So those are cutaneous burns.
burns don’t just happen on the skin.
They can happen anywhere in the body.
And one of the places we need to be very, very concerned
about burns are in the airway.
So airway burns can cause death
due to edema and airway obstruction,
and you really wanna be very aggressive
about managing the airway
in patients who do have evidence of airway burning,
because if they are obstructed a little bit when you meet them,
there’s a good chance that they’re gonna swell more,
and become more obstructed as time goes on.
Please also look for indicators of future airway loss.
So signs of airway obstruction
immediately right now would include stridor.
Just as a reminder,
stridor is a high-pitched inspiratory sound
that’s made because air is being forced
through a very narrowed opening.
that’s what stridor sounds like.
With each inspiration.
You'll also also see pharyngeal swelling.
When you look into the airway,
and the patient typically has some degree of respiratory distress.
If any of those things are present,
you definitely gonna wanna intubate right away.
You also wanna look for indicators of future airway compromise.
So those might include burns around the face or mouth.
Singed nasal hair.
Soot in the mouth or carbonaceous sputum,
so when the patient coughs,
they produce sputum that’s black in color
and any kind of voice changes.
These should all be considered harbingers
of potential compromise of the airway down the line.
Now, one thing I do wanna emphasize
is it's a little bit problematic with airways
and burns is that a lot of patients
who have these traditional indicators
of future airway compromise
will not end up having any airway injury.
And there are patients who have documented airway injury
who lack these findings at presentation.
So it can be a little bit unreliable to assess
for a future airway loss.
So you wanna be aware of the limitations of your clinical exam.
Now, we don’t wanna go just intubating everybody,
because overly aggressive intubation
can lead to its own complications including ARDS,
barotrauma, ventilator-associated pneumonia, etcetera.
So we definitely want to assess the airway whenever we can,
using direct visualization of the airway
either with the larynges scope,
a video larynges scope, a fiber optic scope, etcetera.
if you are the emergency physician caring for this patient,
you’ll have the technical expertise
to manage the patient’s airway on your own,
but these are often difficult airways.
So if you don’t have a lot of experience with airway management
or if you are in a setting
where you don’t have a lot of equipment
that you can use to help manage a failed airway,
get anesthesiology or otolaryngology involved
to help you assess and manage the airway whenever possible.
So we addressed A,
let’s talk about B.
So there are a number of ways in which burns can affect breathing.
you can have thermal burning of the lung tissue
when you inhale superheated air in a fire,
and you can also have smoke inhalation
which can lead to a carbon monoxide poisoning.
When we manage patients
who have respiratory compromise from burns,
we wanna give them oxygen to make sure
that we keep their stats above 92%,
and we wanna humidify that oxygen
because a lot of times
patients who do have thermal burning of the lungs
will find it much more comfortable to breathe air
that’s a little wet as opposed to air that’s dry.
We definitely wanna use inhaled beta agonists like albuterol
for bronchoconstriction and whizzing,
and we do wanna consider intubation
and mechanical ventilation for any patient
who is significantly hypoxic despite supplemental oxygen.
For any patient who has significant respiratory distress
or signs of respiratory failure,
and of course for patients who have head injuries
or other complications of their burns
that have depressed their GCS,
and in those cases
the goals is gonna be protection of the airway.
Now, remember it’s not only thermal burning of the lungs
we have to be concerned about.
It’s actually poisoning with carbon monoxide
that occurs through inhalation of smoke.
Carbon monoxide is a real problem at the cellular level
because what it does is it binds avidly
to hemoglobin displacing oxygen from hemoglobin
and creating a really tight bond with the hemoglobin molecule.
That means that oxygen can’t be effectively delivered to tissue
so this causes tissue level hypoxia.
You always wanna measure the carboxyhemoglobin directly
it's a laboratory assay that’s readily available in most hospitals,
and you should never rely on your oxygen saturation
to assess for carbon monoxide toxicity
because actually, it will be falsely elevated.
So conventional pulse oximeters read carboxyhemoglobin
as a saturated hemoglobin.
So your patient
might have very, very poor tissue level oxygen delivery
but their pulse ox waveform is gonna be saying a 100%.
and you wanna really be careful about that.
So again, measure the carboxyhemoglobin.
Anytime you’re dealing with carbon monoxide poisoning,
your first line treatment is gonna be high flow oxygen.
You wanna get as close as you can to a 100% FIO2
either using a mask or using an endotracheal tube,
depending on the patients' overall clinical status.
High flow oxygen will help displace
the carbon monoxide from the hemoglobin
allowing oxygen to bind back on
to the hemoglobin binding sites
and ultimately be delivered to tissue.
Oxygen also reduces the half-life of carbon monoxide
and allows you to clear it by getting it off of the hemoglobin.
If regular high flow oxygen isn’t enough,
you can consider hyperbaric oxygen.
Now, treatment in hyperbaric chamber is never been shown
to offer any mortality benefit for burn victims.
However, it does potentially reduce the risk
of not long term neurologic sequelae
from carbon monoxide poisoning
so you can consider it in certain cases.
It’s of greatest benefit
when it’s begun within six hours of the burn.
So if you’re gonna do it,
you wanna make sure that you initiate
the necessary process to transfer your patient
to a hyperbaric center as soon as possible.
You should think about hyperbaric oxygen
when your patient has a carboxyhemoglobin of greater than 25%.
That is a lot of carbon monoxide
and their hyperbaric oxygen
is gonna help them clear it more quickly
and hopefully help them have fewer complications from it.
Anytime you have a pregnant patient
who has a carboxyhemoglobin of greater that 15%,
you should also think about of hyperbaric oxygen in that setting,
because the unborn fetus
is much more sensitive to tissue level hypoxia than the adult is,
because tissues are not yet fully formed, etcetara.
You also can think about hyperbaric treatment for patients
who have clinical evidence of carbon monoxide toxicity.
So if they are comatose
or their mental status is altered,
if they are seizing,
if they’re showing evidence of cardiac ischemia or arrhythmias.
These are all situations where you can think about
using carboxyhemoglo — I’m sorry,
using hyperbaric oxygen to try to displace carbon monoxide
from the hemoglobin and restore tissue level perfusion.
Moving on to C,
circulation is a really important issue in major burns
who have significant surface areas of their body burned
can have a lot of insensible fluid loss
and a lot of third-spacing of fluid
that’s supposed to be in the intravascular space.
So you’ve got to really keep very close tabs
on this patient’s volume status
and aggressively treat hypovolemia
and tissue level hypoperfusion.
Any patient who has a burn
greater that 20% total body surface area
or greater than 10% for children
is gonna need careful fluid resuscitation.
And that’s typically done using formulas
that allows to compute the fluid losses associated with burns.
All of these patients should have two large-bore IVs
or central IV access
to make sure that you’ve got a way to give them fluids rapidly
and we’re gonna base our calculation
of how much fluid they need on their total body surface area.