Would you immediately intubate this patient?

[unchartedem]

30 year old M with approx 9% burns to his right arm (2nd degree), in an enclosed large apartment with smoke for about 10 -20 minutes. Patient here vital signs completely stable, no burns to face however has sooty sputum and snot. Lungs completely clear, patient can handle secretions, and denies any SOB. No facial or neck swelling. Would you intubate this person right away? or would you do a flexible bronch or indirect laryngoscopy first? And if you didn't have these services available would you transfer to a burn center(and i guess intubate prior to transfer)? The reason I ask is because I've seen an attending do the latter but the books say the former.

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[EctopicFetus]

NO substitute for experience

 

[RustedFox]

The reason I ask is because I've seen an attending do the latter but the books say the former.

Heh-heh-heh.


No, I would not immediately intubate this patient.

 

[unchartedem]

So technically this should indicate possible(not probable) inhalation injury. I've read that inhalation injuries are part of the criteria for burn unit referral. So if one were to transfer this patient to a burn center it seems it would be prudent to intubate them prior to transfer just in case of the slight chance that things went south in the ambulance. Any thoughts?

 

[tkim]

30 year old M with approx 9% burns to his right arm (2nd degree), in an enclosed large apartment with smoke for about 10 -20 minutes. Patient here vital signs completely stable, no burns to face however has sooty sputum and snot. Lungs completely clear, patient can handle secretions, and denies any SOB. No facial or neck swelling. Would you intubate this person right away? or would you do a flexible bronch or indirect laryngoscopy first? And if you didn't have these services available would you transfer to a burn center(and i guess intubate prior to transfer)? The reason I ask is because I've seen an attending do the latter but the books say the former.

Had a case where a woman had fallen asleep in her apartment while boiling a pot of spaghetti which burned. The entire apartment filled with smoke from the charred noodles, and she was brought by EMS because she had a sooty airway.

She absolutely refused to be intubated or admission and signed out AMA. I fully expected to read about her in the obits. But she came in a couple of weeks later, fine. She was bat**** crazy but otherwise fine.

In residency, had a similar case where a woman had fallen asleep in her apartment and it burned. This woman had a sooty airway, but also burns across her face and chest as well. Etomidate and suxxed her and took a look in her airway and barely had time to throw a bougie down before the glottis swelled and closed around it. I rammed a very small ETT over the bougie and was lucky to get that.

Their airways looked the same, but the presence of other burns and *what* burned seemed to be a predictor of badness.

 

[Apollyon]

In residency, had a similar case where a woman had fallen asleep in her apartment and it burned. This woman had a sooty airway, but also burns across her face and chest as well. Etomidate and suxxed her and took a look in her airway and barely had time to throw a bougie down before the glottis swelled and closed around it. I rammed a very small ETT over the bougie and was lucky to get that.

Their airways looked the same, but the presence of other burns and *what* burned seemed to be a predictor of badness.

Dude, you actually saw the swelling in real time? That is hard core, man! I can imagine the pucker factor going to 11 (at the same rate as the swelling)!

 

[Rendar5]

I'd do nasolaryngoscope to see if there was soot or burns by the cords, and depending on that i'd make my decision. If soot, I'd admit or xfer to a burn unit for observation. If erythema, I'd intubate prior to a xfer, or send to the unit unintubated if staying at my own hospital. If swelling, obviously I'd use plastic

 

[RustedFox]

Nasolaryngoscope ?

Maaan, where do you guys get all these cool toys ? Send some my way.

 

[ptarmigan]

In terms of the airway - How do the oropharynx and nares look? Any uvular edema? Soot or burns all the way back to posterior oropharynx and turbinates? If that is the case, would just go ahead and intubate. Otherwise, I would do a fiberoptic laryngoscopy. If I did not have that, I probably would give ketamine and do video laryngoscopy. If there was badness at the level of the epiglottis or below I would intubate. If not, Obs in ED for some amount of time and admit to ICU for airway monitoring.

