What are the immediate recommendations for paramedics managing potential intubation smoke inhalation?

From the Guidelines

Paramedics managing potential intubation smoke inhalation should immediately prioritize preparation, wear appropriate personal protective equipment (PPE), and focus on prompt and reliable airway management to minimize risk to both the patient and the paramedic team. When managing potential smoke inhalation, it is crucial to assess for signs of upper airway burns, including facial burns, singed nasal hair, carbonaceous sputum, and stridor 1.

Key Recommendations

• Prepare for rapid sequence intubation (RSI) while administering 100% oxygen via a non-rebreather mask.
• Use a videolaryngoscope for tracheal intubation, as it allows for a more distant approach from the airway, reducing the risk of exposure to potential pathogens or irritants 1.
• Select an endotracheal tube size considering potential airway edema, and ensure full neuromuscular blockade before attempting tracheal intubation.
• Maintain ventilation with low tidal volumes (6-8 ml/kg) and consider albuterol nebulization for bronchospasm.
• Monitor oxygen saturation, end-tidal CO2, and assess for carbon monoxide poisoning if possible.

Airway Management Strategy

• A rapid sequence induction (RSI) approach is recommended, with meticulous pre-oxygenation using a well-fitting mask for 3–5 min 1.
• Place a heat and moisture exchange (HME) filter between the catheter mount and the circuit to minimize aerosol generation.
• Ensure patient positioning maximizes safe apnoea time, and consider delayed sequence tracheal intubation in agitated patients.
• Use ketamine (1-2 mg/kg) for induction in patients at risk of cardiovascular instability, followed by rocuronium (1.2 mg/kg) for neuromuscular blockade.

Post-Intubation Care

• Early intubation is crucial as airway edema can progress rapidly, making delayed intubation extremely difficult.
• Fluid resuscitation should be initiated for patients with burns using the Parkland formula, with half of the calculated volume given in the first 8 hours.
• Continuously monitor the patient's oxygen saturation, end-tidal CO2, and assess for signs of carbon monoxide poisoning or other systemic toxicities associated with smoke inhalation.

From the Research

Immediate Recommendations for Paramedics

Paramedics managing potential intubation smoke inhalation should be aware of the following:

• Early identification of patients who will require intubation is crucial, and factors such as soot in the oral cavity, facial burns, and body burns can predict the need for intubation 2
• Patients with these findings should be monitored closely for signs of laryngeal edema and the need for intubation 2
• Treatment for smoke inhalation injury includes airway and respiratory support, lung protective ventilation, 100% oxygen or hyperbaric oxygen therapy for carbon monoxide poisoning, and hydroxocobalamin for cyanide toxicity 3, 4
• High-frequency ventilation, inhaled heparin, and aggressive pulmonary toilet are among the therapies available for patients with smoke inhalation injury 5
• Paramedics should maintain a high index of suspicion for concomitant traumatic injuries and monitor patients closely for development of airway compromise 3, 4

Key Considerations for Intubation

• Life-threatening hypoxemia is the most frequent complication of intubations, and alternatives such as high flow nasal oxygen therapy can improve oxygenation during intubation 6
• Preoxygenation and apneic oxygenation can help prevent desaturation during intubation, and a patent upper airway and sufficient administration of oxygen are key determinants of effective apneic oxygenation 6
• Paramedics should be aware of the importance of maintaining a patent upper airway and providing sufficient oxygen during intubation to prevent desaturation 6