# Long Term BLS Airway Management for Burns



## JoeTheBasic (Sep 12, 2017)

Hi all
So this is a hypothetical that I thought of as I have been looking at my next career. 

You are an EMT-B/ Firefighter on a wild-land fire crew. You are asked to treat a patient on a nearby crew with burns to the upper chest and neck. These injuries were caused by a drip torch being handled improperly (burning fluid made contact with person). superficial and partial thickness burns to the chin and singed nose hairs are observed. A MFR is on scene before you and is providing initial care. 

Patient is A&Ox 3 
HR is rapid
RR is elevated
Skin is Pale Cool Clammy 

Patient will need to be evacuated, patient may be ambulatory.
Time to advanced care 30min+

How would you manage the airway in this situation? What would you have ready to go in case the patient goes south and/or the airway becomes compromised?


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## luke_31 (Sep 12, 2017)

If they are SOB then O2 by nasal cannula would be appropriate for now, switching to nom-rebreather mask as needed. Two this is clearly an ALS call to handle the airway beyond that. If the airway gets worse there is the need for a possible intubation, possibly RSI if the situation warrants.  Frankly without drugs for pain management a 30+ min ride to a hospital is going to suck.  It sounds like the burn is relatively extensive so cool, moist dressings would not be appropriate due to the heat loss they would cause over time. What are the lung sounds?  Your hypothetical situation without having ALS nearby honestly sets this patient up for a high risk of death due to swelling of the airway and not being able to get adequate O2 exchange via BVM after they stop breathing.


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## DrParasite (Sep 12, 2017)

Based on your description, this person has a high probability of internal issues(singed nosehairs makes me thing the superhot stuff was inhaled into the lungs).  This person needs a burn center, and needs more care than an EMT can provide.  honest answer?  call for a medevac, get them there in less than 30, this person is going to either be tubed or RSIed.  

What can a firefighter/EMT do?  not much other than watch the person die, at least without additional resources.


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## Summit (Sep 12, 2017)

If you as an suspect airway burns, you should choose RSI capable ALS / the most rapid extrication method available.

*You have only one intervention: O2*
Literally the only thing you can do for this patient is temporize against impaired oxygen transport / diffusion from the alveoli to the pulm capillaries. Other than that, you can cover the burns with dry dsg and keep them themoregulated...
*
BLS cannot manage airway burns (eg edema of epiglottis and distal). It is not something you can manage with a SGA. *

A helicopter is what you want (not necessarily to RSI, but the threshold will be low) to move them safely with pain control to a burn unit where they should get a bronchoscopy.

Here is a good read:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3653783/


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## ThadeusJ (Sep 12, 2017)

To echo the above recommendations, because your offerings are limited _time_ is of the essence.  That you can minimize as its more in your control. You really don't want to play around while a very serious scenario could be unfolding.  If intubation with or without RSI is needed, it can come on pretty quick and if you don't have the tools or skills...


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## Carlos Danger (Sep 12, 2017)

Outside of inhalation of steam or superheated air in an enclosed space, thermal airway trauma resulting in rapid airway edema and obstruction is actually pretty rare. Singing of nasal hair specifically is a poor predictor of thermal airway trauma.

Airway swelling isn't uncommon in burn patients, but it usually has more to do with a combination of increased vascular permeability and large volume fluid resuscitation than it does airway trauma, and it generally happens slowly over a matter of hours.

This guy is very unlikely to swell up and die in front of you. That said, getting him to a hospital expeditiously is certainly prudent.


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## VentMonkey (Sep 13, 2017)

JoeTheBasic said:


> How would you manage the airway in this situation?
> *Closely...very closely, and probably be ready for endotracheal tube placement.*
> What would you have ready to go in case the patient goes south and/or the airway becomes compromised?
> *Induction agents, an ETT a size or two smaller than normal, and a crash airway kit.*


Op, hypothetical or not, there's no such thing as a _long-term BLS airway_ for this sort of situation. 

Even if this patient is not intubated in the field, they definitely (at minimum) need rapid transportation and ALS-capable providers.


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