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Somwaru B, Grossman D. Intubating Special Populations. Emerg Med Clin North Am 2022; 40:443-458. [DOI: 10.1016/j.emc.2022.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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2
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Expert consensus on the prevention and first-aid management of burns in children. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2021; 23:1191-1199. [PMID: 34911600 PMCID: PMC8690712 DOI: 10.7499/j.issn.1008-8830.2109026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Accepted: 10/08/2021] [Indexed: 01/19/2023]
Abstract
Burns are the second leading cause of unintentional injuries in children and are one of the major causes of disability in children. Timely and effective first-aid management of burns can have a major impact on the prognosis, but there is still a lack of the knowledge on burn management in the general public. With reference to expert opinions and related literature, this consensus summarizes the causes of burns, preventive measures, first-aid methods for common types of burns, and the prevention and treatment of serious complications of burns. It also provides recommendations on the most appropriate pre-hospital treatment. This consensus aims to emphasize the importance of burn prevention, improve the ability of first-aid treatment among witnesses and rescuers, avoid further injury caused by inappropriate treatment, and reduce the mortality and disability rates of burns and the harm to family and society. It can be used as guidance for pre-hospital treatment of childhood burns by first responders, parents, and passers-by.
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4
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Tang JA, Amadio G, Nagappan L, Schmalbach CE, Dion GR. Laryngeal inhalational injuries: A systematic review. Burns 2021; 48:23-33. [PMID: 33814215 DOI: 10.1016/j.burns.2021.02.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 12/19/2020] [Accepted: 02/05/2021] [Indexed: 02/07/2023]
Abstract
Laryngeal inhalation injury carries a significant increase in mortality rate and often indicates immediate airway evaluation. This may be difficult in the setting of clinical deterioration necessitating immediate intubation, which itself can synergistically cause mucosal damage. Prior studies do not encompass predictive factors or long-term outcomes for the laryngotracheal complex. This systemic review of PubMed, Embase, and Cochrane identified studies investigating inhalational injuries of the upper airway. Demographic data as well as presentation, physical findings, and delayed sequelae were documented. Laryngotracheal burn patients were divided into two cohorts based on timing of laryngeal injury diagnosis (before- versus after-airway intervention). 1051 papers met initial search criteria and 43 studies were ultimately included. Airway stenosis was more common in patients that were intubated immediately (50.0%, n = 18 versus 5.2%, n = 13; p = 0.57). Posterior glottic involvement was only identified in patients intubated prior to airway evaluation (71.4%, n = 15). All studies reported a closed space setting for those patients in whom airway intervention preceded laryngeal evaluation. Laryngeal inhalational injuries are a distinct subset that can have a variety of minor to severe laryngotracheal delayed sequelae, particularly for thermal injuries occurring within enclosed spaces. Given these findings, early otolaryngology referral may mitigate or treat these effects.
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Affiliation(s)
- Jessica A Tang
- Department of Otolaryngology, Head and Neck Surgery, Temple University Hospital, Philadelphia, PA, USA
| | - Grace Amadio
- Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Lavanya Nagappan
- Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Cecelia E Schmalbach
- Department of Otolaryngology, Head and Neck Surgery, Temple University Hospital, Philadelphia, PA, USA; Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA; Temple Head and Neck Institute, Philadelphia, PA, USA
| | - Gregory R Dion
- US Army Institute of Surgical Research, Joint Base San Antonio, Fort Sam Houston, TX, USA.
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Dingle L, Wain R, Bishop S, Soueid A, Sheikh Z. Letter to the Editor in response to "Intubation in burns patients- are we following the guidance? A 5-year review of the Manchester regional burns centre experience". Burns 2020; 47:495-496. [PMID: 33268160 DOI: 10.1016/j.burns.2020.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 09/24/2020] [Indexed: 11/19/2022]
Affiliation(s)
- Lewis Dingle
- Manchester University NHS Foundation Trust Manchester, Greater Manchester, United Kingdom.
| | - Richard Wain
- Manchester University NHS Foundation Trust Manchester, Greater Manchester, United Kingdom
| | - Sophie Bishop
- Manchester University NHS Foundation Trust Manchester, Greater Manchester, United Kingdom
| | - Ali Soueid
- Manchester University NHS Foundation Trust Manchester, Greater Manchester, United Kingdom
| | - Zeeshan Sheikh
- Manchester University NHS Foundation Trust Manchester, Greater Manchester, United Kingdom
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Dyson K, Baker P, Garcia N, Braun A, Aung M, Pilcher D, Smith K, Cleland H, Gabbe B. To intubate or not to intubate? Predictors of inhalation injury in burn‐injured patients before arrival at the burn centre. Emerg Med Australas 2020; 33:262-269. [DOI: 10.1111/1742-6723.13604] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 07/19/2020] [Accepted: 07/22/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Kylie Dyson
- Department of Epidemiology and Preventive Medicine Monash University Melbourne Victoria Australia
- Centre for Research and Evaluation Ambulance Victoria Melbourne Victoria Australia
| | - Paul Baker
- Victorian Adult Burns Service Alfred Hospital Melbourne Victoria Australia
| | - Nicole Garcia
- Victorian Adult Burns Service Alfred Hospital Melbourne Victoria Australia
| | - Anna Braun
- Victorian Adult Burns Service Alfred Hospital Melbourne Victoria Australia
| | - Myat Aung
- Intensive Care Unit Alfred Hospital Melbourne Victoria Australia
| | - David Pilcher
- Intensive Care Unit Alfred Hospital Melbourne Victoria Australia
| | - Karen Smith
- Centre for Research and Evaluation Ambulance Victoria Melbourne Victoria Australia
| | - Heather Cleland
- Victorian Adult Burns Service Alfred Hospital Melbourne Victoria Australia
- Central Clinical School Monash University Melbourne Victoria Australia
| | - Belinda Gabbe
- Department of Epidemiology and Preventive Medicine Monash University Melbourne Victoria Australia
- Health Data Research UK Swansea University Medical School Swansea UK
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7
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Intubation in burns patients: a 5-year review of the Manchester regional burns centre experience. Burns 2020; 47:576-586. [PMID: 32861535 DOI: 10.1016/j.burns.2020.07.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 06/16/2020] [Accepted: 07/24/2020] [Indexed: 12/14/2022]
Abstract
Despite criteria to guide intubation from the American Burn Association (ABA), concerns remain regarding over-intubation of burns patients. The purpose of this study was to review appropriateness of intubation at a UK regional burns centre over a 5-year period. A 5-year retrospective review of adult patients admitted to the Manchester Burns Centre who underwent intubation at or prior to admission was performed. Intubations for non-burn indications or burns >40%TBSA were excluded. Patient demographic and burn characteristics data were extracted from medical records. Indications for intubation were compared to ABA and Denver criteria. 47 patients were identified, of which 40 met inclusion criteria for analysis. 72.5% and 95% of these patients met ABA or Denver criteria respectively. 30.8% of patients were extubated within 48 h. 50% patients extubated within 48 h had ≤1 indication for intubation or negative laryngoscopy. Complications related to intubation and ventilation were noted in 37.5% of patients, with ventilation associated pneumonia (VAP) being the most common occurring in 27.5%. 95% of patients fulfilled recognised criteria for intubation. However, 30% were extubated within 48 h, suggesting potentially avoidable intubation. This study suggests current intubation criteria may over-estimate risk of airway compromise and supports results from non-UK studies that a proportion of patients may be suitable for close observation rather than early intubation.
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Abstract
Management of the pediatric burn patient presents a variety of clinical challenges for the pediatric anesthesiologist. Despite the high incidence of burn injuries, standard management strategies are far from universal. The complex physiologic changes presented by burn injuries present airway management and resuscitation challenges and mandate careful consideration of adequate nutritional support. Long hospital stays with frequent operations and dressing changes necessitate creative approaches to anxiolysis and pain control. Underutilized modalities warranting further research include regional anesthesia and nonpharmacologic approaches, such as virtual reality. Further research and collaboration between burn centers are needed to standardize care for this population.
