Management of Upper Airways Burns

INITIAL STABILISATION

1. Airway

• Complete Obstruction

• summon help from the doctor most experienced in airway management.
• Use basic airway opening techniques (GE suction , head position, pharyngeal airway, pharyngeal airway) and attempt ventilation via bag valve mask attached to oxygen
• Attempt incubation without the use of muscle relaxants initially
• If unsuccessful, proceed to emergency surgical airway

• Partial Obstruction

          Diagnosis based on the presence of stride, hoarse voice and/or respiratory distress.

• Humidified oxygen
• Notify anesthetist / surgeon
• Transfer to operating thereat accompanied by skilled staff for examination under an aesthetic / incubation or tracheotomy
• Do not transfer the patient to another institution until incubated

• Potential Obstruction

          Diagnosis based on the presence of sore throat, circumferential neck burns, sooty sputum, burnt mouth/tongue/nasal hairs or history of fire or explosion in confined space. Consider incubation.

2. Breathing

• Measure respiratory rate, and if inadequate, assist ventilation with bag valve mask attached to oxygen.
• Measure SA O2. If <95% and not requiring assisted ventilation, administer high flow oxygen ( 100% O2 via non re breather mask if carbon monoxide poisoning is a possibility)

3. Circulation

• Measure pulse rate, PB and capillary refill
• Attach to a cardiac monitor and assess the rhythm
• Insert IV annular
• Take blood for FBC, biochemistry

4. Disability

          Record a G CS and pupil response. Consider incubation (if this has not already been done), if G CS 8 or below, to protect the airway.

5. Monitor

          - PB, ECG, SA O2

6. Summon

          senior doctor with airway skills

DIRECTED HISTORY AND EXAMINATION

     Ask about

      Event

• Circumstances of the burn(GE enclosed area, explosion, steam)
• Associated trauma if explosion was involved
• Episodes of loss of consciousness (possibly associated carbon monoxide poisoning or head injury)

     Symptoms

• stride / dyspepsia
• cough
• sore mouth/throat
• hoarse voice

Past History

• associated respiratory illnesses (GE asthma)
• medications
• allergies
• medical problems

Look for

Stride, voice changes, oral or nasal burns, facial or circumferential neck burns, nature of cough

Tests

Blood gases, Carboy Hb

DISPOSITION

For complete obstruction with surgical airway in place or partial obstruction:

• Notify anesthetist, NET surgeon
• Notify operating theaters
• When all resources are assembled transfer to the operating theatres accompanied by skilled staff, oxygen, Am bu bag, difficult incubation tray and surgical airway equipment

For potential obstruction, admit to an Intensive Care Unit

If patient transfer is to occur, consider incubation prior to transfer

IMPORTANT POINTS

1. Incubate early if signs or history suggesting airway involvement in burns.

2. Be prepared for a difficult incubation.

3. Involve the available doctor most experienced in airway management.