1 Assessment at the Scene

First responders have a crucial role in the early management of burn patients. In addition to the usual trauma assessments, emergency medical service (EMS) staff must determine whether the patient’s condition warrants immediate intubation in the field or the patient can be observed. Indications for intubation at the trauma scene include the following^4,5:

Patients with a flame injury from a barbecue or fire in an open space may have burns to the neck and face but no airway involvement and therefore do not require early intubation.

In addition to initial medical management of the patient, EMS staff gathers information about the type of injury and the patient’s medical history. The information should be recorded for transport with the patient to a specialized burn center.

The practice of prehospital intubation of the burned patient has been questioned. Eastman and colleagues⁶ reviewed the charts of 1272 patients admitted after field intubation over a period of 23 years and found that 69% of them survived. However, 30% of the survivors were extubated on admission or on the second day after the burn. None required reintubation. Klein and associates⁷ reviewed the charts of patients admitted to the Washington Burn Center after a transport of more than 90 miles for the period of 2000 through 2003. They examined parameters such as duration of transport, error in burn severity estimation, fluid management, appropriateness of intubation, and transport complications. Of 1877 patients, 424 were transported more than 90 miles to the burn center. No patient died during transport, and 111 patients arrived intubated, with only 61% having inhalational burns. More than 50% of patients were extubated within the first 24 hours after admission.

Failure to secure an airway was one of the most common complications occurring during patient transport. The fact that airway obstruction can develop very quickly in burn patients and that the experience and equipment of EMS are often limited supports intubation in the field before transport in the patient with a potential for respiratory compromise.

2 Assessment in the Hospital

Roughly 10% of burn patients also present with other traumatic injuries. All burn patients are considered trauma patients and consequently undergo a primary trauma survey (i.e., the ABCDE algorithm: airway, breathing, circulation, disability, and exposure).⁸ The extent and surface area of the burn are noted, other traumatic injuries identified and treated, and the airway secured if indicated. The incidence of inhalational trauma, length of hospital stay, and mortality rate are increased for patients presenting with burns and other traumatic nonburn injuries.⁹

On arrival of the patient at the burn center, the tube position is confirmed with carbon dioxide (CO₂) monitoring and auscultation of the lung fields. Uncertainty about endotracheal tube (ETT) placement should be remedied by direct laryngoscopy or fiberoptic bronchoscopy. The mouth, pharynx, and larynx are examined by laryngoscopy to assess edema and identify any burned mucosa and the presence of soot (Fig. 44-1). A radiograph is obtained to verify the ETT position and identify other potential injuries, such as a pneumothorax. Lung parenchymal injuries usually are not immediately detectable by radiography immediately after injury. Patients presenting with a supralaryngeal airway (SLA) on arrival at the hospital require endotracheal intubation or a surgical airway.

Figure 44-1 Carbonaceous sputum, singed nasal hairs, and facial burns indicate possible upper airway thermal injury.

In the unintubated patient, the presence of soot in the sputum, dyspnea, tachypnea, hoarseness, and stridor are signs of impending airway obstruction. Fiberoptic endoscopy is the gold standard for the diagnosis of inhalational trauma.^10–17 In the awake patient, a nasal fiberoptic examination under local anesthesia can be performed to evaluate the larynx and confirm the presence or absence of edema and soot. Patients with altered mental status, dyspnea, hoarseness, or stridor require immediate intubation.

A relevant history for airway management after burn injury includes the following information:

Rarely, inhalation of hot steam and hot fluids can lead to a rapidly progressive upper airway edema. Chemical fires can have more complex sequelae because the chemicals themselves can injure tissues after extinction of the fire. The circumstances of the burn injury and its duration can help to discern the likelihood of carbon monoxide (CO), cyanide (CN), and other toxicities.

3 Altered Mental Status

An isolated burn injury usually does not produce a mental status change early in the disease course. A disoriented, stuporous, or unconscious burn patient should be closely examined for additional trauma. Burn-related reasons for altered mental status include inhalation-induced hypoxemia, CO poisoning, CN toxicity, and electrical injury. Other sources of altered mental status include head trauma, alcohol or drug ingestion, metabolic disorders, seizures, and psychosis. Patients with altered mental status should be intubated and ventilated with 100% O₂ until CO poisoning and CN toxicity can be ruled out. Intubation should be performed using maneuvers to stabilize the cervical spine (C-spine) if neck injury has not been ruled out.^{10,12,17,20,21}

4 Cardiovascular Abnormalities

Cardiovascular instability, dysrhythmia, and cardiac arrest can be consequences of CO intoxication. Cardiac disturbances can also result from innate cardiac disease combined with the response to traumatic injury. Hypotension is often caused by fluid loss associated with burns. Hemorrhagic and neurogenic shock can also lead to hypotension in these patients as a consequence of nonburn injuries. The airway should be secured in hemodynamically unstable patients.^10,17,22

5 Neck and Face Burns

Extensive burns of the face and neck produce facial edema, making direct laryngoscopy difficult or impossible. These patients may have pharyngeal and laryngeal edema, further complicating intubation (Fig. 44-2). Delay in securing the airway can lead to a “cannot intubate, cannot ventilate” situation. Surgical airways must be performed in this instance.^10,17,21,23

Figure 44-2 Severe airway edema continues to progress for several days after initial injury and intubation.

6 Extensive Burns

Patients with large body surface area burns frequently have airway burns as well (Fig. 44-3). Edema after resuscitative efforts can make intubation impossible. After massive burns, patients develop a hypermetabolic state leading to increased CO₂ production requiring ventilator support. Some physicians suggest prophylactic intubation for total body surface area burns greater than 30%.^10,12,17,22

Figure 44-3 Extensive burns to the chest and neck can require immediate escharotomy to facilitate ventilation.

7 Additional Injuries

Burn injuries can occur in explosions. In this setting, blast injuries, including pneumothorax and eardrum perforation, must be addressed. To escape a fire, victims often jump from windows, sustaining fractures. Burns caused by vehicular trauma can be associated with other traumatic injuries. Electrical high-voltage contact can be accompanied by brain edema, cardiac dysrhythmias, myonecrosis, and rhabdomyolysis with renal injury. C-spine injury should be ruled out as expeditiously as possible in the course of patient management, depending on the nature of the primary injury.

1 Injury to the Respiratory Tract