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Yoshino Y, Hashimoto A, Ikegami R, Irisawa R, Kanoh H, Sakurai E, Nakanishi T, Maekawa T, Tachibana T, Amano M, Hayashi M, Ishii T, Iwata Y, Kawakami T, Sarayama Y, Hasegawa M, Matsuo K, Ihn H, Omoto Y, Madokoro N, Isei T, Otsuka M, Kukino R, Shintani Y, Hirosaki K, Motegi S, Kawaguchi M, Asai J, Isogai Z, Kato H, Kono T, Tanioka M, Fujita H, Yatsushiro H, Sakai K, Asano Y, Ito T, Kadono T, Koga M, Tanizaki H, Fujimoto M, Yamasaki O, Doi N, Abe M, Inoue Y, Kaneko S, Kodera M, Tsujita J, Fujiwara H, Le Pavoux A. Wound, pressure ulcer and burn guidelines – 6: Guidelines for the management of burns, second edition. J Dermatol 2020; 47:1207-1235. [DOI: 10.1111/1346-8138.15335] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 03/05/2020] [Indexed: 01/28/2023]
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Yamamoto R, Matsumura K, Sasaki J. Reply to Methodological issues on developing a novel scale for prediction of delayed intubation in patients with inhalation injury. Burns 2020; 47:258. [PMID: 33280956 DOI: 10.1016/j.burns.2020.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Accepted: 04/07/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Ryo Yamamoto
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo 160-8582, Japan
| | - Kazuki Matsumura
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo 160-8582, Japan
| | - Junichi Sasaki
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo 160-8582, Japan
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Legrand M, Barraud D, Constant I, Devauchelle P, Donat N, Fontaine M, Goffinet L, Hoffmann C, Jeanne M, Jonqueres J, Leclerc T, Lefort H, Louvet N, Losser MR, Lucas C, Pantet O, Roquilly A, Rousseau AF, Soussi S, Wiramus S, Gayat E, Blet A. Management of severe thermal burns in the acute phase in adults and children. Anaesth Crit Care Pain Med 2020; 39:253-267. [PMID: 32147581 DOI: 10.1016/j.accpm.2020.03.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVES To provide recommendations to facilitate the management of severe thermal burns during the acute phase in adults and children. DESIGN A committee of 20 experts was asked to produce recommendations in six fields of burn management, namely, (1) assessment, admission to specialised burns centres, and telemedicine; (2) haemodynamic management; (3) airway management and smoke inhalation; (4) anaesthesia and analgesia; (5) burn wound treatments; and (6) other treatments. At the start of the recommendation-formulation process, a formal conflict-of-interest policy was developed and enforced throughout the process. The entire process was conducted independently of any industry funding. The experts drew up a list of questions that were formulated according to the PICO model (Population, Intervention, Comparison, and Outcomes). Two bibliography experts per field analysed the literature published from January 2000 onwards using predefined keywords according to PRISMA recommendations. The quality of data from the selected literature was assessed using GRADE® methodology. Due to the current paucity of sufficiently powered studies regarding hard outcomes (i.e. mortality), the recommendations are based on expert opinion. RESULTS The SFAR guidelines panel generated 24 statements regarding the management of acute burn injuries in adults and children. After two scoring rounds and one amendment, strong agreement was reached for all recommendations. CONCLUSION Substantial agreement was reached among a large cohort of experts regarding numerous strong recommendations to optimise the management of acute burn injuries in adults and children.
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Affiliation(s)
- Matthieu Legrand
- Department of Anaesthesia and Perioperative Care, University of California, San Francisco, United States.
| | - Damien Barraud
- Hôpital de Mercy, Intensive Care Medicine and Burn Centre, CHR Metz-Thionville, Ars-Laquenexy, France
| | - Isabelle Constant
- Anaesthesiology Department, Hôpital Armand-Trousseau, Sorbonne Université, Assistance publique-Hôpitaux de Paris, Paris, France
| | | | - Nicolas Donat
- Burn Centre, Percy Military Teaching Hospital, Clamart, France
| | - Mathieu Fontaine
- Burn Intensive Care Unit, Saint-Joseph Saint-Luc Hospital, 20, quai Claude-Bernard, 69007 Lyon, France
| | - Laetitia Goffinet
- Paediatric Burn Centre, University Hospital of Nancy, 54511 Vandœuvre-Lès-Nancy, France
| | | | - Mathieu Jeanne
- CHU Lille, Anaesthesia and Critical Care, Burn Centre, 59000 Lille, France; University of Lille, Inserm, CHU Lille, CIC 1403, 59000 Lille, France; University of Lille, EA 7365 - GRITA, 59000 Lille, France
| | - Jeanne Jonqueres
- Burn Intensive Care Unit, Saint-Joseph Saint-Luc Hospital, 20, quai Claude-Bernard, 69007 Lyon, France
| | - Thomas Leclerc
- Burn Centre, Percy Military Teaching Hospital, Clamart, France
| | - Hugues Lefort
- Department of emergency medicine, Legouest Military Teaching Hospital, Metz, France
| | - Nicolas Louvet
- Anaesthesiology Department, Hôpital Armand-Trousseau, Sorbonne Université, Assistance publique-Hôpitaux de Paris, Paris, France
| | - Marie-Reine Losser
- Hôpital de Mercy, Intensive Care Medicine and Burn Centre, CHR Metz-Thionville, Ars-Laquenexy, France; Paediatric Burn Centre, University Hospital of Nancy, 54511 Vandœuvre-Lès-Nancy, France; Inserm UMR 1116, Team 2, 54000 Nancy, France; University of Lorraine, 54000 Nancy, France
| | - Célia Lucas
- Department of Anaesthesiology, Critical Care and Burn Centre, Lariboisière-Saint-Louis Hospitals, DMU Parabol, AP-HP Nord, University of Paris, Paris, France
| | - Olivier Pantet
- Service of Adult Intensive Care Medicine and Burns, Lausanne University Hospital (CHUV), BH 08-651, Rue du Bugnon 46, 1011 Lausanne, Switzerland
| | - Antoine Roquilly
- Department of Anaesthesia and Critical Care, Hôtel-Dieu, University Hospital of Nantes, Nantes, France; Laboratoire UPRES EA 3826 "Thérapeutiques cliniques et expérimentales des infections", University of Nantes, Nantes, France
| | | | - Sabri Soussi
- Department of Anaesthesiology, Critical Care and Burn Centre, Lariboisière-Saint-Louis Hospitals, DMU Parabol, AP-HP Nord, University of Paris, Paris, France; Interdepartmental Division of Critical Care, Keenan Research Centre for Biomedical Science and Institute of Medical Sciences, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Sandrine Wiramus
- Department of Anaesthesia and Intensive Care Medicine and Burn Centre, University Hospital of Marseille, La Timone Hospital, Marseille, France
| | - Etienne Gayat
- Department of Anaesthesiology, Critical Care and Burn Centre, Lariboisière-Saint-Louis Hospitals, DMU Parabol, AP-HP Nord, University of Paris, Paris, France; Inserm UMR-S 942, Cardiovascular Markers in Stress Conditions (MASCOT), University of Paris, Paris, France
| | - Alice Blet
- Department of Anaesthesiology, Critical Care and Burn Centre, Lariboisière-Saint-Louis Hospitals, DMU Parabol, AP-HP Nord, University of Paris, Paris, France; Inserm UMR-S 942, Cardiovascular Markers in Stress Conditions (MASCOT), University of Paris, Paris, France; Department of Research, University of Ottawa Heart Institute, Ottawa, ON, Canada
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12
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Matsumura K, Yamamoto R, Kamagata T, Kurihara T, Sekine K, Takuma K, Kase K, Sasaki J. A novel scale for predicting delayed intubation in patients with inhalation injury. Burns 2020; 46:1201-1207. [PMID: 31982185 DOI: 10.1016/j.burns.2019.12.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 12/17/2019] [Accepted: 12/31/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Strategies to predict delayed airway obstruction in patients with inhalation injury have not been extensively studied. This study aimed to develop a novel scale, predicting the need for Delayed Intubation after inhalation injury (PDI) score. METHODS We retrospectively identified patients with inhalation injury at four tertiary care centers in Japan between 2012 and 2018. We included patients aged 15 or older and excluded those intubated within 30 min after hospital arrival. Predictors for delayed intubation were identified with univariate analyses and scored on the basis of odds ratios. The PDI score was evaluated with the area under the receiver operating characteristic (AUROC) curve and compared with other scaling systems for burn injuries. RESULTS Data from 158 patients were analyzed; of these patients, 18 (11.4%) were intubated during the delayed phase. Signs of respiratory distress, facial burn, and pharyngolaryngeal swelling observed on laryngoscopy, were identified as predictors for delayed intubation. The discriminatory power of the PDI (AUROC curve = 0.90; 95% confidence interval, 0.83 to 0.97; p < 0.01) was higher than that of the other scaling systems. CONCLUSIONS We developed a novel scale for predicting delayed intubation in inhalation injury. The score should be further validated with other population.
