Remember that There Are Special Considerations Involved with both Intubation and Chronic Airway Management of Burn Patients



Remember that There Are Special Considerations Involved with both Intubation and Chronic Airway Management of Burn Patients


Marisa H. Ferrera MD

Shushma Aggarwal MD



Burns can result from thermal, chemical, electrical, or radiation injury. Thermal injury is most common, accounting for up to 90% of all burn insults. Carbon monoxide poisoning is the most frequent cause of death during and immediately after a fire. If the patient survives the first few hours, morbidity and mortality are related to the total body surface area involved, the depth of the burn, and the patient’s age. The likelihood of airway compromise increases with more serious burns.

Characteristics of major burns include:



  • Partial-thickness burns involving >25% of total body surface area (TBSA) in adults


  • Full-thickness burns involving >10% of TBSA


  • Presence of inhalational injury


  • Involvement of the face, eyes, ears, hands, feet, or perineum causing impairment


  • Caustic chemical burn etiology


  • High-voltage electrical burns


  • Burns in patients with coexisting debilitating disease

Characteristics of moderate burns include:



  • Partial-thickness burns involving 15% to 25% of TBSA in adults


  • Full-thickness burns involving 2% to 10% TBSA

Burns range from first- to fourth-degree, depending on the depth of the destroyed skin. First-degree burns are limited to the epidermis. Second-degree burns extend into the dermis and are divided into superficial and deep partial-thickness burns based on upper or lower dermis involvement, respectively. Third-degree burns include the entire epidermis and dermis, and fourth-degree burns extend into muscle, fascia, or bone.

Total body surface area of burned skin is estimated using the “rule of nines.” Body parts are divided into allotments or multiples of 9% (Table 8.1).


ACUTE MANAGEMENT

Burn patients with inhalational injury may require endotracheal intubation and ventilatory support at the site of the fire. If the patient has an endotracheal
tube (ETT) on arrival to the hospital, do not change the tube; it may be difficult to get another one in place. It is not unusual that burn patients present asymptomatically. These patients have the potential to become problematic because of subsequent sequelae of burn injury that lead to a challenging airway. Burn patients develop excessive amounts of upper- and lower-airway edema as a result of mucosal destruction and capillary leakage that is further exacerbated by fluid resuscitation. Airway edema and narrowing continues for 12 to 24 hours after the initial burn insult. A thorough history and physical are helpful in determining which patients are candidates for early intubation. While assessing the patient, administer oxygen by face mask and monitor oxygen saturation with pulse oximetry.








TABLE 8.1 RULE OF NINES
























Entire head and neck

9%


Each arm

9%


Anterior upper/lower trunk

18%


Posterior upper/lower trunk

18%


Each lower extremity

18%


Genitals and perineum

1%


Each hand

1%


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Jul 1, 2016 | Posted by in ANESTHESIA | Comments Off on Remember that There Are Special Considerations Involved with both Intubation and Chronic Airway Management of Burn Patients

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