ATLS Protocol for Intubating a Burn Patient
Burn patients with face or neck involvement should NOT be routinely intubated; however, intubation is indicated when specific high-risk criteria are present, including deep circular neck burns, signs of airway obstruction (voice changes, stridor, laryngeal dyspnea), or extensive burns (TBSA ≥40%). 1
Indications for Immediate Intubation
Non-Specific Emergency Indications
Proceed with immediate intubation without delay if any of the following are present: 1
- Severe respiratory distress
- Severe hypoxia or hypercapnia
- Coma or altered mental status
Burn-Specific Indications for Patients with Full-Face Burns
Consider intubation when one or more of these criteria exist: 1
- Deep and circular burn on the neck - circumferential burns can rapidly compromise the airway as edema develops
- Symptoms of airway obstruction:
- Very extensive burns (TBSA ≥40%) 1
Additional High-Risk Features
- Carbonaceous sputum or soot in the airway 1
- Singed facial or nasal hairs 1
- History of confinement in a burning environment 1
- Wheeze 1
- Dyspnea or desaturation 1
Critical Pitfalls to Avoid
Unnecessary early intubation carries significant risks. Nearly one-third of prehospital burn intubations are unnecessary, and these patients experience more complications compared to those intubated at burn centers. 1 The primary driver of unnecessary intubation is fear of airway obstruction rather than actual clinical need. 1
Special pediatric consideration: Tracheal intubation is NOT recommended in children burned by hot fluids (scalding), even with face/neck/skull involvement, unless respiratory distress is present. 1
Intubation Technique
Preferred Approach
Modified rapid sequence intubation (RSI) is usually the most appropriate technique for burn patients requiring intubation. 1
Key Technical Considerations
- Anticipate difficult intubation - a difficult intubation procedure should be implemented in burn patients with face/neck involvement 1
- Avoid succinylcholine from 24 hours post-injury onward to prevent life-threatening hyperkalemia 1
- Use an uncut tracheal tube to accommodate subsequent facial swelling 1
- Insert a gastric tube after securing the airway, as this becomes increasingly difficult with progressive edema 1
- Consider videolaryngoscopy - increases intubation success rates in difficult airways 1
Alternative: Awake Intubation
Awake intubation is an option but requires: 1
- Cooperative, stable patients
- Minimal airway soot and swelling
Management of Patients NOT Immediately Intubated
Monitoring Protocol
For patients with face/neck burns who don't meet immediate intubation criteria: 1
- Close monitoring for glottic edema and respiratory distress, especially if exposed to vapors or inhaled smoke 1
- Regular clinical re-evaluation during transport and after hospital admission 1
- Observation in high-dependency area 1
- Nurse head-up position 1
- Keep nil-by-mouth 1
- Reassess frequently to detect deterioration early 1
Important Caveat
Large volume fluid resuscitation worsens airway swelling - this creates a clinical dilemma requiring senior decision-making about timing of intubation. 1
Smoke Inhalation Considerations
Do NOT perform bronchial fibroscopy outside burn centers to avoid transfer delays. 1 While fibroscopy is considered the gold standard for diagnosing smoke inhalation, it should not delay definitive care or transfer. 1
Suspect smoke inhalation with: 1
- Fire in enclosed space
- Soot on face
- Dysphonia
- Dyspnea
- Wheezing
- Blackish sputum
Decision-Making Framework
Obtain specialist advice early from a burns center when the decision to intubate early (to prevent deterioration) versus manage conservatively (as ventilation may worsen outcome) is complex. 1 This requires a senior decision-maker, as clinical signs lack sensitivity and are unreliable predictors of intubation requirement. 1