A 9% burn that involves only the RUE would be circumferential from the shoulder to the tips of the fingers. If that is indeed the case that's a pretty bad burn which may require escharotomy and will definitely be complex because it crosses multiple joints and involves the dominant hand in a young person. I would want the patient in a burn center promptly for a circumfrential complete RUE burn. Hand or foot burns are referral criteria.

If the burn wasn't actually that bad, like it was maybe only 5% and not cirumfrential and the hand didn't look that bad, then I would admit to trauma surgery at my own facility for airway monitoring. If the burn truly is entire RUE circumfrential, I would transfer. If my fiberoptic laryngoscopy looked good I would not intubate for the transfer as long as the recieving center and the transfer team were comfortable with that. If I wasn't able to fully evaluate the airway visually I would lean towards intubating unless the recieving facility had a strong argument otherwise. But I would get the burn center on the line and tell them what I had and get their thoughts. Would do the same with the local trauma surgeon.

 

[Zanegray]

I have intubated a sooty airway for transfer to a burn facility in a young guy. He had severe hand burns and was complaining of some feeling of swelling/ horseness. He did have singed nares and maybe mild erythema of posterior oropharynx. No clear uvular edema. They extubated him on arrival. Still I felt better safe than sorry.

Transferred a face burn yesterday because of complaint of "lip swelling." Nothing obvious about her lips to me on exam. Partial thickness to half her face, singed nose hairs, no evidence of uvular edema, erythema or posterior oropharynx changes. After speaking to burn attending at receiving faciliyt, transferred in private vehicle.

 

[ptarmigan]

One useful tidbit is that flash burns to the face (i.e. smoking on O2) usually do not afect the airway. I have seen people intubate these before, and it is generally discouraged by the burn docs I work with. These people are generally hard to get of the vent because of their comorbidities so I think it is frustrating for them, especially when they almost never have an airway burn anyway.

 

[tkim]

Dude, you actually saw the swelling in real time? That is hard core, man! I can imagine the pucker factor going to 11 (at the same rate as the swelling)!

It was one of those 'time dilation' moments, when events seems to simultaneously slow down while the feeling that everything is happening very fast. Or that the swelling was taking seconds while my bouginage was taking minutes. Or something like that. In any event, I drank heavily after that shift.

 

[ccfccp]

I think most of my 2 pack per day smokers have carbonaceous sputum. I'd be more curious about what the airway itself looked like. Although I did just get to use the flexible bronch for a rapidly developing ACE induced angioedema... That was fun.

 

[Tiger26]

If they need to be transferred, I have an extremely low threshold to intubate

 

[Arcan57]

If they need to be transferred, I have an extremely low threshold to intubate

I can't get my burn center(s) to except a patient with even possible airway involvement without prior intubation. The first couple of times you consent a patient for their own intubation is kinda unsettling. I had a woman who took a radiator cap off (thought it was the reservoir) and sucked down a lungful of steam. She came in within about 5 min of it happening and had erythematous nasal and pharyngeal mucousa. I consented her while a tech tried to wrangle the 3 yo and 7 yo that were in the room with her. I think they ended up sitting in the employee lounge coloring until their dad came.

 

[joeDO2]

So if one were to transfer this patient to a burn center it seems it would be prudent to intubate them prior to transfer just in case of the slight chance that things went south in the ambulance. Any thoughts?

had one of these type transfers to a burn center, non-intubated. the hospital sent a resident along with an airway kit and a surgical pack. i guess if you have the resources for it, this works out. it certainly helped me out knowing there would another set of hands in back if things went south.

 

[deleted109597]

I can't get my burn center(s) to except a patient with even possible airway involvement without prior intubation. The first couple of times you consent a patient for their own intubation is kinda unsettling.

