What is the management of inhalation burns in pediatric patients?

Management of Inhalation Burns in Pediatric Patients

Immediately administer 100% oxygen to all pediatric patients with suspected inhalation injury, secure the airway early if any signs of compromise are present, and transfer directly to a specialized burn center, as inhalation injury triples mortality risk in children even with small burn surface areas. 1, 2

Immediate Recognition and Assessment

Suspect inhalation injury in any child exposed to fire in an enclosed space, and look for these specific signs:

• Facial burns, soot around nose/mouth, or singed nasal hairs 1, 2
• Dysphonia, stridor, hoarse voice, or wheezing 3, 1
• Carbonaceous or blackish sputum 1, 2
• Respiratory distress, polypnea, or dyspnea 3, 1

Critical pitfall to avoid: Normal oxygen saturation, normal chest X-ray, and normal arterial blood gases do NOT exclude inhalation injury and should not provide false reassurance. 2

Airway Management - The Most Critical Decision

Intubate immediately without delay if ANY of the following are present:

• Severe respiratory distress or signs of airway obstruction 1, 2
• Severe hypoxia or hypercapnia 1, 2
• Altered mental status, confusion (GCS ≤13), or coma 3, 1
• Deep circular neck burns or extensive facial burns with TBSA ≥40% 2

For children without immediate intubation indications, implement close continuous monitoring as glottic edema can develop progressively and unpredictably over hours. 1, 2 The key error is delaying intubation when signs of airway compromise are present. 1

Oxygen Therapy - First-Line Treatment

Administer 100% oxygen immediately to ALL children with suspected smoke inhalation:

• Via high-concentration mask if spontaneously breathing 3, 1, 4
• Via 100% FiO2 for 6-12 hours if mechanically ventilated 3, 1, 4
• Continue until carboxyhemoglobin levels normalize and symptoms resolve 4

This reduces carboxyhemoglobin half-life from 320 minutes on room air to approximately 74 minutes. 4

Cyanide Poisoning Management - Selective Use Only

Hydroxocobalamin should NOT be routinely administered after smoke inhalation. 1 Restrict treatment to children with moderate or severe signs of cyanide poisoning: 3, 1

Moderate poisoning indicators:

• GCS score ≤13, confusion 3
• Stridor, hoarse voice, polypnea, dyspnea 3
• Soot particles in airways 3

Severe poisoning indicators:

• GCS score ≤8, seizures, coma, mydriasis 3
• Severe hemodynamic disorders, collapse 3
• Respiratory depression 3
• Plasma lactate >8 mmol/L (83% correlation with cyanide poisoning) 3, 1

Pediatric dosing: 70 mg/kg, maximum 5 g 3, 1

Children are more vulnerable to cyanide poisoning than adults due to higher alveolar ventilation per minute and lower body mass index. 3

Hyperbaric Oxygen Therapy - Case-by-Case Only

HBOT should NOT be routinely administered for suspected carbon monoxide poisoning after smoke inhalation. 3, 1 Consider HBOT only in highly selected cases: 1, 4

• Children with altered consciousness or coma 1, 4
• Neurological, respiratory, or cardiac symptoms present 1, 4
• Pregnant adolescents with any CO exposure 4

HBOT is often contraindicated in severe burns due to hemodynamic or respiratory instability in the acute phase, creating significant risks. 3

Diagnostic Bronchoscopy

Perform flexible bronchoscopy at the burn center to assess severity of inhalation injury, as bronchoscopic findings correlate with morbidity, ICU length of stay, duration of mechanical ventilation, and hypoxemia severity. 1, 2 Only perform bronchoscopy in patients who are already intubated due to risk of airway compromise during the procedure. 2

Burn Wound Management During Transport

• Cool thermal burns with clean running water for 5-20 minutes 1, 2
• Remove all jewelry before swelling occurs to prevent vascular ischemia 2
• Monitor children closely for hypothermia during cooling 2
• Remove all burning materials and flammable substances 1

Transfer to Specialized Care - Non-Negotiable Priority

Direct admission to a burn center is strongly preferred over staged transfer, as it reduces time to definitive treatment and improves morbidity and mortality. 2

Transfer immediately if:

• Second- or third-degree burns involving face, hands, feet, genitals 2
• Burns >5% body surface area in children 2
• Any smoke inhalation injury present 2

**Smoke inhalation increases pediatric mortality three-fold and significantly increases morbidity even with TBSA <10%.** 2 In children with inhalation injury and TBSA >47.5%, mortality risk increases 5-fold. 5

Additional Supportive Measures

• Administer over-the-counter analgesics for pain control during transport 2
• Consider multimodal analgesia with titrated intravenous ketamine for severe burn-induced pain once at the burn center 4
• Ensure thorough and aseptic pulmonary toilet 6
• Reserve tracheotomy only for true glottic or supraglottic airway obstructions 6
• Consider escharotomy if deep burns induce compartment syndrome affecting airways, respiration, or circulation 1

Follow-Up Care

All children treated for acute CO poisoning require clinical follow-up at 1-2 months post-event to assess for delayed neurological sequelae including memory disturbance, depression, anxiety, vestibular problems, and motor dysfunction. 1