Was intubation indicated or appropriate?

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FLEMTP

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Ok.. I have a scenario for you folks... I want some opinions.

You respond to a 21 yo male with facial burns

Upon arrival on scene you find a 21 y/o male laying on the ground next to a full size pickup with an ice pack on his face and crying. He states his face burns. You look at the truck and the hood is raised and the radiator cap is missing.

When you question him about the series of events, he states about an hour ago he returned home and parked his truck because it was overheating. He let it sit about half an hour to cool off, went outside and took off the radiator cap, and looked into the radiator, and in the process a burst of steam hit him in the face. his face is red and slightly swollen, with some small blisters forming on his lips. He states he cannot open his eyes because it hurts too bad.

He states he was originally going to have his girlfriend drive him to the ER, but changed his mind because of the pain. He states this happened about 15 minutes ago.

He denies any medical history, medications or allergies. He states he does not smoke, drink, or use illegal substances. He is very insistent that there was only water in the radiator, as he has been dealing with a leak in it & overheating for several weeks now.

His blood pressure is slightly elevated at 142/90, heart rate is 110 and he is breathing at 24 times a minute. He is showing a sinus tachycardia with no ectopy, and his SpO2 is 97% on room air.

His only complaint is pain to the face at the time of your initial exam, pain score 10/10. He denies any respiratory distress, and his lungs sound clear. When you open his mouth to examine his throat you note that he is a Mallampati Class 3 airway, with the soft & hard palate clearly visible. You note no soot, redness or irritation to the muscosa in the throat when he opens his mouth for you to inspect it.

At this point how would you treat the patient?







ok... now some additional:

5-10 minutes into transport he begins to complain of shortness of breath, and you notice he is coughing quite a bit. You note his Sp02 is now 95% on room air, and when he coughs he has a slight barking quality to it. His respirations are now 28, and he does appear to have some mild difficulty breathing. He is becoming anxious, but has no history of anxiety, and states he is scared because he cannot breathe.

How would your treatment change if at all?

Some things to consider:

Nearest hospital to your location is 7-10 minutes away. The nearest trauma center is a Level II trama center 15 minutes away. The nearest burn center is an hour away by air, and 2 hours away by ground.

You do have access to and can perform a drug assisted intubation should you need it. You also have an LMA as a backup, and cricothyroidotomy is in your scope of practice and you do have the tools available to perform this.

You are only with your partner who is driving, but you have access to additional fire or EMS responders who can be to your location within 4 minutes. You have a helicopter available with a 10 minute ETA and a Landing Zone 5 minutes away.

Im interested to see some responses & ideas.
 
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What was his Capnography readings and waveform on initial assessment and upon this change? Did the readings rapidly change or was it a slow progression?
 
medic417 said:
What was his Capnography readings and waveform on initial assessment and upon this change? Did the readings rapidly change or was it a slow progression?
Click to expand...

assume capnography was not placed on initial assessment

Once I get some more responses I'll give out further details.

I dont want to give out *too* much info until I am able to get some opinions.
 
The LMA is out. Definitely not a consideration. I also would definitely not jump right to a cric.

What do his lungs sound like? How's the air movement?

As rapidly as he seems to be progressing, I would be hesitant to pack him up and fly him to the burn center, but the trauma center is likely to be ill-equipped to completely manage his care.

My first inclination is to call for the helicoptor and send him to the burn center, but I say that with a little hesitation. How's that for sure and decisive action?
 
First off.... was the face washed off of any residual chems? Next, pain management. And I usually dose liberally with burns. Does this help any possible pain induced anxiety?
If not... I have 2 choices based on how the pt is presenting and then my 'gut' feeling.

1 - Aggresive: Sedate/paralize and intubate before things get to far with edema. This is one case where I prefer a direct airway vs an indirect method.

2 - Talk calmly with to the pt, consider albuterol and solumedrol for irritation and think strongly about option #1.

Ultimatley he will go to a burn center, but the closest ED will have more tools at hand for stabilization... and they can fly from there. ( and of course... a well placed phone call into med control can help whether to take an extra 5 minutes to the LII center.

Honestly.... with the past thermal airway burns I have had with signs of lower airway involvement... I have gone with option 1, before I have an issue maintaining an airway.
 
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He is getting tubed immediately and we are going to the trauma center 15 minutes away.

I am not waiting for ems or fire responders. I am not waiting for a helicopter. 4 and 10 minute responses are too long. Its time I could be closer to the trauma center or at least the closest hospital.

If I have any trouble getting the tube, we divert to the nearest hospital. The cric might come into play. I like to avoid it though. Ill have the ED preped for ti though.
 
