Airway management for inhalation injury

[Chris07]

A few months back when taking a WFR course, I was presented with an unusual scenario:
24 y/o female intoxicated with ETOH was cooking when her stove exploded in her face causing 2nd and 3rd degree burns across her face. After a couple minutes she began developing wheezing due to lower airway swelling.

From a BLS standpoint, that wheezing is the last thing you want to hear as there is nothing you can do to manage the patient's airway once it's fully constricted. Thus diesel is the only tool in the arsenal.

From an ALS standpoint, correct me of I'm wrong, but wouldn't RSI be indicated so that you could get a tube in place before the airway completely closes shut?

The question that's really baking my noodle is what could a medic do if their system did not allow RSI? (like most systems) Is there really anything? I'd imagine that in an urban environment (<15 min transport time) that it's all about rapid transport. With extended transport times, let's say >30 min, does this patient really even stand a chance with a rapidly swelling airway due to inhalation burns?

Thanks for the insight guys.

 

[blindsideflank]

K well I'll try to answer some things. Burns usually only burn the upper airway because the mucosa and fluids cool it down before it gets too far, there are always exceptions but you only usually see this with chemical inhalations and steam.

Couple things that will be brought up as well. Hyperkalemia from sux isn't a worry until several hours (5?) after the burn but can still happen in as low as ?!?! 7% BSA.

If you hear wheezing... You may have lower airway burn. Intubate and peep? With atrovent especially to decrease secretions. I'd pretreat with ketamine too. Steroids?
Stridor is bad news and indicates upper airway swelling. rsi is indicated

Can you drug them without paralytics and intubate, spray lots lido on those cords if you use ketamine cuz you don't want a spasm.

What can you do? Try a tube when gcs is low? Or go straight to crichothyroidotomy . If you didn't tube prehospitally then this is what the hospital will have to do.

 

[blindsideflank]

[youtube]bDRTzmuwMnQ[/youtube]


If embed didn't work
http://m.youtube.com/index?desktop_uri=/&gl=CA#/watch?v=bDRTzmuwMnQ

 

[Chris07]

Thanks for the reply!

How uncommon are lower airway burns with "flames to the face"?

After thinking about it, The scenario was probably trying to show an upper airway burn. I assumed that it was audible wheezing and assumed lower airway burn but in the scenario it may very well have been stridor. It was a little difficult to tell the difference with an actor instead of the real thing.

 

[Christopher]

A few months back when taking a WFR course, I was presented with an unusual scenario:
24 y/o female intoxicated with ETOH was cooking when her stove exploded in her face causing 2nd and 3rd degree burns across her face. After a couple minutes she began developing wheezing due to lower airway swelling.

If you're out in WFR/WEMT land (I'm a WEMT) then you're looking at a cric if they fall out.

If you're not in WFR/WEMT land then it is a matter of patient condition versus transport time.

At one of my services we're aggressive with RSI, but would likely ride this patient in unless we had >15-20 minutes of transport or a sense of impending respiratory arrest.

Otherwise you could provide high flow O2 and perhaps just nebulize normal saline to make it "humidified". High-fowlers positioning and LOTS of pain control.

Lots. Of. Pain. Control.

You won't make the slightest dent in their respiratory drive if they really have sustained substantial burns. Versed and fentanyl and keep it coming until you run out of both or you make it to the hospital, whichever comes first.

 

[blindsideflank]

I work rural and we get one a year from camp stoves blowing or kids throwing gas/spray paint into bonfires. But these don't always get the airway, often just facial burns.


http://www.easyauscultation.com/lung-sounds.aspx
There might be better sites to learn lung sounds but this one looks good. Take a chance to listen to lots of lungs when you can and get used to trying to hear them in crying kids, even if it's a hangnail.

How common? Not common but I think it is mentioned in the itls book and they seem to give statistics but I don't have the book so maybe someone else can find it. Like I said though, chemical burns and steam get deep into lungs.


Standby for better answers than I can give though...

 

[Veneficus]

Lower airway burns are not as common as upper airway.

As for not having RSI, You can try a nasal-tracheal intubation.

In a burn you may need a smaller tube.

If in your ability, you may also want to "consider" some steroids, as the swelling from the burn is actually an inflammatory process.
(I would think the onset of the steroids would be too slow to help in the acute airway phase for the record)

If the injury is to the lower airways, increased positive pressure of ventilation will really be the key.

