From the Guidelines
Intubation in burn patients is indicated when there are signs of airway compromise, respiratory distress, or anticipated airway edema, particularly in patients with facial burns, inhalation injury, or extensive burns (>40% total body surface area). The decision to intubate should be made promptly, as thermal injury to the airway causes progressive swelling that peaks at 24-48 hours post-injury 1. Specific indications for intubation include:
- Facial burns with deep and circular neck burn, symptoms of airway obstruction, or extensive burns (>40% total body surface area) 1
- Inhalation injury with carbonaceous sputum or vocal cord edema 1
- Stridor, respiratory distress with increased work of breathing, or hypoxemia despite supplemental oxygen 1
- Extensive burns (>40% total body surface area) causing systemic inflammatory response 1
For intubation, rapid sequence induction with etomidate (0.3 mg/kg) or ketamine (1-2 mg/kg) and succinylcholine (1-1.5 mg/kg) or rocuronium (1-1.2 mg/kg) is typically used, though succinylcholine should be avoided after 24 hours post-burn due to risk of hyperkalemia 1. Post-intubation, patients require mechanical ventilation with lung-protective strategies, adequate sedation with medications like propofol (25-75 mcg/kg/min) or midazolam (1-5 mg/hr), and pain control with fentanyl (25-100 mcg/hr) or morphine (2-10 mg/hr) 1.
The experts agree that patients with severe burns involving the whole face should be intubated if one or more of the following criteria are met: deep circular neck burn, symptoms of airway obstruction, or very extensive burn (i.e. TBSA 40%) 1. Additionally, patients with face/neck burns who were exposed to vapors or who inhaled smoke should be closely monitored due to the risk of glottis edema and respiratory distress 1.
It is essential to note that the literature on intubation criteria in burn patients is limited, and unnecessary intubations can lead to increased complications and longer hospital stays 1. Therefore, the decision to intubate should be made cautiously and based on individual patient assessment.
From the Research
Indications for Intubation in Burn Patients
The indications for intubation in patients with burns are diverse and can be identified through various symptoms, physical findings, and medical examinations. Some of the key indications include:
- Respiratory distress, stridor, hypoventilation, use of accessory respiratory muscles, blistering or edema of the oropharynx, or deep burns to the face or neck 2
- Full thickness facial burns, stridor, respiratory distress, swelling on laryngoscopy, upper airway trauma, altered mentation, hypoxia/hypercarbia, hemodynamic instability, suspected smoke inhalation, and singed facial hair 3
- Burn size, facial burns, neck burns, use of accessory respiratory muscles, and carboxyhemoglobin levels (COHb) 4
- Increasing total body surface area (%TBSA) burned, flame, enclosed space, face burns, hoarse voice, soot in mouth and shortness of breath 5
Predictive Factors for Inhalation Injury
Several factors can predict the likelihood of inhalation injury in burn patients, including:
- Increasing %TBSA burned, flame, enclosed space, face burns, hoarse voice, soot in mouth and shortness of breath 5
- Burn size, facial burns, neck burns, use of accessory respiratory muscles, and COHb 4
- Fiberoptic bronchoscopy findings from above the glottis were mainly related with patients' symptoms, while findings from below the glottis were mainly related with BWT and COHb 4
Decision-Making for Intubation
The decision to intubate a burn patient should be based on a combination of clinical criteria, including the Denver criteria, which exhibits an increased sensitivity for long-term intubations 3. Patients lacking these criteria should not be intubated. The use of fiberoptic bronchoscopy and other diagnostic tools can also aid in decision-making 4, 6.