Page 1662 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

CHAPTER 123: Critical Care of the Burn Patient 1181

hospital stays, decreases in morbidity and mortality rates due to the
development of resuscitation protocols, improved respiratory support,
support of the hypermetabolic response, infection control, early burn
wound closure, and early enteral nutrition. Complete care of the burn
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patient requires the participation of most disciplines in the hospital for
both the inpatient as well as the outpatient follow-up care. The optimal
initial management of the severely burned patient follows guidelines
established and refined by the American Burn Association (ABA)
over the last 20 years. It is crucial that the patient be managed prop-
erly in the early hours after injury because the initial management of
a seriously burned patient can significantly affect long-term outcome.
Regionalization makes it common for the initial care of the seriously
burned patient to occur outside the burn center. Burns are a specialized
form of trauma, therefore, the first steps in emergency care, the ABCs
(airway, breathing, circulation) are the same as for the trauma patient:
airway with cervical spine stabilization if appropriate, breathing, circula-
tion, disability, and exposure. Also, the burn patient could be a victim of
other associated traumas. It is easy to be sidetracked by the obvious and
often dramatic thermal injury. Only after the primary and secondary
surveys have been performed should the severity of the burn injury itself FIGURE 123-1. Photograph demonstrating an endotracheal tube secured to the teeth
be evaluated. It is important to obtain as much information as possible with dental wire. The bite block is in the right side of the patient’s mouth. Note the absence of
regarding the incident and about the patient. An easy way to remember pressure points on the patient’s face.
the information is the mnemonic AMPLE: allergies, medications, past
medical history, last meal, and events leading up to the burn. Universal
precautions appropriate for each burn patient must be implemented by
every member of the health care team. 2 inserted and wired between the maxilla and mandible to prevent the
patient from biting on the ETT (Fig. 123-1). If the patient is edentulous,
the wire can safely be passed through the maxilla via an 18-gauge needle
AIRWAY MANAGEMENT gently tapped through the maxilla and passing the wire through the
needle. This method of securing the ETT allows care of the facial burns
Patients at risk of requiring early intubation include those with a his- to be performed as needed, prevents decubitus ulcers from ties around
tory of being in an enclosed space with or without facial burns, history the nasal septum, on the face, or over the ears, and allows for endotra-
of unconsciousness, carbonaceous sputum, hoarseness, or complaints of cheal suctioning and/or bronchoscopy. It also provides for a very safe
a “lump in the throat.” In isolation, these factors do not predict the airway protection method that allows the health care team to ambulate
need for intubation, but the more signs present, the more elevated the the patient while still intubated without putting the airway at risk. This
risk of requiring early intubation. Patients presenting with stridor or in patient population is one in which there cannot be inadvertent extuba-
respiratory distress should be intubated on presentation. A carboxyhe- tions, as regaining control of the airway may be impossible.
moglobin level taken within 1 hour after injury is strongly indicative of
smoke inhalation if >10%. Acute upper airway obstruction occurs in BREATHING
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20% to 33% of hospitalized burn patients with inhalation injury and is a
major hazard because of the possibility of rapid progression from mild The care of inhalation injury largely remains supportive. Even the gold
pharyngeal edema to complete upper airway obstruction. If there is a standard of bronchoscopy within the first 24 hours of admission can-
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significant cutaneous burn requiring resuscitation, the need for intuba- not accurately predict the severity of inhalation injury, although work
tion will be greater. The small cross-sectional diameter of the pediatric is in progress that grades the inhalation injury based on bronchoscopic
airway places children at higher risk of requiring emergent intuba- findings for patients with inhalation injury and correlate those find-
tion. Intubation itself is not without risk so should not be undertaken ings with outcomes. For patients with inhalation injury, no ideal ven-
routinely simply because there are facial burns. If intubation is tilator strategy has emerged. According to the American College of
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needed, the most experienced clinician in airway management should Chest Physicians, recommendations for mechanical ventilation serve as
perform the endotracheal intubation. Oral intubation is the pre- general guidelines: Use a ventilator mode that is capable of supporting
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ferred route, and given the concern for upper airway edema, having oxygenation and ventilation that the clinician has experience using,
more advanced airway adjuncts such as awake fiberoptic intubation, limit plateau pressures to 35 cm H O, allow P CO 2 to increase if needed
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a GlideScope, and the ability to perform an emergent surgical airway to minimize plateau pressures, and use the appropriate level of positive
(cricothyrotomy) if needed should be readily available. Given that airway end-expiratory pressure. Unless contraindicated, use of a daily sedation
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edema in this emergent setting tends to be at or above the vocal cords, the vacation to assess readiness to liberate from the ventilator should be
use of a laryngeal mask airway (LMA) is not a useful airway management performed. Roughly 70% of patients with inhalation injury will develop
device in this setting. Tracheostomy is not an emergency procedure and ventilator-associated pneumonia. Routine pneumonia prevention strate-
should only be performed in the elective setting for airway management. gies should include elevating the head of the bed 30°, turning the patient
Once the patient is intubated, securing the airway is another issue that side to side every 2 hours, oral care every 6 hours, and using endotra-
differs dramatically from other intubated patients. Most burn patients cheal tubes with subglottic suctioning ports. Routine use of prophy-
who require intubation have burns that involve the face, precluding laxis against gastrointestinal ulceration/bleeding raises some concern
use of the standard methods of securing the endotracheal tube. A safer about changing the gastric pH and increasing the risk of pneumonia.
method that prevents having anything in contact with the facial burns However, in the critically burned patient, the risks of gastric ulceration
is to secure the endotracheal tube (ETT) to the teeth of the maxilla. and bleeding far outweigh the proposed concerns using stress ulcer pro-
Using 0.018-inch dental wire, secure the endotracheal tube around the phylaxis, and its use is strongly recommended. Using the daily ventilator
base of the tube, wrapping the wire around the ETT just tight enough to liberation protocols being used in nonburn critical care areas around
indent the tube slightly without but not narrowing the tube significantly the country should have the same benefits in burn critical care areas.
to preclude passing the suction catheter. A rubber bite block should be The other assessment tool that is necessary for burn patients which may

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