Airway management for the burn patient

[Spock]

We have two hospitals with burn units in Pittsburgh and I work at the only one that is also a Level 1 trauma center. Just the other day we received a patient that had been trapped in an apartment fire. He had burns to his face, chest, back, and left arm for about a 50% BSA burn mostly second degree. The medics did a good job with early airway control by getting him intubated in the field. The pt arrived with an SBP of 135 and pulse rate of around 100 and was still breathing. The problem was the medics intubated him with a 6.0 tube that had a pretty good air leak even though the cuff was inflated to the maximum. I had to change the tube and although the procedure went well it was not fun. The pt was at least six foot and weighed 230 and I intubated him with an 8.0 tube. Total time from fire to my intubation was about an hour and the airway was full of soot.

My question is: What are your guidlelines/protocols for intubation of the burn patient? Do people routinely place small tubes because that is what you were taught? This was not an isolated instance as I have had to do this several times on patients that have arrived by ground and air and transferred from community hospitals. I'm just curious as to what everyone has been taught across the country. The crew left before I could talk to them.

Live long and prosper.

Spock

[TechMedic05]

I was taught, especially in burn patients, to be aggressive with airway management, especially with facial and airway injuries. There was no mention of using a smaller sized ETT, however.

[Ridryder 911]

We don't have specific "protocols" except to maintain an adequate airway, from there it is the medics discretion.

I personally prefer to RSI, ASAP if there is signs of respiratory burns, that appear to compromise upper or lower airway.

I worked as a burn nurse at a large burn center, and I can attest it definitely harder after edema, and it appears to happen quickly when it does.

I know one should be cautious using Sux, etc. due to K+, but that is usually after 24 hr fluid shift, but I try to use an alternative paralytic. I had to trach. a patient once with severe edema to the face, throat. It was an event, I prefer not to have ever due again.

Be safe,

R/r 911

[vs-eh?]

We don't have specific "protocols" either. Just follow the same rule of thumb as Rid, minus the RSI for me...

Tube size wise, in my opinion you always want the largest tube that the patient can handle. What is it Postilele's (sp) Rule/Law with lumen size and resistance to flow? Wouldn't a 6.0 in a man of this size cause issues with increased vent pressures and what not? It's been awhile since I did that stuff...

I thought maybe they used a 6.0 because of angioedema, but obviously you could pass an 8.0 so I dunno...Maybe they just grabbed the wrong tube...

Did they start the Parkland burn formula in the field too?

[Ace844]

Hi All,

Just gonna throw this into the ring as a possibility. I would tend to wonder if this is just as likely a case where (even though the medic should have been and this is no excuse) the medic was abit 'stressed' because their pt was 'sick' and thought that 'he' had grabbed an 7.5 or an 8 out of the tube roll when in fact 'he' had grabbed a 6. So while dong many other things or trying to do 2 things at once this happened in error and sadly perhaps it was recognized but the airway was pateent by then and secured, or worse went unrecognized. It's not right, but I do see it happen A LOT more than it should.

Food for thought

ACE844

[chbare]

Spock, our hospital does not have a protocol for intubating burn patients. We will usually intubate any burn pt suspected of having respiratory injury early. We generally use a 7.0-8.0 on an adult. In addition our docs like to use vec over sux in the burn patients, even prior to the 24 hour fluid shift period. (just to play it safe) Our county only has 2 paramedics that work EMS. (all BLS & ILS) All the other medics work for the hospital or the transport service, so we do not get allot of intubated patients from the field. In addition paramedics cannot RSI in the field without a special skill designation in our area, so we get patients that should be intubated, but the medics opt out of intubation because the patients are awake and have intact gag reflexes. I can only guess that the medic grabbed the wrong tube in the chaos of the situation, or decided to be very conservative because of the airway edema.

Take care,

chbare.

[Gumballs]

We have a guideline that reads:

Female: 6.0 - 7.5

Male: 7.5 - 9.0

However, we are also taught to have a size above and below close by just in case.

Also, I have also been taught that a rough guideline is to compare the finger nail of the 5th digit (pinkie) to that of the id of the ETT to assist in the proper size determination.

[vs-eh?]

We have a guideline that reads:

Female: 6.0 - 7.5

Male: 7.5 - 9.0

However, we are also taught to have a size above and below close by just in case.

Also, I have also been taught that a rough guideline is to compare the finger nail of the 5th digit (pinkie) to that of the id of the ETT to assist in the proper size determination.

I have been told by multiple RT's and Dr.'s, that unless there is a complicating factor surrounding ETT size, the minimum should be 7.5mm for adults. This lumen size facilitates vent. strats, suctioning, etc...

The whole finger thing is mainly for pediatrics as a rough guideline. I have never heard it apply for adults.

[ERDoc]

Unless there is a reason not to, I always put at least a 7.5 in women and an 8.0 in men. Imagine trying to breath through a straw for a few days and you can appreciate what these pts feel. Also, in critical cases you want to be able to get as much oxygen as you can and blow off as much CO2 as you can. For peds I generally use the (16+age)/4.

[AZCEP]

Ditto Doc!

I tend to start with an 8.0 and have one size bigger and smaller readily available. The kids get the biggest tube that will fit.

For the burn patient, there is no specific guidline, other than early management as needed. If the airway looks toasty, they get the biggest tube possible.