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Affiliation(s)
- Kazuki Matsumura
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, 160-8582, Japan
| | - Ryo Yamamoto
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, 160-8582, Japan.
| | - Tomohiro Kamagata
- Department of Emergency and Critical Care Medicine, Tokyo Saiseikai Central Hospital, 1-4-17 Mita, Minatoku, Tokyo, 108-0073, Japan
| | - Tomohiro Kurihara
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, 160-8582, Japan
| | - Kazuhiko Sekine
- Department of Emergency and Critical Care Medicine, Tokyo Saiseikai Central Hospital, 1-4-17 Mita, Minatoku, Tokyo, 108-0073, Japan
| | - Kiyotsugu Takuma
- Department of Emergency Medicine, Kawasaki Municipal Kawasaki Hospital, 12-1 Shinkawadori, Kawasakiku, Kanagawa, 210-0013, Japan
| | - Kenichi Kase
- Department of Emergency Medicine, Saiseikai Utsunomiya Hospital, 911-1 Takebayashimachi, Utsunomiya, Tochigi, 321-9574, Japan
| | - Junichi Sasaki
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, 160-8582, Japan
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13
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Abstract
Inhalation injury is a serious consequence of a fire or an explosion, with potential airway compromise and respiratory complications. We present a case series of five patients with inhalational burns who presented to Singapore General Hospital and discuss our approach to their early management, including early evaluation and planning for the upper and lower airway, coexisting cutaneous burns, and monitoring their ICU (intensive care unit) severity of illness, sepsis and acute respiratory distress syndrome. All five patients suffered various grades of inhalation injury. The patients were initially assessed by nasolaryngoscopy, and three patients were prophylactically intubated before being sent to the emergency operating theatre for definitive airway and burns management with fibreoptic bronchoscopy. All patients were successfully extubated and discharged stable. Various complications can arise as a result of an inhalation injury. Based on our cases and literature review, we propose a standardised workflow for patients with inhalation injury.
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Affiliation(s)
- Suneel Ramesh Desai
- Department of Surgical Intensive Care, Singapore General Hospital, Singapore.,Department of Anaesthesiology, Singapore General Hospital, Singapore
| | - Delong Zeng
- Department of Burns and Plastic Surgery, Singapore General Hospital, Singapore
| | - Si Jack Chong
- Department of Burns and Plastic Surgery, Singapore General Hospital, Singapore
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14
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Moshrefi S, Sheckter CC, Shepard K, Pereira C, Davis DJ, Karanas Y, Rochlin DH. Preventing Unnecessary Intubations: A 5-Year Regional Burn Center Experience Using Flexible Fiberoptic Laryngoscopy for Airway Evaluation in Patients With Suspected Inhalation or Airway Injury. J Burn Care Res 2019; 40:341-346. [DOI: 10.1093/jbcr/irz016] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Shawn Moshrefi
- Regional Burn Center, Santa Clara Valley Medical Center, San Jose, California
- Division of Plastic and Reconstructive Surgery, Stanford University Medical Center, Palo Alto, California
| | - Clifford C Sheckter
- Regional Burn Center, Santa Clara Valley Medical Center, San Jose, California
- Division of Plastic and Reconstructive Surgery, Stanford University Medical Center, Palo Alto, California
| | - Kimberly Shepard
- Division of Otolaryngology, Santa Clara Valley Medical Center, San Jose, California
| | - Clifford Pereira
- Regional Burn Center, Santa Clara Valley Medical Center, San Jose, California
- Division of Plastic and Reconstructive Surgery, Stanford University Medical Center, Palo Alto, California
| | - Drew J Davis
- Regional Burn Center, Santa Clara Valley Medical Center, San Jose, California
- Division of Plastic and Reconstructive Surgery, Stanford University Medical Center, Palo Alto, California
| | - Yvonne Karanas
- Regional Burn Center, Santa Clara Valley Medical Center, San Jose, California
- Division of Plastic and Reconstructive Surgery, Stanford University Medical Center, Palo Alto, California
| | - Danielle H Rochlin
- Regional Burn Center, Santa Clara Valley Medical Center, San Jose, California
- Division of Plastic and Reconstructive Surgery, Stanford University Medical Center, Palo Alto, California
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15
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Mercer SJ, Jones CP, Bridge M, Clitheroe E, Morton B, Groom P. Systematic review of the anaesthetic management of non-iatrogenic acute adult airway trauma. Br J Anaesth 2018; 117 Suppl 1:i49-i59. [PMID: 27566791 DOI: 10.1093/bja/aew193] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/23/2016] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION Non-iatrogenic trauma to the airway is rare and presents a significant challenge to the anaesthetist. Although guidelines for the management of the unanticipated difficult airway have been published, these do not make provision for the 'anticipated' difficult airway. This systematic review aims to inform best practice and suggest management options for different injury patterns. METHODS A literature search was conducted using Embase, Medline, and Google Scholar for papers after the year 2000 reporting on the acute airway management of adult patients who suffered airway trauma. Our protocol and search strategy are registered with and published by PROSPERO (http://www.crd.york.ac.uk/PROSPERO, ID: CRD42016032763). RESULTS A systematic literature search yielded 578 articles, of which a total of 148 full-text papers were reviewed. We present our results categorized by mechanism of injury: blunt, penetrating, blast, and burns. CONCLUSIONS The hallmark of airway management with trauma to the airway is the maintenance of spontaneous ventilation, intubation under direct vision to avoid the creation of a false passage, and the avoidance of both intermittent positive pressure ventilation and cricoid pressure (the latter for laryngotracheal trauma only) during a rapid sequence induction. Management depends on available resources and time to perform airway assessment, investigations, and intervention (patients will be classified into one of three categories: no time, some time, or adequate time). Human factors, particularly the development of a shared mental model amongst the trauma team, are vital to mitigate risk and improve patient safety.
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Affiliation(s)
- S J Mercer
- Anaesthetic Department, Aintree University Hospital NHS Foundation Trust, Longmoor Lane, Aintree, Liverpool L9 7AL, UK Defence Medical Services, Royal Centre for Defence Medicine, Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Edgbaston, Birmingham B15 2WB, UK Postgraduate School of Medicine, University of Liverpool, Cedar House, Ashton Street, Liverpool L69 3GE, UK
| | - C P Jones
- Anaesthetic Department, Aintree University Hospital NHS Foundation Trust, Longmoor Lane, Aintree, Liverpool L9 7AL, UK
| | - M Bridge
- Anaesthetic Department, Aintree University Hospital NHS Foundation Trust, Longmoor Lane, Aintree, Liverpool L9 7AL, UK
| | - E Clitheroe
- Anaesthetic Department, Aintree University Hospital NHS Foundation Trust, Longmoor Lane, Aintree, Liverpool L9 7AL, UK
| | - B Morton
- Anaesthetic Department, Aintree University Hospital NHS Foundation Trust, Longmoor Lane, Aintree, Liverpool L9 7AL, UK Honorary Research Fellow, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK
| | - P Groom
- Anaesthetic Department, Aintree University Hospital NHS Foundation Trust, Longmoor Lane, Aintree, Liverpool L9 7AL, UK
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17
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Abstract
A significant proportion of patients appeared to arrive at our American Burn Association-verified burn center intubated without clear benefit. The current study aims to evaluate regional prehospital intubation practices and their outcomes. All consecutive admissions from November 2012 to June 2014 were reviewed for data points associated with intubation. Demographics and outcomes for patients who were intubated before arrival or within 24 hours of admission were compared using χ, Fisher's exact test, and the Kruskal-Wallis test as appropriate. During this period, 958 patients were admitted. Of these, 120 were intubated before arrival, and 91 survived their injuries. Of these 91 survivors, 45 were extubated within 2 days, suggesting unnecessary intubation rate in 37.5%. Intubation-related complications were roughly three times as common among those intubated before arrival (12.5% vs 4.4%). Patients intubated before arrival to our burn center had a shorter median duration of intubation (1.0 vs 4.0 days), median hospital LOS (5.0 vs 22.0 days), and median intensive care unit length of stay (3.0 vs 10.0 days). Furthermore, we found a significant difference in the pattern of ventilator support duration between those arriving intubated, with a median of 2.0 days, and those intubated at our burn center, with a median of 5.5 days. Patients intubated by pre burn center providers have shorter intubation durations and shorter hospitalizations, suggesting inappropriate use of resources. Impending loss of airway appears unlikely among patients with adequate gas exchange at the time of examination. The current criteria for prehospital intubation should be revised to more accurately identify those who truly benefit from advanced airway maneuvers.
