Paediatric Burns Series: #3

Airway

Predicting presence of airway burn:

Mechanism: entrapment, explosion, altered level of conscious (at any time). Few facial scalds require intubation.
Symptoms: voice change, retrosternal burning sensation, sensation of difficult breathing

Signs: reduced level of consciousness, voice change, perioral or perinasal burns (not just facial burns), soot in the oropharynx (not just nose), erythema or oedema of tongue, stridor

Undertaking intubation:

• Techniques: RSI, inhalation induction (good body of evidence), awake fibreoptic (probably not available everywhere)

• Requirement: Experienced staff, full range of equipment, ED or operating theatre, oral/nasal tube (uncut), document airway findings (if normal at the time consider discontinuing intubation, but certainly will help with planning onward care)
• Be prepared for hypotension (consider preparing phenylephidrine to counteract)
• Tracheal tube fixation, as appropriate to patient and institution: sticking plaster, ribbon tape ties, post-nasal sling, suture/wire to nasal septum or maxilla (may need maxfax assistance)

Pitfalls:

• Facial burn does not equate to airway burn
• No airway injury found at laryngoscopy (may choose to discontinue intubation attempts)
• Late intervention in airway injury: be prepared with senior staff and helpers
• Cutting tube (DON’T)
• If in doubt intubate BUT consider
  • More patients are intubated now than 15 years ago
  • Incidence of confirmed inhalation injury is the same or falling
  • Rate and severity of intubation/ventilation complications is significant (safety, transfer logistics, ventilator related problems)
  • Ventilation of patients without inhalation injury associated with increased sepsis, ionotrope usage, mortality

Clare Bosanko, Febr 2017