Airway Management in Burn Patients
Primary Recommendation
Burn patients with facial or neck involvement should NOT be routinely intubated; instead, use selective intubation based on specific high-risk criteria to prevent mortality from airway obstruction while avoiding the significant complications of unnecessary intubation, which occurs in approximately one-third of pre-burn center intubations. 1, 2, 3
Critical Indications Requiring IMMEDIATE Intubation
Intubate immediately if ANY of the following are present:
- Severe respiratory distress 1, 2
- Dyspnea, desaturation, or stridor 1, 2
- Severe hypoxia or hypercapnia 1, 2
- Coma or altered mental status 1, 2
- Symptoms of airway obstruction: voice modification, stridor, or laryngeal dyspnea 1, 2
Selective Intubation Criteria for Facial/Neck Burns
For patients with facial or neck burns WITHOUT immediate respiratory compromise, intubate ONLY if ALL of the following are present:
- Burns involving the entire face AND
- At least ONE of the following:
Clinical Signs That Are UNRELIABLE Predictors
The following classic signs lack sensitivity and should NOT trigger automatic intubation in isolation:
- Hoarseness, dysphagia, drooling 1, 2
- Carbonaceous sputum 1
- Soot in the airway 1
- Singed facial or nasal hairs 1
- History of confinement in burning environment 1
These signs indicate exposure but do not reliably predict who will require intubation. 1, 2
Special Pediatric Considerations
Children with scald burns involving the face, skull, or neck should NOT be intubated in the absence of respiratory distress. 1, 2
Conservative Management Protocol (When NOT Intubating)
For patients without immediate intubation indications:
- Observe in high-dependency area with continuous monitoring 1, 2
- Position head-up to reduce airway edema 1, 2
- Keep nil-by-mouth due to potential airway deterioration 1, 2
- Perform regular reassessment to detect deterioration early 1, 2
- Obtain specialist advice early from a burns center 1, 2
- Avoid large volume fluid resuscitation as this worsens airway swelling 1
Intubation Technique When Required
Preferred Method
Modified rapid sequence induction (RSI) is the most appropriate technique for most burn patients requiring intubation. 1, 2
Alternative Approach
Awake intubation should be actively considered in stable, cooperative patients with minimal airway soot and swelling. 1, 2
Technical Considerations
- Anticipate difficult intubation and prepare accordingly 1, 2
- Use videolaryngoscopy if available and the operator is skilled, as it increases success rates with minimal cervical movement 1, 2
- Have front-of-neck access (FONA) equipment immediately available 1
- Use manual-in-line stabilization if cervical spine injury is suspected 1
- Consider using a bougie during direct laryngoscopy 1
Critical Medication Considerations
AVOID Succinylcholine
Do NOT use succinylcholine from 24 hours post-injury onward due to risk of life-threatening hyperkalemia. 1, 2
Equipment Specifications
- Use an uncut tracheal tube to allow for subsequent facial swelling 1, 2
- Insert a gastric tube after securing the airway, as this may become difficult later 1, 2
Role of Bronchoscopy
- Normal nasendoscopic mucosal appearance is reassuring and can be repeated at intervals or if clinical deterioration occurs 1
- Bronchial fibroscopy should NOT be performed outside burns centers to avoid transfer delays 1, 2
- Chest X-rays and blood gas analyses are NOT indicative of smoke inhalation diagnosis 1, 2
Critical Pitfalls to AVOID
Unnecessary Intubation
Approximately 31-40% of patients intubated before burn center transfer are extubated within 1-2 days, indicating unnecessary intubation. 4, 3 These unnecessary intubations result in:
Fear-Based Decision Making
Three-quarters of prehospital intubations are performed due to "fear of airway obstruction" rather than objective criteria. 1 This leads to overtreatment with significant consequences.
Delayed Intubation
Do NOT delay intubation when objective signs of airway compromise are present, as progressive edema can rapidly lead to complete obstruction. 1, 2
Multiple Intubation Attempts
If intubation fails, do NOT attempt multiple intubation attempts or SGA rescue; proceed promptly to front-of-neck access with scalpel technique and vertical incision. 1