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18
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Gupta K, Mehrotra M, Kumar P, Gogia AR, Prasad A, Fisher JA. Smoke Inhalation Injury: Etiopathogenesis, Diagnosis, and Management. Indian J Crit Care Med 2018; 22:180-188. [PMID: 29657376 PMCID: PMC5879861 DOI: 10.4103/ijccm.ijccm_460_17] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Smoke inhalation injury is a major determinant of morbidity and mortality in fire victims. It is a complex multifaceted injury affecting initially the airway; however, in short time, it can become a complex life-threatening systemic disease affecting every organ in the body. In this review, we provide a summary of the underlying pathophysiology of organ dysfunction and provide an up-to-date survey of the various critical care modalities that have been found beneficial in caring for these patients. Major pathophysiological change is development of edema in the respiratory tract. The tracheobronchial tree is injured by steam and toxic chemicals, leading to bronchoconstriction. Lung parenchyma is damaged by the release of proteolytic elastases, leading to release of inflammatory mediators, increase in transvascular flux of fluids, and development of pulmonary edema and atelectasis. Decreased levels of surfactant and immunomodulators such as interleukins and tumor-necrosis-factor-α accentuate the injury. A primary survey is conducted at the site of fire, to ensure adequate airway, breathing, and circulation. A good intravenous access is obtained for the administration of resuscitation fluids. Early intubation, preferably with fiberoptic bronchoscope, is prudent before development of airway edema. Bronchial hygiene is maintained, which involves therapeutic coughing, chest physiotherapy, deep breathing exercises, and early ambulation. Pharmacological agents such as beta-2 agonists, racemic epinephrine, N-acetyl cysteine, and aerosolized heparin are used for improving oxygenation of lungs. Newer agents being tested are perfluorohexane, porcine pulmonary surfactant, and ClearMate. Early diagnosis and treatment of smoke inhalation injury are the keys for better outcome.
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Affiliation(s)
- Kapil Gupta
- Department of Anaesthesia, Vardhaman Mahavir Medical College & Safdarjung Hospital, New Delhi, India
| | - Mayank Mehrotra
- Department of Anesthesia, Integral Institute of Medical Sciences, Lucknow, India
| | - Parul Kumar
- Department of Emergency Medicine, Sinai Health Systems, Chicago, USA
| | - Anoop Raj Gogia
- Department of Anaesthesia, Vardhaman Mahavir Medical College & Safdarjung Hospital, New Delhi, India
| | - Arun Prasad
- Department of Anaesthesia, University Health Network, and University of Toronto, Toronto, Canada
| | - Joseph Arnold Fisher
- Department of Anaesthesia, University Health Network, and University of Toronto, Toronto, Canada
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Higgs A, McGrath BA, Goddard C, Rangasami J, Suntharalingam G, Gale R, Cook TM. Guidelines for the management of tracheal intubation in critically ill adults. Br J Anaesth 2017; 120:323-352. [PMID: 29406182 DOI: 10.1016/j.bja.2017.10.021] [Citation(s) in RCA: 449] [Impact Index Per Article: 64.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 10/23/2017] [Accepted: 10/25/2017] [Indexed: 12/17/2022] Open
Abstract
These guidelines describe a comprehensive strategy to optimize oxygenation, airway management, and tracheal intubation in critically ill patients, in all hospital locations. They are a direct response to the 4th National Audit Project of the Royal College of Anaesthetists and Difficult Airway Society, which highlighted deficient management of these extremely vulnerable patients leading to major complications and avoidable deaths. They are founded on robust evidence where available, supplemented by expert consensus opinion where it is not. These guidelines recognize that improved outcomes of emergency airway management require closer attention to human factors, rather than simply introduction of new devices or improved technical proficiency. They stress the role of the airway team, a shared mental model, planning, and communication throughout airway management. The primacy of oxygenation including pre- and peroxygenation is emphasized. A modified rapid sequence approach is recommended. Optimal management is presented in an algorithm that combines Plans B and C, incorporating elements of the Vortex approach. To avoid delays and task fixation, the importance of limiting procedural attempts, promptly recognizing failure, and transitioning to the next algorithm step are emphasized. The guidelines recommend early use of a videolaryngoscope, with a screen visible to all, and second generation supraglottic airways for airway rescue. Recommendations for emergency front of neck airway are for a scalpel-bougie-tube technique while acknowledging the value of other techniques performed by trained experts. As most critical care airway catastrophes occur after intubation, from dislodged or blocked tubes, essential methods to avoid these complications are also emphasized.
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Affiliation(s)
- A Higgs
- Anaesthesia and Intensive Care Medicine, Warrington and Halton Hospitals NHS Foundation Trust, Cheshire, UK(8).
| | - B A McGrath
- Anaesthesia and Intensive Care Medicine, University Hospital South Manchester, Manchester, UK(9)
| | - C Goddard
- Anaesthesia & Intensive Care Medicine, Southport and Ormskirk Hospitals NHS Trust, Southport, UK(8)
| | - J Rangasami
- Anaesthesia & Intensive Care Medicine, Wexham Park Hospital, Frimley Health NHS Foundation Trust, Slough, UK(8)
| | - G Suntharalingam
- Intensive Care Medicine and Anaesthesia, London North West Healthcare NHS Trust, London, UK(10)
| | - R Gale
- Anaesthesia & Intensive Care Medicine, Countess of Chester Hospital NHS Foundation Trust, Chester, UK(11)
| | - T M Cook
- Anaesthesia and Intensive Care Medicine, Royal United Hospitals Bath NHS Foundation Trust, Bath, UK(12)
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Freno D, Sahawneh J, Harrison S, Sahawneh T, Patterson S, Kahn SA. Determining the role of nasolaryngoscopy in the initial evaluation for upper airway injury in patients with facial burns. Burns 2017; 44:539-543. [PMID: 29122412 DOI: 10.1016/j.burns.2017.09.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Revised: 08/23/2017] [Accepted: 09/18/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Upper airway injuries can be fatal in burn patients if not recognized, a scenario that causes a significant amount of anxiety for physicians providing initial assessment of burn patients. Early elective intubation is often performed; sometimes unnecessarily. However, some providers employ nasolaryngoscopy for patients presenting with facial burns or signs/symptoms of upper airway injury in order to assess the need for intubation, but this practice is not considered standard of care and may also be unnecessary. Evidence is currently lacking about the utility of nasolaryngoscopy as an adjuvant assessment during evaluation of potential upper airway burn injuries. The objective of this study was to determine if nasolaryngoscopy provides additional information to the history and physical in making the decision to electively intubate patients with facial burns. METHODS This study was a retrospective analysis of all patients who underwent fiberoptic nasolaryngoscopy after facial burn injury to evaluate for upper airway injury associated with burns over a 2 year period at a regional burn center. During this time period, all patients who presented with facial burns, soot, or carbonaceous sputum underwent nasolaryngoscopy to look for upper airway injury regardless of mechanism of injury. Patients intubated prior to arrival were excluded from the study. Patients were considered to have signs/symptoms of airway injury (symptomatic) if they presented with dyspnea, tachypnea, hypoxia, or significant burns to buccal mucosa. Procedure notes were used to determine if supraglottic/glottic injury (erythema or edema) was present on nasolaryngoscopy. Presence of pathologic changes and whether they led to intubation were evaluated in the asymptomatic and the symptomatic groups of patients. Select individual records were inspected further to help determine if the nasolaryngoscopy findings altered management plans and if intubation was ultimately necessary based upon the presence or absence of a cuff leak and the duration of intubation. RESULTS Twenty-two patients were symptomatic upon presentation, 14 of which had positive findings on laryngoscopy and 7 (50%) were intubated. One-hundred and eighty-eight patients were asymptomatic, 58 (31%) of which had either erythema or edema or carbonaceous debris on nasolaryngoscopy, and only 2 (1%) were intubated. These patients were both extubated within two days. None of the 130 asymptomatic patients with negative nasolaryngoscopy were intubated. CONCLUSIONS This study showed disparity between signs and symptoms of airway injury and nasolaryngoscopy findings. Asymptomatic patients showed pathologic changes in 30% of scopes, but this finding only changed management 1% of the time. Furthermore, the two patients in this group were extubated quickly, suggesting they may have been suitable for observation without intubation. These results indicate that the presence of erythema or edema is of questionable clinical significance in asymptomatic patients and nasolaryngoscopy is of limited benefit in this group. Only 50% of the symptomatic patients with airway injury evident on nasolaryngoscopy were actually intubated, also bringing into question the significance of the pathologic changes in this group. However, negative nasolaryngoscopy may have had some benefit in preventing intubation in a few, select symptomatic patients. This study suggests that a thorough history and physical is the best tool to identify patients at higher risk of upper airway injury who need intubation, but this should be further studied in prospective trials to determine the definitive role of nasolaryngoscopy.
