It’s 1993. You are doing a month of elective in Bogotá General Hospital in Colombia. It’s your first week, and you are eating the empanada you got on the street. You turn on the TV: “A HUGE CAR BOMB KILLS 15 IN BOGOTÁ”. The blast has wrecked the fashionable Center 93 mall and nearby shops on the busy 15th Avenue in northern Bogotá. The Government has blamed the fugitive drug trafficker Pablo Escobar for the attack.
As you take the last bite, the red phone rings. EMS is bringing a 30-year old male who was extricated from the scene. The estimated time of arrival is 3 minutes. They hang up the phone. You are stressed, but you keep reminding yourself that you are trained at Kings County Hospital. You got this.
EMS rolls the patient in. This is what you see:
The patient is moaning and not answering your questions. You are not able to “bag” him.
Q: What are some Indications for endotracheal intubation in the burn patient? Early and aggressive airway management is required when inhalation injury is suspected in burn patients.
You grab a Mac 3 blade, and all you see is edematous oropharynx with black soot. The attending asks if you can visualize the cords? You reposition the blade a few times, but still cannot visualize the cords.
Q: What other options do you have to secure an airway in this patient? If you are able to visualize the cords, you can use Bougie. You also can use video laryngyscopy, fiberoptic intubation, or retrograde tracheal intubation. But most importantly you should also be prepared to perform a surgical airway if the upper airway is damaged and orotracheal intubation is not possible. (Remember that the best technique for intubation is dependent on operator expertise.) **When a difficult airway is anticipated, some experts suggests considering an awake intubation with intravenous opioids and local anesthesia**
Q: Which burn patients are at increased risk for inhalation injury? Those found in closed spaces, facial burns, and advanced age are at increased risk. Absence of classic signs of airway obstruction (stridor, voice change, dyspnea) should not reassure one that there is no inhalation injury present. Post-burn edema can progress to complete airway obstruction within minutes to hours, and symptoms of obstruction secondary to laryngeal edema may occur up to 24 hours after injury. Intubation of these patients is extremely difficult. Any patient with visible burns or edema of the oropharynx, full thickness nasolabial burns, or circumferential neck burns should be considered for early endotracheal intubation.
Q: What are the most common physical findings in patients with inhalation injury?
Q: Let's assume the patient did not have obvious signs of inhalation Injury. Who should you intubate prophylactically? Prophylactic intubation is recommended in adults with Total Burn Surface Area > 40% until the resuscitation is complete (first 48 hours), even if inhalation injury is not present.
Q: What are different types of inhalation Injury? Inhalation Injury can be classified into three types: **All three types may coexist.**
Q: What is gold-standard for diagnosis of inhalation injury? (Hint: This is not typically used in the Emergency Department setting) Fiberoptic bronchoscopy is a gold standard for diagnosis of inhalation injury. However, it might be negative if performed immediately after injury. Repeat bronchoscopy should be performed 24-48 hours after).
Special Thanks to Dr. deSouza
bobakzonnoor
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