Intubation Considerations for Structure Fire Patients
Patients with burns involving the face or neck should NOT be routinely intubated, but selective intubation is indicated when specific high-risk features are present to prevent mortality from airway obstruction while avoiding the complications of unnecessary intubation. 1
Key Decision Framework
Do NOT Routinely Intubate For:
- Facial or neck burns alone without additional concerning features 1
- Classic symptoms in isolation (hoarseness, drooling, dysphagia) - these lack sensitivity and do not reliably predict need for intubation 1, 2
- Pediatric scald burns involving face/skull/neck in the absence of respiratory distress 1
DO Intubate Immediately For:
Non-Specific Critical Indications:
- Severe respiratory distress 1
- Severe hypoxia or hypercapnia 1
- Coma or altered mental status 1
- Dyspnea, desaturation, or stridor 1
Specific Burn-Related Indications (when burns involve the ENTIRE face):
Intubate if ≥1 of the following is present: 1
- Deep and circular burn on the neck 1
- Symptoms of airway obstruction:
- Very extensive burns (TBSA ≥40%) 1
Critical Monitoring Requirements
Patients with face/neck burns exposed to smoke or vapors require close monitoring due to risk of glottic edema and respiratory distress, even without immediate intubation 1
High-Risk Features Requiring Vigilant Observation:
- Fire in enclosed space 1, 3
- Soot on face or in oral cavity (strong predictor of need for intubation) 1, 2
- Carbonaceous/blackish sputum 1
- Singed facial or nasal hairs 1, 2
- Facial burns (correlate with laryngeal edema) 2
- Body burns (correlate with vocal fold edema) 2
Clinical re-evaluation must occur regularly during transport and after hospital admission 1
Technical Intubation Considerations
Approach:
- Modified rapid sequence induction (RSI) is the most appropriate technique 1
- Anticipate difficult intubation - these patients require a difficult airway approach 1
- Consider video laryngoscopy if available and operator is skilled 1
- Awake intubation should be actively considered in stable, cooperative patients 1
Medication Cautions:
- Avoid succinylcholine from 24 hours post-injury onward due to risk of hyperkalemia 1
Equipment:
- Use an uncut tracheal tube to allow for subsequent facial swelling 1
- Insert gastric tube after securing airway as this becomes difficult later 1
Common Pitfalls to Avoid
The Problem of Unnecessary Intubation:
Nearly one-third of burn patients are unnecessarily intubated in the prehospital setting, driven by fear of airway obstruction 1. This carries significant consequences:
- More complications compared to patients intubated only after arrival at burn centers 1
- Longer hospital stays 1
- Increased morbidity and mortality from mechanical ventilation 1
Diagnostic Tool Considerations:
- Flexible fiberoptic laryngoscopy (FFL) can prevent unnecessary intubations - in one study, 98% of patients meeting traditional intubation criteria were safely monitored without intubation based on FFL findings 4
- Nasolaryngoscopy with normal mucosal appearance is reassuring and can be repeated if clinical deterioration occurs 1, 5
- Bronchial fibroscopy should NOT be performed outside burn centers to avoid transfer delays 1
- Chest X-rays and blood gas analyses are NOT indicative of smoke inhalation diagnosis 1
Management Considerations:
- Large volume fluid resuscitation worsens airway swelling - this must be balanced against resuscitation needs 1
- Carbon monoxide poisoning artificially increases pulse oximetry readings, masking tissue hypoxia 1
- Cyanide poisoning may compound the emergency and worsen tissue hypoxia 1
Conservative Management Protocol
For patients WITHOUT immediate intubation indications: 1
- Observe in high-dependency area
- Nurse head-up position
- Keep nil-by-mouth
- Regular reassessment to detect deterioration early
- Obtain specialist advice early from a burns center 1