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Affiliation(s)
- Daniel Freno
- Department of Surgery, University of South Alabama School of Medicine, 2451 Fillingim Street, Mobile, AL, 36695, USA.
| | - James Sahawneh
- Department of Surgery, University of South Alabama School of Medicine, 2451 Fillingim Street, Mobile, AL, 36695, USA
| | - Sarah Harrison
- Department of Surgery, University of South Alabama School of Medicine, 2451 Fillingim Street, Mobile, AL, 36695, USA
| | - Tim Sahawneh
- Department of Surgery, University of South Alabama School of Medicine, 2451 Fillingim Street, Mobile, AL, 36695, USA
| | - Scott Patterson
- Department of Surgery, University of South Alabama School of Medicine, 2451 Fillingim Street, Mobile, AL, 36695, USA.
| | - Steven A Kahn
- Department of Surgery, University of South Alabama School of Medicine, 2451 Fillingim Street, Mobile, AL, 36695, USA.
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Abstract
Smoke inhalation injury can cause severe physiologic perturbations. In pediatric patients, these perturbations cause profound changes in cardiac and pulmonary physiology. In this review, we examine the pathology, early management options, ventilator strategy, and long-term outcomes in pediatric patients who have suffered a smoke inhalation injury.
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Affiliation(s)
- Soman Sen
- Division of Burn Surgery, Department of Surgery, University of California Davis, Shriners Hospital for Children Northern California, Sacramento, USA
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Sturgess DJ, Greenland KB, Senthuran S, Ajvadi FA, van Zundert A, Irwin MG. Tracheal extubation of the adult intensive care patient with a predicted difficult airway - a narrative review. Anaesthesia 2016; 72:248-261. [PMID: 27804108 DOI: 10.1111/anae.13668] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/12/2016] [Indexed: 12/17/2022]
Abstract
Management of the difficult airway is an important, but as yet poorly-studied, component of intensive care management. Although there has been a strong emphasis on prediction and intubation of the difficult airway, safe extubation of the patient with a potentially difficult airway has not received the same attention. Extubation is a particularly vulnerable time for the critically ill patient and, because of the risks involved and the consequences of failure, it warrants specific consideration. The Royal College of Anaesthetists 4th National Audit Project highlighted differences in the incidence and consequences of major complications during airway management between the operating room and the critical care environment. The findings in the section on Intensive Care and Emergency Medicine reinforce the importance of good airway management in the critical care environment and, in particular, the need for appropriate guidelines to improve patient safety. This narrative review focuses on strategies for safe extubation of the trachea for patients with potentially difficult upper airway problems in the intensive care unit.
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Affiliation(s)
- D J Sturgess
- Mater Research Institute, The University of Queensland, Brisbane, Queensland, Australia
| | - K B Greenland
- Department of Anaesthesiology, University of Hong Kong, Hong Kong SAR
| | - S Senthuran
- School of Medicine, James Cook University, Townsville, Queensland, Australia
| | - F A Ajvadi
- Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - A van Zundert
- Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - M G Irwin
- Department of Anaesthesiology, University of Hong Kong, Hong Kong SAR
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Enkhbaatar P, Pruitt BA, Suman O, Mlcak R, Wolf SE, Sakurai H, Herndon DN. Pathophysiology, research challenges, and clinical management of smoke inhalation injury. Lancet 2016; 388:1437-1446. [PMID: 27707500 PMCID: PMC5241273 DOI: 10.1016/s0140-6736(16)31458-1] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Revised: 08/11/2016] [Accepted: 08/16/2016] [Indexed: 01/02/2023]
Abstract
Smoke inhalation injury is a serious medical problem that increases morbidity and mortality after severe burns. However, relatively little attention has been paid to this devastating condition, and the bulk of research is limited to preclinical basic science studies. Moreover, no worldwide consensus criteria exist for its diagnosis, severity grading, and prognosis. Therapeutic approaches are highly variable depending on the country and burn centre or hospital. In this Series paper, we discuss understanding of the pathophysiology of smoke inhalation injury, the best evidence-based treatments, and challenges and future directions in diagnostics and management.
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Affiliation(s)
- Perenlei Enkhbaatar
- Department of Anesthesiology, University of Texas Medical Branch, Galveston, TX, USA.
| | - Basil A Pruitt
- Department of Surgery, Division of Trauma, University of Texas Health Science Center, San Antonio, TX, USA
| | - Oscar Suman
- Department of Surgery, University of Texas Medical Branch, Galveston, TX, USA; Shriners Hospitals for Children, Galveston, TX, USA
| | - Ronald Mlcak
- Shriners Hospitals for Children, Galveston, TX, USA; Department of Respiratory Care, School of Health Professions, University of Texas Medical Branch, Galveston, TX, USA
| | - Steven E Wolf
- Department of Surgery, University of Texas, Southwestern Medical Center, Dallas, TX, USA
| | - Hiroyuki Sakurai
- Department of Plastic and Reconstructive Surgery, Tokyo Women's Medical University, Tokyo, Japan
| | - David N Herndon
- Department of Surgery, University of Texas Medical Branch, Galveston, TX, USA; Shriners Hospitals for Children, Galveston, TX, USA
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24
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Ziegler B, Hirche C, Horter J, Kiefer J, Grützner PA, Kremer T, Kneser U, Münzberg M. In view of standardization Part 2: Management of challenges in the initial treatment of burn patients in Burn Centers in Germany, Austria and Switzerland. Burns 2016; 43:318-325. [PMID: 27665246 DOI: 10.1016/j.burns.2016.08.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Revised: 08/03/2016] [Accepted: 08/05/2016] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Initial therapy of severe burns in specialized burn trauma centers is a challenging task faced by the treating multi-professional and interdisciplinary team. A lack of consistent operating procedures and varying structural conditions was recently demonstrated in preliminary data of our group. These results raised the question on how specific treatment measures in acute burn care are met in the absence of standardized guidelines. MATERIAL AND METHODS A specific questionnaire containing 57 multiple-choice questions was sent to all 22 major burn centers in Germany, Austria and Switzerland. The survey included standards of airway management and ventilation, fluid management and circulation, body temperature monitoring and management, topical burn wound treatment and a microbiological surveillance. Additionally, the distribution of standardized course systems was covered. RESULTS 17 out of 22 questionnaires (77%) were returned completed. Regarding volume resuscitation, results showed a similar approach in estimating initial fluid while discrepancies persisted in the use of colloidal fluid and human albumin. Elective tracheostomy and the need for bronchoscopy with suspected inhalation injury were the most controversial issues revealed by the survey. Topical treatment of burned body surface also followed different principles regarding the use of synthetic epidermal skin substitutes or enzymatic wound debridement. Less discrepancy was found in basic diagnostic measures, body temperature management, estimation of the extent of burns and microbiological surveillance. CONCLUSION While many burn-related issues are clearly not questionable and managed in a similar way in most participating facilities, we were able to show that the most contentious issues in burn trauma management involve initial volume resuscitation, management of inhalation trauma and topical burn wound treatment. Further research is required to address these topics and evaluate a potential superiority of a regime in order to increase the level of evidence.
