regional hospital Emergency Department approximately 3 hours ago and now requires retrieval to a specialist burns centre.
Relevant information
Questions
33.1 Describe the findings illustrated in the picture on the previous page.
33.2 Outline the specific issues relevant to the management and safe retrieval of this patient.
33.3 What would be the indication for lower limb escharotomy in this retrieval environment? If indicated, how should the procedure be performed?
Discussion
33.1 There is a significant facial burn injury, which appears to include areas of both deep partial thickness (wet, erythematous) and full thickness (dry and pale or charred) burn injury involving the entire face but not the neck. There is extensive associated tissue oedema. Both nares are heavily coated with soot, blood or charred tissue. There is a dressing over the left anterior shoulder. An oral tracheal tube is visible at the lips and has been pre-cut. A gastric tube is also visible adjacent to the tracheal tube. A tracheal tube tie is in situ but partially obscured by the tissue oedema. Ventilation circuitry is visible, including sidestream ETCO2 chamber and sampling tubing.
33.2 Pre-departure
Assessment
Although overt, the burn injury may be only one of a number of serious injuries. The mechanism of an explosion should flag the need to consider blunt, penetrating and blast trauma pathophysiology. Seek collateral historical information if available (e.g. from coworkers) and clarify the patient’s past medical history, tetanus status, known allergies and current medications. Also clarify the nature of the pre-hospital scene including enclosed-space fire exposure (raising the risk of carbon monoxide, cyanide and prolonged super-heated gas inhalation) and additional trauma mechanisms such as a secondary fall from height. The clinical findings and therapy both pre-hospital and in the Emergency Department should also be reviewed. Questions to ask would include:
• Was he anaesthetised only to protect his airway from actual or impending oedema and obstruction?
• Was he developing respiratory failure?
• Was he unconscious?
• Was there evidence of a head injury?
In addition, ask what radiological investigations have been done.
A thorough head-to-toe clinical review should then occur with specific focus on airway security, vascular access and evidence of additional injuries.
Interventions
The initial concern here is airway security as a pre-cut tracheal tube has been placed and facial tissue oedema is likely to progress. There is no avoiding the need to exchange the tracheal tube as extubation in transit is a very real possibility if the current tracheal tube remains secured to the swelling facial tissues. This is a high-risk procedure. Involvement of on-site senior anaesthetic personnel and/or additional ‘difficult airway’ equipment (e.g. airway exchange catheter, fibreoptic scope) is advised. A contingency plan including emergency surgical airway (note the neck is relatively spared) should be made and clearly articulated to all team members (see Case 6 and Appendix 1.1). If a fibreoptic scope is available, endobronchial burn injury can also be ascertained.
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