My only pragmatic aside to this is as follows.
Hopefully we are pretty adept at laryngoscopy, and can intubate this patient without causing much physical harm (teeth, cords, etc). Thus, intubating is one of the few fairly harmless procedures we can do ideally. Then it follows that not tubing them can cause them to die, or worse, suffer hypoxic brain injury. Tubing them causes them temporary discomfort that we can medicate for.
I'll tube them any day of the week. Twice on Sunday.

 

[Tiger26]

My only pragmatic aside to this is as follows.
Hopefully we are pretty adept at laryngoscopy, and can intubate this patient without causing much physical harm (teeth, cords, etc). Thus, intubating is one of the few fairly harmless procedures we can do ideally. Then it follows that not tubing them can cause them to die, or worse, suffer hypoxic brain injury. Tubing them causes them temporary discomfort that we can medicate for.
I'll tube them any day of the week. Twice on Sunday.

agree--you can always take it out. you can't always put it in

 

[jdh71]

agree--you can always take it out. you can't always put it in

From a guy who's sent many a tached long vent wean to a LTAC . . . sort of true . . . kind of like Romney's non-tax cut tax cuts

We do usually take the ET tube out at some point

 

[deleted109597]

From a guy who's sent many a tached long vent wean to a LTAC . . . sort of true . . . kind of like Romney's non-tax cut tax cuts

We do usually take the ET tube out at some point

I will add the caveat that I respect those patients who have some type of chronic pulmonary disorder, and will comtemplate the outcomes prior to intubation on them.

Thankfully, they usually aren't the inhalational burn patients.

 

[dotcb]

I would not intubate that patient. There is a continuum from fine to airway collapse. Stridor is on that continuum. I would admit the patient to stepdown or ICU. If I had to transfer the patient and I felt nervous at all about the trip, I would intubate them. I would document thoroughly either way.

 

[jdh71]

I will add the caveat that I respect those patients who have some type of chronic pulmonary disorder, and will comtemplate the outcomes prior to intubation on them.

Thankfully, they usually aren't the inhalational burn patients.

Don't mind me, I'm just trolling your fine forum. What goes in almost always does come out, and don't worry too much about their chronic lung disease before making sure they've got a secure airway if you're actually worried about it, that's why they pay us. I promise I don't really want one of these guys sitting in my ICU with a questionable airway. I tend to trust my EM colleague's judgement about when a patient does and does not need a tube, implicitly.

(rarely one goes in that comes out very soon afterwars and we all giggle, but that kind of proves the original point I responded to huh? )

 

[Groove]

Hard to say... From what you're describing, it would really need to be within a clinical context and me seeing the patient and examining the airway. I would have no problem intubating this patient at the slightest concern for inhalation injury. You have to remember, it's not just the heat, it's all the other things... cyanide, aldehydes, chlorine, hydrocarbons, ad nauseum that can cause airway injury and could push them into a horrible pneumonitis or flash pulmonary edema, etc.. along with the obvious concern that there's soot in the airway and possibly supraglottic swelling. I don't think anyone would fault you for emergently intubating a patient where you had the slightest concern for airway protection. If I was ultimately going to transfer them, I'd have even less of a threshold. If you transfer, they look fine prior to transferring and then crump halfway to burn center, how do you defend that exactly? If you tube them and they do fine, and possibly would have done fine anyway, nobody is going to fault you for intubation because of an airway concern in a burn patient with soot in their mouth. That's how I see it, but I will admit I've seen a few patients from smoke filled environments that had soot on their face and possibly in their mouth, but relatively no cursory findings of a thermal insult to their upper airway.

I'm of the opinion that if you're going to take the time to do nasopharygoscopy to look for airway swelling because of suspicion of thermal insult, then you might as well tube them. There's bound to be some erythema and mild swelling from all the coughing and inhaled irritants alone so I doubt I'd be able to document "100% no evidence of airway swelling".

That's just me though. Obviously, I haven't been doing this as long as the other guys.