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Affiliation(s)
- Benjamin Ziegler
- Department of Hand, Plastic and Reconstructive Surgery-Burn Center, BG Trauma Center Ludwigshafen/Rhine, Hand and Plastic Surgery, University Heidelberg, Ludwig-Guttmann-Str. 13, D-67071 Ludwigshafen, Germany
| | - Christoph Hirche
- Department of Hand, Plastic and Reconstructive Surgery-Burn Center, BG Trauma Center Ludwigshafen/Rhine, Hand and Plastic Surgery, University Heidelberg, Ludwig-Guttmann-Str. 13, D-67071 Ludwigshafen, Germany
| | - Johannes Horter
- Department of Hand, Plastic and Reconstructive Surgery-Burn Center, BG Trauma Center Ludwigshafen/Rhine, Hand and Plastic Surgery, University Heidelberg, Ludwig-Guttmann-Str. 13, D-67071 Ludwigshafen, Germany
| | - Jurij Kiefer
- Department of Hand, Plastic and Reconstructive Surgery-Burn Center, BG Trauma Center Ludwigshafen/Rhine, Hand and Plastic Surgery, University Heidelberg, Ludwig-Guttmann-Str. 13, D-67071 Ludwigshafen, Germany
| | - Paul Alfred Grützner
- Department of Trauma and Orthopedic Surgery, Air Rescue Center, BG Trauma Center Ludwigshafen/Rhine, Ludwig-Guttmann-Str. 13, D-67071 Ludwigshafen, Germany
| | - Thomas Kremer
- Department of Hand, Plastic and Reconstructive Surgery-Burn Center, BG Trauma Center Ludwigshafen/Rhine, Hand and Plastic Surgery, University Heidelberg, Ludwig-Guttmann-Str. 13, D-67071 Ludwigshafen, Germany
| | - Ulrich Kneser
- Department of Hand, Plastic and Reconstructive Surgery-Burn Center, BG Trauma Center Ludwigshafen/Rhine, Hand and Plastic Surgery, University Heidelberg, Ludwig-Guttmann-Str. 13, D-67071 Ludwigshafen, Germany
| | - Matthias Münzberg
- Department of Trauma and Orthopedic Surgery, Air Rescue Center, BG Trauma Center Ludwigshafen/Rhine, Ludwig-Guttmann-Str. 13, D-67071 Ludwigshafen, Germany.
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Burns During Pregnancy: Implications for Maternal-Perinatal Providers and Guidelines for Practice. Obstet Gynecol Surv 2016; 70:633-43. [PMID: 26490163 DOI: 10.1097/ogx.0000000000000219] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
IMPORTANCE When a major burn is suffered during pregnancy, the obstetric provider is challenged to respond on an evidence basis because personal experience usually is lacking. Currently, there is a paucity of publications to inform the obstetrician, guide practice, and impact early critical decision making. OBJECTIVE The aims of this study were to summarize the available information on early management of burns during pregnancy and to identify components of best practices for optimal outcome. EVIDENCE ACQUISITION The PubMed database was searched for relevant titles and abstracts involving pregnant patients suffering from second-/third-degree burns. Among these studies, the bibliographies were investigated for further relevant literature. A total of 114 studies were identified during the initial search, and only studies published in English and French were included for a total of 42. Variable data were available for 1141 patients, with complete data for 139 cases. Mediation and regression analysis were used for available data. Insufficient data were available to undertake a systematic review. RESULTS Total body surface area of burns (TBSAB) was positively associated with maternal death, and the odds of maternal mortality increase by 1.08 per percentage increase of TBSAB (P < 0.001). Fetal survival depends on maternal survival (P ≤ 0.001). Maternal survival declines incrementally when TBSAB exceeds 55%, and inhalation injury further exacerbates maternal-perinatal risk. CONCLUSIONS Emergent assessment of the pregnant burn victimincludes determination of gestational age, extent of TBSAB, presence of inhalation injury, and continuous fetal monitoring. If gestational age is 24 weeks or longer and TBSAB exceeds 55%, urgent cesarean delivery appears desirable for the mother and baby. RELEVANCE A specific analysis of maternal-perinatal outcome based on TBSAB and gestational age is relevant to obstetric and emergency providers who provide care to pregnant burn patients.
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Yoshino Y, Ohtsuka M, Kawaguchi M, Sakai K, Hashimoto A, Hayashi M, Madokoro N, Asano Y, Abe M, Ishii T, Isei T, Ito T, Inoue Y, Imafuku S, Irisawa R, Ohtsuka M, Ogawa F, Kadono T, Kawakami T, Kukino R, Kono T, Kodera M, Takahara M, Tanioka M, Nakanishi T, Nakamura Y, Hasegawa M, Fujimoto M, Fujiwara H, Maekawa T, Matsuo K, Yamasaki O, Le Pavoux A, Tachibana T, Ihn H. The wound/burn guidelines - 6: Guidelines for the management of burns. J Dermatol 2016; 43:989-1010. [PMID: 26971391 DOI: 10.1111/1346-8138.13288] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Accepted: 12/04/2015] [Indexed: 12/16/2022]
Abstract
Burns are a common type of skin injury encountered at all levels of medical facilities from private clinics to core hospitals. Minor burns heal by topical treatment alone, but moderate to severe burns require systemic management, and skin grafting is often necessary also for topical treatment. Inappropriate initial treatment or delay of initial treatment may exert adverse effects on the subsequent treatment and course. Therefore, accurate evaluation of the severity and initiation of appropriate treatment are necessary. The Guidelines for the Management of Burn Injuries were issued in March 2009 from the Japanese Society for Burn Injuries as guidelines concerning burns, but they were focused on the treatment for extensive and severe burns in the acute period. Therefore, we prepared guidelines intended to support the appropriate diagnosis and initial treatment for patients with burns that are commonly encountered including minor as well as moderate and severe cases. Because of this intention of the present guidelines, there is no recommendation of individual surgical procedures.
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Affiliation(s)
- Yuichiro Yoshino
- Department of Dermatology, Japanese Red Cross Kumamoto Hospital, Kumamoto, Japan
| | - Mikio Ohtsuka
- Department of Dermatology, Fukushima Medical University, Fukushima, Japan
| | - Masakazu Kawaguchi
- Department of Dermatology, Yamagata University Faculty of Medicine, Yamagata, Japan
| | - Keisuke Sakai
- Intensive Care Unit, Kumamoto University Hospital, Kumamoto, Japan
| | - Akira Hashimoto
- Department of Dermatology, Tohoku University Graduate School of Medicine, Miyagi, Japan
| | - Masahiro Hayashi
- Department of Dermatology, Yamagata University Faculty of Medicine, Yamagata, Japan
| | - Naoki Madokoro
- Department of Dermatology, Mazda Hospital, Hiroshima, Japan
| | - Yoshihide Asano
- Department of Dermatology, Faculty of Medicine, University of Tokyo, Tokyo, Japan
| | - Masatoshi Abe
- Department of Dermatology, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Takayuki Ishii
- Department of Dermatology, Faculty of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Ishikawa, Japan
| | - Taiki Isei
- Department of Dermatology, Kansai Medical University, Osaka, Japan
| | - Takaaki Ito
- Department of Dermatology, Hyogo College of Medicine, Hyogo, Japan
| | - Yuji Inoue
- Department of Dermatology and Plastic Surgery, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Shinichi Imafuku
- Department of Dermatology, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Ryokichi Irisawa
- Department of Dermatology, Tokyo Medical University, Tokyo, Japan
| | - Masaki Ohtsuka
- Department of Dermatology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Fumihide Ogawa
- Department of Dermatology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Takafumi Kadono
- Department of Dermatology, Faculty of Medicine, University of Tokyo, Tokyo, Japan
| | - Tamihiro Kawakami
- Department of Dermatology, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Ryuichi Kukino
- Department of Dermatology, NTT Medical Center, Tokyo, Japan
| | - Takeshi Kono
- Department of Dermatology, Nippon Medical School, Tokyo, Japan
| | - Masanari Kodera
- Department of Dermatology, Japan Community Health Care Organization Chukyo Hospital, Aichi, Japan
| | - Masakazu Takahara
- Department of Dermatology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Miki Tanioka
- Department of Dermatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Takeshi Nakanishi
- Department of Dermatology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | | | - Minoru Hasegawa
- Department of Dermatology, Faculty of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Ishikawa, Japan
| | - Manabu Fujimoto
- Department of Dermatology, Faculty of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Ishikawa, Japan
| | - Hiroshi Fujiwara
- Department of Dermatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Takeo Maekawa
- Department of Dermatology, Jichi Medical University, Tochigi, Japan
| | - Koma Matsuo
- Department of Dermatology, The Jikei University School of Medicine, Tokyo, Japan
| | - Osamu Yamasaki
- Department of Dermatology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | | | - Takao Tachibana
- Department of Dermatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Hironobu Ihn
- Department of Dermatology and Plastic Surgery, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
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The Evaluation of Physical Exam Findings in Patients Assessed for Suspected Burn Inhalation Injury. J Burn Care Res 2015; 36:197-202. [DOI: 10.1097/bcr.0000000000000175] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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You K, Yang HT, Kym D, Yoon J, HaejunYim, Cho YS, Hur J, Chun W, Kim JH. Inhalation injury in burn patients: establishing the link between diagnosis and prognosis. Burns 2014; 40:1470-5. [PMID: 25406889 DOI: 10.1016/j.burns.2014.09.015] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2014] [Revised: 09/13/2014] [Accepted: 09/16/2014] [Indexed: 01/10/2023]
Abstract
This study was to re-evaluate inhalation injury as a prognostic factor in burn patients and to determine the factors that should be considered when refining the definition of inhalation injury. A total of 192 burn patients (152 men, 40 women; mean age, 46.1±13.8 years) who were suspected to have an inhalation injury and underwent bronchoscopy between January 2010 and June 2012 were included in this prospective observational study. All patients underwent bronchoscopy within 24h of sustaining the burn. The bronchoscopic findings were classified as normal, mild, moderate, and severe. Mechanical ventilation was administered, when required. Age, percentage of TBSA burned, ABSI score, requirement of mechanical ventilation and PF ratio, but not inhalation injury, COHb level, and bronchoscopic grades, significantly differed between the survivors and non-survivors (p<0.05). Mechanical ventilation (adjusted odds ratio [OR]: 9.787) and severe inhalation injury on bronchoscopy (adjusted OR: 45.357) were independent predictors of mortality on multivariate logistic regression analysis. Inhalation injury diagnosed through history does not predict mortality from burns. Other components such as severity of inhalation injury determined using bronchoscopy, and administration of mechanical ventilation might help predict the morbidity and mortality of burn patients with inhalation injury and all of the factors should be considered when the definition of inhalation injury is refined.
