Inhalational Injury and Airway Management William J C van Niekerk Consultant Burns and Plastic Surgeon Queen Elizabeth Hospital Birmingham and Birmingham.

Inhalational Injury and Airway Management

William J C van NiekerkConsultant Burns and Plastic Surgeon

Queen Elizabeth Hospital Birmingham andBirmingham Children’s Hospital

Scope

• Importance of early recognition

• Signs and symptoms of inhalational injury

• Pathophysiology• History• Initial management• Longer term therapy

Acknowledgement

• Dr Gerwyn Rees, Consultant Anaesthetist

Importance of Early Recognition and Intervention

• Thermal injury and smoke inhalation set off the inflammatory cascade

• Associated vasodilatation, oedema, and capillary leak

• Intervene early before rapid progression to upper airway obstruction ensues

Primary Survey

• A (with c-spine immobilisation and intubation if required), B (give O2), C, D, and E

• Early airway security is paramount before oedema and airway compromise develop

• Much higher mortality/ morbidity associated with inhalation burns

• Large cutaneous burns often indicate an inability to escape flame and risk smoke inhalation

Secondary Survey: Signs and Symptoms of Inhalational Burn

• Hoarseness• Change in voice• Complaints of sore

throat• Odynophagia• Carbonaceous sputum• Tachypnea• Singed facial hair• Wheezing, rales, and

use of accessory muscles

• Burn injury of peri-oral/nasal regions

Pathophysiology• Asphyxiation - reduces

inspired oxygen concentration• Thermal Burn

– Thermal damage - upper airway affected due to poor conductivity of air

• Chemical Burn and Toxicity– Carbon Monoxide toxicity,

Cyanide toxicity, Methaemoglobinaemia

– Pulmonary irritation - causes direct irritation, tissue damage, bronchospasm, and inflammatory response

– A vast array of other chemicals

History• AMPLE history• Specifically to elicit inhalation

injury:– Fires in closed spaces increase risk

of inhalational injury– Particular materials in fires may

contain dangerous asphyxiants and toxins

– Polyurethane, wool, and silk increase risk of CN toxicity

– Loss of consciousness at scene – Any pre-morbid respiratory factors

e.g. asthma, COPD

Management• Oxygen, oxygen, O2, O2, O2,

O2, O2, O2, O2, O2 ...• High index of suspicion/early

recognition• Most experienced

anaesthetist available to assess and manage

• If intubation is indicated: use UNCUT endotracheal tube to allow for further swelling

• Tied initially but later wired to teeth to prevent proximal dislodgement during swelling

Further Management on ITU

• Ventilatory support on ITU• Inhalation injury equires more fluid than suggested by

TBSA% burn• CO:

– Half life of 4 hours– 1 Hour on 100% O2– Not only haem-bound, but also cellular

• Physiotherapy• Bronchoscopy and lavage• Nebulisers: epinephrine, N acetylcysteine, and heparin• Sputum cultures• Early ambulation

Summary

• History, signs and symptoms of inhalational injury

• Early airway security is paramount• Experienced anaesthetist• Pathophysiology – so as not to forget CO, etc.• Uncut endotracheal tube• Management on ITU

Questions?