At this point in my education, he's getting a tube.

Signs are showing that he will quite possibly need one soon, and I'd think it would be better to go for it before any edema makes it all but impossible.

Then off to the trauma center we go to stabilize before heading to the burn center.

Again, my education isn't complete (Is it ever?), so hopefully I didn't kill him too bad.
 
Don't forget to call poison control. Radiator fluid is toxic.
 
Have you called Poison Control recently?
 
Dang. Good call on Poison Control. I'd assumed while reading and shouldn't have missed that.
 
I'd go for the tube, but I'd lean a bit more towards nasal while we still have the ability and he's awake / breathing.

I'd be headed for the trauma center as well. Let them do what they need to, then fly / drive him to the burn center once 'stabilized'.




I actually had a facial burn patient the other night with 1/2/3 degree burns to the face, eyes, nose and mouth...
 
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Ok, let me rephrase that. Has anyone called Poison Control recently? Unless you have 10 minutes to spare, let the hospital call them. Seriously. I have had them argue with me because of which center my cell phone routed to. Once you do get through they want a call back number, the name, address, and phone number of the hospital, your ETA to said hospital, the patients name, birthday, address, and SSN before they will give you instructions. I know of a couple of ER doctors who will not call them anymore because of issues they have had.
 
Aidey said:
Ok, let me rephrase that. Has anyone called Poison Control recently? Unless you have 10 minutes to spare, let the hospital call them. Seriously. I have had them argue with me because of which center my cell phone routed to. Once you do get through they want a call back number, the name, address, and phone number of the hospital, your ETA to said hospital, the patients name, birthday, address, and SSN before they will give you instructions. I know of a couple of ER doctors who will not call them anymore because of issues they have had.
Click to expand...

I've never had a problem. I do not allow it to delay care. If I need to do something else I let someone else hold phone. Never has taken more than a couple of minutes.
 
A few of the agencies around here, mine included, are allowed/expected to call Poison Control with toxicological emergencies and use them in place of med control.



But have I called? No. Never been in the situation to have to.
 
It may be a question of regional policies/practices, but I know I am not the only one who has had issues. The fact that ER doctors are refusing to call them is a big indication that I'm not imagining things.
 
Meh, rather silly that they choose not to call for that reason.


That's like not asking a cardiologist about a cardiac patient...
 
If you don't like one cardiologist you can always consult another. Just becuase you don't call PC doesn't mean you can't get the information you need.
 
First, did we visualize any signs of airway burns when we looked at his malampati? Did his pharnyx look unusual at all?

Tubed via medication and flown to a burn center. The flight crew should be able to handle this pt once the airway is secure. If when we go to look at cords there is any damage that looks like it may interfere with airway placement, go directly to crich, do not pass go, do not collect $200.

Once his airway is secure, heavy doses of sedation and pain control as approprite. Hopefully we have access to a vent, as a BVM is a poor choice in this case.
 
usalsfyre said:
First, did we visualize any signs of airway burns when we looked at his malampati? Did his pharnyx look unusual at all?

Tubed via medication and flown to a burn center. The flight crew should be able to handle this pt once the airway is secure. If when we go to look at cords there is any damage that looks like it may interfere with airway placement, go directly to crich, do not pass go, do not collect $200.

Once his airway is secure, heavy doses of sedation and pain control as approprite. Hopefully we have access to a vent, as a BVM is a poor choice in this case.
Click to expand...

The thing that makes me hesitant about this situation is that his sats are already dropping off. With lower airway burns, the longer he's not on a ventilator with controlled airway pressures, the more potential for further trauma to his lungs, so he needs to be on a non-transport vent as soon as possible. But on the flip side, if he's deteriorating this quickly, he's going to need the burn center because in 3 days he's not going to be tolerating ANY ventilation and will be on an oscillator.

It's all about buying time to get him to an appropriate facility.

Since it seems like he'll be a relatively difficult intubation, I think it would be best to hold on till we're waiting at the LZ for the helicoptor and tube him then. Many hands makes light work. There will only be one attempt on this tube...I would want all the planets that I had control of to be aligned, no shooting from the hip.
 
How are his lung sounds? Is there any stridor or increased work of breathing? What about a second look in his mouth, is his tongue getting bigger, do we note any new redness or swelling elsewhere in his mouth? I think without any further findings other than a complaint of difficulty breathing I would be hesitant to tube him. That being said, tubes would be ready and should his voice change or start to have stridor or an increase in anxiety and a further drop in sats I'd nasally tube him. I'm interested to see how it all turns out.
 
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