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Affiliation(s)
- Kicheol You
- Department of Emergency Medicine, Burn Center, Hangang Sacred Heart Hospital, College of Medicine, Hallym University, 12, Beodeunaru-ro 7-gil (Youngdeungpo-dong 2-ga), Youngdeungpo-gu, Seoul 150-719, Republic of Korea
| | - Hyeong-Tae Yang
- Department of Surgery, Burn Center, Hangang Sacred Heart Hospital, College of Medicine, Hallym University, 12, Beodeunaru-ro 7-gil (Youngdeungpo-dong 2-ga), Youngdeungpo-gu, Seoul 150-719, Republic of Korea; Department of Surgery, Kangwon National University College of Medicine, Kangwondaehak 1 gil, Chuncheon-si, Gangwon-do 200-701, Republic of Korea
| | - Dohern Kym
- Department of Surgery, Burn Center, Hangang Sacred Heart Hospital, College of Medicine, Hallym University, 12, Beodeunaru-ro 7-gil (Youngdeungpo-dong 2-ga), Youngdeungpo-gu, Seoul 150-719, Republic of Korea.
| | - Jaechul Yoon
- Department of Surgery, Burn Center, Hangang Sacred Heart Hospital, College of Medicine, Hallym University, 12, Beodeunaru-ro 7-gil (Youngdeungpo-dong 2-ga), Youngdeungpo-gu, Seoul 150-719, Republic of Korea
| | - HaejunYim
- Department of Surgery, Burn Center, Hangang Sacred Heart Hospital, College of Medicine, Hallym University, 12, Beodeunaru-ro 7-gil (Youngdeungpo-dong 2-ga), Youngdeungpo-gu, Seoul 150-719, Republic of Korea
| | - Yong-Suk Cho
- Department of Surgery, Burn Center, Hangang Sacred Heart Hospital, College of Medicine, Hallym University, 12, Beodeunaru-ro 7-gil (Youngdeungpo-dong 2-ga), Youngdeungpo-gu, Seoul 150-719, Republic of Korea
| | - Jun Hur
- Department of Surgery, Burn Center, Hangang Sacred Heart Hospital, College of Medicine, Hallym University, 12, Beodeunaru-ro 7-gil (Youngdeungpo-dong 2-ga), Youngdeungpo-gu, Seoul 150-719, Republic of Korea
| | - Wook Chun
- Department of Surgery, Burn Center, Hangang Sacred Heart Hospital, College of Medicine, Hallym University, 12, Beodeunaru-ro 7-gil (Youngdeungpo-dong 2-ga), Youngdeungpo-gu, Seoul 150-719, Republic of Korea
| | - Jong-Hyun Kim
- Department of Surgery, Burn Center, Hangang Sacred Heart Hospital, College of Medicine, Hallym University, 12, Beodeunaru-ro 7-gil (Youngdeungpo-dong 2-ga), Youngdeungpo-gu, Seoul 150-719, Republic of Korea
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Kameda T, Fujita M. Point-of-care ultrasound detection of tracheal wall thickening caused by smoke inhalation. Crit Ultrasound J 2014; 6:11. [PMID: 25097745 PMCID: PMC4105106 DOI: 10.1186/2036-7902-6-11] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2014] [Accepted: 07/01/2014] [Indexed: 11/21/2022] Open
Abstract
Smoke inhalation is the leading cause of death due to fires. When a patient presents with smoke inhalation, prompt assessment of the airway and breathing is necessary. Point-of-care ultrasonography (US) is used for the rapid assessment of critically ill or injured patients. We herein present a case report of a 54-year-old male who was transferred to the emergency department with shortness of breath, coughing, carbonaceous sputa, and rhinorrhea after inhaling smoke caused by a fire in his locked bedroom. He had no surface burns on the face and no edema or erosion in the oral cavity. He had hoarseness without stridor. His breath sounds were positive for expiratory wheezes. Laryngoscopy showed light edema and erosive findings on the supraglottic region. Bedside point-of-care US revealed hypoechoic thickening of the tracheal wall. The thickening was confirmed by a computed tomographic scan. The patient was carefully monitored with preparation for emergency airway management and was treated with supplemental oxygen and an aerosolized beta-2 adrenergic agonist in the intensive care unit. The symptoms were subsequently relieved, and reexamination by US after 2 days showed remission of the wall thickening. Point-of-care US may therefore be a useful modality for the rapid diagnosis and effective follow-up of tracheal wall thickening caused by smoke inhalation.
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Affiliation(s)
- Toru Kameda
- Department of Emergency Medicine, Red Cross Society Azumino Hospital, 5685 Toyoshina, Azumino, Nagano 399-8292, Japan
| | - Masato Fujita
- Department of Emergency and Intensive Care Medicine, Red Cross Society Azumino Hospital, 5685 Toyoshina, Azumino, Nagano 399-8292, Japan
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Antonio ACP, Castro PS, Freire LO. Smoke inhalation injury during enclosed-space fires: an update. J Bras Pneumol 2014; 39:373-81. [PMID: 23857686 PMCID: PMC4075838 DOI: 10.1590/s1806-37132013000300016] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2013] [Accepted: 04/25/2013] [Indexed: 11/22/2022] Open
Abstract
In view of the tragic fire at a nightclub in the city of Santa Maria, Brazil, which culminated in the sudden death of 232 young people, we decided to review the literature regarding smoke inhalation injury caused by enclosed-space fires, which can be divided into direct thermal damage, carbon monoxide poisoning, and cyanide poisoning. Such injuries often call for immediate orotracheal intubation, either due to acute airway obstruction or due to a reduced level of consciousness. The diagnosis and the severity of the thermal injury can be determined by fiberoptic bronchoscopy. The levels of gases and gas by-products in the bloodstream should be assessed as rapidly as possible, even while still at the scene of the incident. First responders can also treat carbon monoxide poisoning, with immediate administration of oxygen at 100%, as well as cyanide poisoning, with oxygen therapy and hydroxocobalamin injection.
