Airway management for the burn patient

[Roostmonkey]

Our closest burn center needs a 7.0 for a bronchioscopy. I've never had to ETI a burn pt., but you can be damn sure they are getting the biggest tube that will fit as fast as is humanly possible.

[stever]

Where I work, we would use a 7.5 for females and an 8 for males. In burns pts we would use the same size but reinforced tubes, to allow for any oedema. We also use vec instead of sux.

Glad I did a search before posting my question. This is a great thread.

We had a burn pt at my service this weekend, though not mine, I always like to arm chair good calls.

Obviously it's important to be aggressive with airway management, but I'm curious what you all would use to paralyze. My first thought would be to use 1/10 the dose of vec instead of sux, for de-fasciculation, but K+ shift is probably a good reason too.

Thoughts? How would you RSI a burn pt?

BTW - we carry etomidate, versed, suxs, vec . . .

[ERDoc]

At the place where I did my residency the surgeons scoffed at those who feared sux in a burn pt. They felt that if the pt was being monitored properly that you should pick up any K problem and fix it before it became an issue. They said that if you could not do that you were not properly montioring the pt. In the field and in the ER for that matter, you will not see the affects of sux on potassium, it is a delayed issue that the ICU teams have to deal with. I had a burn pt that set the bed on fire while he was smoking some crack. Burned pretty much his entire back from top to bottom. He was relatively calm in the helicopter. As soon as he got to the ER the adrenalin must have shut off and the pain must have kicked in, because he was trying to jump off of the strecher. There was no way we were able to assess the airway. We basically intubated him just to get him to lay down. Turned out it was the right call. He had soot in his nose and mouth. About 30 minutes later a CT showed that the airway had swollen completely and the only opening was the ETT. We we were getting ready to put him down, we asked the surgeon that there what he would prefer to have us use instead of sux. He said that sux was fine and that he could deal with the potassium later. Granted it is anecdotal, so take it for what it's worth. Oh yeah and follow your local protocols.

[AZCEP]

The concern for using succinylcholine in the burn patient is admirable, but not directly applicable to the emergent setting as ERDoc mentioned.

If the patient is more than 24 hours removed from the initial injury, you should consider another agent, as the cellular membranes have leaked the K+ out by that time. The laundry list of other contraindications for succinylcholine should be considered, but most are manageable.

[Timmy]

I have yet another question. Hypothetically if you had a patient who was on a pit crew at a car race event. These particular cars use fuel (I forget the name) that if it ignites you can’t see the flame. If this crew member has been unlucky enough to ignite and has possibly swallowed this fuel/flame, how would you deal with it?

You would make sure the scene is safe.

Would you make him drink water just in case his throat is on fire?

What would be the next step?

[ERDoc]

I have yet another question. Hypothetically if you had a patient who was on a pit crew at a car race event. These particular cars use fuel (I forget the name) that if it ignites you can’t see the flame. If this crew member has been unlucky enough to ignite and has possibly swallowed this fuel/flame, how would you deal with it?

You would make sure the scene is safe.

Would you make him drink water just in case his throat is on fire?

What would be the next step?

I would keep him NPO. Treat as you would any other burn pt. The flame isn't going to cause a fire in the airway, but a burn will be a problem.

[AZCEP]

Timmy, the fuel you are thinking of is methanol and aside from top-fuel dragsters or formula 1/indy cars, very few racers will use the stuff. Really expensive and most engines can't tolerate the heat too well.

Unless the victim had the unfortunate ability to inhale the fuel as it was burning, going against every natural selective law that I'm aware of, the fuel would not be a major concern for the damage done to the airway. Interesting thought, but not too likely.

[kevkei]

It's probably a combination of poor planning and preparation as well as assumption.

I agree that you should pass the largest ETT size the pt will be able to tolerate. If you plan ahead and have 1 each of ETT sizes from say a 6.0-9.0 ready to go, you can perform the laryngoscopy and take a look and then decide what sized tube to pass. Typically from what I have seen, if you only open up a 6.0 from it's packaging, that is what people will use even if your view is unobstructed and there is minimal edema.

An extra 20-30 seconds worth of planning and preparation will save you in the long run and will also benefit the patient. It is value added time with exponential reward.

As for the use of Sux, if you are anticipating a difficult intubation, why not use it in the event you fail and run into a can't intubate/can't ventilate situation? How long is the serum K+ shift affected in relation to the Sux's duration of action? I understand that it is often advantageous to be 'better safe than sorry' but I think it better applies to a controlled situation with optimum conditions and if you have an acceptable alternative.

The problem that I see is people revert to "I was taught....." which doesn't neccesarily lead to the best decision making. If you have one paralytic and one oportunity to attempt an intubation, use it. I do agree that in the situation of "we prefer to use...", it demonstrates a valid thought process but shouldn't be limiting.

On another note, is there any consideration of either nebulized epi or racemic epi as a bridge in these situations?

[Ridryder 911]

The K[sup:017a10982c]+[/sup:017a10982c] shift that one worries about in burns and the use of Sux, doe not occur until several hours after the burn. So initially, one can use Sux if performed immediately after the burn as well as the dosage that will be used for initial RSI, should not be that large amount. However; I would recommend another paralytic for keeping sedation/paralytic long term.

If one is going to perform RSI on a previous burn patient (i.e ICU/hospital transfer) then I would look at the time and lab values. I would go to another alternate paralytic as well.

R/r 911

[Spock]

Suxs is OK to use in the first 24 hours post burn. After that it is probably best to avoid it. If you can't get an airway the possible hyperkalemia will never be an issue because the patient won't be alive.

I worked a fire/rescue crew once at a dirt track and the sprint cars used methanol. We used water fire extinguishers as a first response and opened up as soon as you felt any heat or saw a 'shimmering wave". It was interesting.

Live long and prosper.

Spock