A surgical cric will do nothing for occlusion of the bronchioles. There will also be significant alveolar edema.

The one cell layer thick alveoli also do not hold up well to injury.

So actual oxygenation may be more difficult than simple ventilation.

 

[Doczilla]

RSI is a pretty safe bet (I know that wasn't part of the original question). If you have ketamine as an induction agent, I would be suprised; but great drug for that.

I would consider 2mg/kg of solu medrol if I had the time for it. Onset time is fairly respectable compared to dex.

I don't know if systems use racemic epi, been in the army too long.

 

[blindsideflank]

At one of my services we're aggressive with RSI, but would likely ride this patient in unless we had >15-20 minutes of transport or a sense of impending respiratory arrest.

If you are comfortable with the tube ( experience and lemons) then I would get it. The hospital will thank you and if there is swelling you will only get a small tube in if it's not too late. Any airway sounds, to me, imply impending response problems ( in an acute burn) of course you are looking for facial burns, carbonaceous sputum etc.

This is why I like ketamine, if you miss the tube you may still have response drive and tone, although the argument is to paralyze and get the best shot at hitting the tube. I have a book that recommends paralyzingly everybody because it can increase success by 30%. (I look for the source) this doesn't take into account being out of hospital though.

 

[Christopher]

If you are comfortable with the tube ( experience and lemons) then I would get it. The hospital will thank you and if there is swelling you will only get a small tube in if it's not too late. Any airway sounds, to me, imply impending response problems ( in an acute burn) of course you are looking for facial burns, carbonaceous sputum etc.

We're comfortable, just a median transport time of 7 minutes. Factor in the time it takes to call for RSI orders, establish an IV, draw up and push the meds...we're hospital based so they're usually comfortable with our decision either way.

This is why I like ketamine, if you miss the tube you may still have response drive and tone, although the argument is to paralyze and get the best shot at hitting the tube. I have a book that recommends paralyzingly everybody because it can increase success by 30%. (I look for the source) this doesn't take into account being out of hospital though.

I wish we had ketamine...soon though, soon!

 

[Handsome Robb]

As for not having RSI, You can try a nasal-tracheal intubation.

Beat me to it.

I don't have the option to RSI, so it's lots of lido jelly and spray, an apology and a NTI.

With that said, airway burns meet our criteria for HEMS to the burn center and depending on the geographical location they will either do a scene flight or meet you at the landing pad at the ER and our flight crews can do RSI so that's an option too.

They are often dispatched simultaneously to an "airborne standby" if a serious sounding call drops in one of the outlying valleys we cover.

 

[Steam Engine]

A few months back when taking a WFR course, I was presented with an unusual scenario:
24 y/o female intoxicated with ETOH was cooking when her stove exploded in her face causing 2nd and 3rd degree burns across her face. After a couple minutes she began developing wheezing due to lower airway swelling.

From a BLS standpoint, that wheezing is the last thing you want to hear as there is nothing you can do to manage the patient's airway once it's fully constricted. Thus diesel is the only tool in the arsenal.

From an ALS standpoint, correct me of I'm wrong, but wouldn't RSI be indicated so that you could get a tube in place before the airway completely closes shut?

The question that's really baking my noodle is what could a medic do if their system did not allow RSI? (like most systems) Is there really anything? I'd imagine that in an urban environment (<15 min transport time) that it's all about rapid transport. With extended transport times, let's say >30 min, does this patient really even stand a chance with a rapidly swelling airway due to inhalation burns?

Thanks for the insight guys.

So what was the suggested treatment by a WFR?

 

[EMT John]

Out here in Cali we don't have RSI so NTI would be the way to go. Might have to do a cricotomy.

 

[Chris07]

Out here in Cali we don't have RSI so NTI would be the way to go. Might have to do a cricotomy.

But do all counties in CA allow you to do NTI? Kind of SOL if you're in a place where even NTI isn't allowed.

So what was the suggested treatment by a WFR?

Not much. Supportive care and Emergent evac. "Get to the choppa!"

 

[Veneficus]

Out here in Cali we don't have RSI so NTI would be the way to go. Might have to do a cricotomy.

You have a protocol for surgical cricothyrotomy, but not NTI?

Where do they get these medical directors from?

 

[EMT John]

No I said we have protocol for NTI, not for RSI.


I appoligize... I miss spoke about the cricotomy I meant needle cricothyrotomy.