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Oscier C, Emerson B, Handy JM. New perspectives on airway management in acutely burned patients. Anaesthesia 2014; 69:105-10. [DOI: 10.1111/anae.12565] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- C. Oscier
- Chelsea and Westminster NHS Foundation Trust; London UK
| | - B. Emerson
- St Andrews Centre for Plastic Surgery and Burns; Mid Essex Hospitals NHS Trust; Chelmsford UK
| | - J. M. Handy
- Chelsea and Westminster NHS Foundation Trust; London UK
- Imperial College London; London UK
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Zhao R, La-na D, Chun-Quan W, Fang-gang N, Guo-an Z. Circulational heat dissipation of upper airway: Canine model of inhalational thermal injury. Burns 2013; 39:1212-20. [DOI: 10.1016/j.burns.2013.01.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2012] [Revised: 12/21/2012] [Accepted: 01/04/2013] [Indexed: 11/26/2022]
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Zhao R, Di LN, Zhao XZ, Wang C, Zhang GA. Measuring surface temperature and grading pathological changes of airway tissue in a canine model of inhalational thermal injury. Burns 2013; 39:767-75. [DOI: 10.1016/j.burns.2012.10.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2012] [Revised: 10/24/2012] [Accepted: 10/24/2012] [Indexed: 12/29/2022]
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Cotte J, Prunet B, Esnault P, Lacroix G, D'aranda E, Cungi PJ, Goutorbe P, Dantzer E, Meaudre E. Early onset pneumonia in patients with severely burned face and neck: a 5-year retrospective study. Burns 2013; 39:892-6. [PMID: 23332161 DOI: 10.1016/j.burns.2012.12.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2012] [Revised: 12/01/2012] [Accepted: 12/04/2012] [Indexed: 11/18/2022]
Abstract
Patients with face and neck burns (FNBs) often undergo prehospital intubation, or sustain inhalation injury which are risk factors for pneumonia in specific populations. Early onset pneumonia (EOP) might be caused by initial management. The primary goal of this study was to find risk factors for EOP in FNB patients. This is a retrospective, single-center trial. We screened all FNB patients for EOP with the Clinical Pulmonary Infection Score. Pneumonia diagnosis was with culture from a mini broncho-alveolar lavage. Potential risk factors for EOP were recorded. We included 152 patients, EOP was diagnosed in 58 (38.2%). EOP patients had a greater burned surface area median (20±17% vs. 10±17%; p<0.001), were more frequently intubated during prehospital care (65.5% vs. 21.3%; p<0.001), had more abnormal fiberoptic bronchoscopy at admission (58.6% vs. 19.1%; p=0.002) and a lower initial PaO2/FiO2 ratio (median 314±118.6 vs. 365±105.7; p=0.01). Multivariate analysis showed that only prehospital intubation was independently associated with EOP (odds ratio 3.6; 95% confidence interval, 1.34-10). Prehospital intubation appears to be an independent risk factor for EOP in severe burn patients. Assessments of the risk-benefit ratios of intubating and of not intubating those patients are indicated.
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Affiliation(s)
- Jean Cotte
- Burn Intensive Care Unit, Sainte Anne Military Teaching Hospital, Toulon, France.
| | - Bertrand Prunet
- Burn Intensive Care Unit, Sainte Anne Military Teaching Hospital, Toulon, France
| | - Pierre Esnault
- Burn Intensive Care Unit, Sainte Anne Military Teaching Hospital, Toulon, France
| | - Guillaume Lacroix
- Burn Intensive Care Unit, Sainte Anne Military Teaching Hospital, Toulon, France
| | - Erwan D'aranda
- Burn Intensive Care Unit, Sainte Anne Military Teaching Hospital, Toulon, France
| | - Pierre Julien Cungi
- Burn Intensive Care Unit, Sainte Anne Military Teaching Hospital, Toulon, France
| | - Philippe Goutorbe
- Burn Intensive Care Unit, Sainte Anne Military Teaching Hospital, Toulon, France
| | - Eric Dantzer
- Burn Intensive Care Unit, Sainte Anne Military Teaching Hospital, Toulon, France
| | - Eric Meaudre
- Burn Intensive Care Unit, Sainte Anne Military Teaching Hospital, Toulon, France
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Abstract
PURPOSE OF REVIEW To update critical care practitioners on the recent advancements in burn care. RECENT FINDINGS Particular topics discussed include airway management, acute resuscitation, issues within the intensive care unit, nutrition, and wound management. SUMMARY This is a concise review of the recent burn literature tailored to the critical care practitioner. Criteria for extubation of burn patients are examined, as is the need for cuffed endotracheal tubes in pediatric burn patients. Strategies to avoid over-resuscitation are discussed, including use of colloid, as well as nurse-driven and computer-guided resuscitation protocols. New data regarding common ICU issues such as insulin therapy, delirium, and preferred intravenous access are reviewed. The importance of nutrition in the burn patient is emphasized, particularly early initiation of enteral nutrition, continuation of nutrition during surgical procedures, and use of adjuncts such as immunonutrition and beta blockade. Finally, both short-term and long-term wound issues are addressed via sections on laser Doppler assessment of burns and pressure garment therapy to prevent long-term scarring.
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Abstract
Smoke inhalation injury, a unique form of acute lung injury, greatly increases the occurrence of postburn morbidity and mortality. In addition to early intubation for upper-airway protection, subsequent critical care of patients who have this injury should be directed at maintaining distal airway patency. High-frequency ventilation, inhaled heparin, and aggressive pulmonary toilet are among the therapies available. Even so, immunosuppression, intubation, and airway damage predispose these patients to pneumonia and other complications.
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Abstract
With advances in burn care, many children are surviving severe burn injuries. Inhalation injury remains a predictor of morbidity and mortality in burn injury. Inhalation of smoke and toxic gases leads to pulmonary complications, including airway obstruction from bronchial casts, pulmonary edema, decreased pulmonary compliance, and ventilation-perfusion mismatch, as well as systemic toxicity from carbon monoxide poisoning and cyanide toxicity. The diagnosis of inhalation injury is suggested by the history and physical exam and can be confirmed by bronchoscopy. Management consists of supportive measures, pulmonary toilet, treatment of pulmonary infection and ventilatory support as needed. This review details the pathophysiology, diagnosis, and management options for inhalation injury.
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Affiliation(s)
- Christina W Fidkowski
- Department of Anesthesia and Critical Care, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston MA 02155, USA
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Abstract
Major burn injury remains a significant cause of morbidity and mortality in pediatric patients. With advances in burn care and with the development of experienced multi-disciplinary teams at regionalized burn centers, many children are surviving severe burn injury. As members of the multi-disciplinary care team, anesthesia providers are called upon to care for these critically ill children. These children provide several anesthetic challenges, such as difficult airways, difficult vascular access, fluid and electrolyte imbalances, altered temperature regulation, sepsis, cardiovascular instability, and increased requirements of muscle relaxants and opioids. The anesthesia provider must understand the physiologic derangements that occur with severe burn injury as well as the subsequent anesthetic implications.
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Affiliation(s)
- Gennadiy Fuzaylov
- Department of Anesthesia and Critical Care, Pediatric Anesthesia Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA.
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Bedside assessment of swallowing is predictive of an abnormal barium swallow examination. J Burn Care Res 2008; 29:89-96. [PMID: 18182903 DOI: 10.1097/bcr.0b013e31815f5a4c] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Adequate nutritional support after thermal burn injury is essential for achieving successful patient outcomes. Dysphagia is common in burn patients. Our objective was to analyze hospitalized burn patients referred to speech pathology for swallowing evaluation. A retrospective study of burn patients admitted to our center and evaluated by speech pathology from December 2001 through July 2006 was performed. Of the 16 patients, 5 (31%) had a normal bedside swallow examination, did not undergo a modified barium swallow study (MBSS), and were excluded. Six (55%) of the 11 included patients were men. The average age was 44 +/- 18 years. All 11 patients had a thermal burn with an average total body surface area burn of 36% +/- 16%. Facial burns were present in 91% (10 of 11) of the patients, and inhalation injury was confirmed by bronchoscopy in 55% (6 of 11) of the patients. The average length of stay was 84 +/- 45 days. Of the 11 abnormal bedside assessments performed, 10 (91%) were associated with an abnormal MBSS. One patient had evidence of oral dysphagia only and one patient had evidence of pharyngeal dysphagia only. Six patients had oral and pharyngeal dysphagia, and two patients had pharyngeal and esophageal dysphagia. One tracheal-esophageal fistula was identified. A bedside assessment of swallowing performed by a speech pathologist is predictive of an abnormal modified barium swallow in burn patients. Burn patients with facial burns, inhalation injury, pneumonia, and a prolonged ICU stay are at increased risk for dysphagia. Prospective studies are necessary to determine in which patients an MBSS adds additional relevant clinical information.
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Affiliation(s)
- Tina L Palmieri
- Shriners Hospitals for Children-Northern California, and Department of Surgery, University of California-Davis, 2425 Stockton Boulevard, Sacramento, CA 95817, USA
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