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Inhalational Injury and Airway Management

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Inhalational Injury and Airway Management

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  1. Inhalational Injury and Airway Management William J C van Niekerk Consultant Burns and Plastic Surgeon Queen Elizabeth Hospital Birmingham and Birmingham Children’s Hospital

  2. Scope • Importance of early recognition • Signs and symptoms of inhalational injury • Pathophysiology • History • Initial management • Longer term therapy

  3. Acknowledgement • Dr Gerwyn Rees, Consultant Anaesthetist

  4. Importance of Early Recognition and Intervention • Thermal injury and smoke inhalation set off the inflammatory cascade • Associated vasodilatation, oedema, and capillary leak • Intervene early before rapid progression to upper airway obstruction ensues

  5. Primary Survey • A (with c-spine immobilisation and intubation if required), B (give O2), C, D, and E • Early airway security is paramount before oedema and airway compromise develop • Much higher mortality/ morbidity associated with inhalation burns • Large cutaneous burns often indicate an inability to escape flame and risk smoke inhalation

  6. Secondary Survey: Signs and Symptoms of Inhalational Burn • Hoarseness • Change in voice • Complaints of sore throat • Odynophagia • Carbonaceous sputum • Tachypnea • Singed facial hair • Wheezing, rales, and use of accessory muscles • Burn injury of peri-oral/nasal regions

  7. Pathophysiology • Asphyxiation - reduces inspired oxygen concentration • Thermal Burn • Thermal damage - upper airway affected due to poor conductivity of air • Chemical Burn and Toxicity • Carbon Monoxide toxicity, Cyanide toxicity, Methaemoglobinaemia • Pulmonary irritation - causes direct irritation, tissue damage, bronchospasm, and inflammatory response • A vast array of other chemicals

  8. History • AMPLE history • Specifically to elicit inhalation injury: • Fires in closed spaces increase risk of inhalational injury • Particular materials in fires may contain dangerous asphyxiants and toxins • Polyurethane, wool, and silk increase risk of CN toxicity • Loss of consciousness at scene • Any pre-morbid respiratory factors e.g. asthma, COPD

  9. Management • Oxygen, oxygen, O2, O2, O2, O2, O2, O2, O2, O2 ... • High index of suspicion/early recognition • Most experienced anaesthetist available to assess and manage • If intubation is indicated: use UNCUT endotracheal tube to allow for further swelling • Tied initially but later wired to teeth to prevent proximal dislodgement during swelling

  10. Further Management on ITU • Ventilatory support on ITU • Inhalation injury equires more fluid than suggested by TBSA% burn • CO: • Half life of 4 hours • 1 Hour on 100% O2 • Not only haem-bound, but also cellular • Physiotherapy • Bronchoscopy and lavage • Nebulisers: epinephrine, N acetylcysteine, and heparin • Sputum cultures • Early ambulation

  11. Summary • History, signs and symptoms of inhalational injury • Early airway security is paramount • Experienced anaesthetist • Pathophysiology – so as not to forget CO, etc. • Uncut endotracheal tube • Management on ITU

  12. Questions?