1. Inhalational Injury and Airway Management William J C van Niekerk Consultant Burns and Plastic Surgeon Queen Elizabeth Hospital Birmingham and Birmingham Childrens Hospital

2. Scope Importance of early recognition Signs and symptoms of inhalational injury Pathophysiology History Initial management Longer term therapy

3. Acknowledgement Dr Gerwyn Rees, Consultant Anaesthetist

4. Importance of Early Recognition and Intervention Thermal injury and smoke inhalation set off the inflammatory cascade Associated vasodilatation, oedema, and capillary leak Intervene early before rapid progression to upper airway obstruction ensues

5. Primary Survey A (with c-spine immobilisation and intubation if required), B (give O 2 ), C, D, and E Early airway security is paramount before oedema and airway compromise develop Much higher mortality/ morbidity associated with inhalation burns Large cutaneous burns often indicate an inability to escape flame and risk smoke inhalation

6. Secondary Survey: Signs and Symptoms of Inhalational Burn Hoarseness Change in voice Complaints of sore throat Odynophagia Carbonaceous sputum Tachypnea Singed facial hair Wheezing, rales, and use of accessory muscles Burn injury of peri- oral/nasal regions

7. Pathophysiology Asphyxiation - reduces inspired oxygen concentration Thermal Burn – Thermal damage - upper airway affected due to poor conductivity of air Chemical Burn and Toxicity – Carbon Monoxide toxicity, Cyanide toxicity, Methaemoglobinaemia – Pulmonary irritation - causes direct irritation, tissue damage, bronchospasm, and inflammatory response – A vast array of other chemicals

8. History AMPLE history Specifically to elicit inhalation injury: – Fires in closed spaces increase risk of inhalational injury – Particular materials in fires may contain dangerous asphyxiants and toxins – Polyurethane, wool, and silk increase risk of CN toxicity – Loss of consciousness at scene – Any pre-morbid respiratory factors e.g. asthma, COPD

9. Management Oxygen, oxygen, O 2, O 2, O 2, O 2, O 2, O 2, O 2, O 2... High index of suspicion/early recognition Most experienced anaesthetist available to assess and manage If intubation is indicated: use UNCUT endotracheal tube to allow for further swelling Tied initially but later wired to teeth to prevent proximal dislodgement during swelling

10. Further Management on ITU Ventilatory support on ITU Inhalation injury equires more fluid than suggested by TBSA% burn CO: – Half life of 4 hours – 1 Hour on 100% O 2 – Not only haem-bound, but also cellular Physiotherapy Bronchoscopy and lavage Nebulisers: epinephrine, N acetylcysteine, and heparin Sputum cultures Early ambulation

11. Summary History, signs and symptoms of inhalational injury Early airway security is paramount Experienced anaesthetist Pathophysiology – so as not to forget CO, etc. Uncut endotracheal tube Management on ITU

12. Questions?