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?