Positive signs on physical examination are not always indications for endotracheal tube intubation in patients with facial burn

Abstract

Background After clinical evaluation in the emergency department (ED), facial burn patients are usually intubated to protect their airways. However, the possibility of unnecessary intubation or delayed intubation after admission exists. Objective criteria for the evaluation of inhalation injury and the need for airway protection in facial burn patients are needed. Methods Facial burn patients between January 2013 and May 2016 were reviewed. Patients who were and were not intubated in the ED were compared. All the intubated patients received routine bronchoscopy and laboratory tests to evaluate whether they had inhalation injuries. The patients with and without confirmed inhalation injuries were compared. Multivariate logistic regression analysis was used to identify the independent risk factors for inhalation injuries in the facial burn patients. The reasons for intubation in the patients without inhalation injuries were also investigated. Results During the study period, 121 patients were intubated in the ED among a total of 335 facial burn patients. Only 73 (60.3%) patients were later confirmed to have inhalation injuries on bronchoscopy. The comparison between the patients with and without inhalation injuries showed that shortness of breath (odds ratio = 3.376, p = 0.027) and high total body surface area (TBSA) (odds ratio = 1.038, p = 0.001) were independent risk factors for inhalation injury. Other physical signs (e.g., hoarseness, burned nostril hair, etc.), laboratory examinations and chest X-ray findings were not predictive of inhalation injury in facial burn patients. All the patients with a TBSA over 60% were intubated in the ED even if they did not have inhalation injuries. Conclusions In the management of facial burn patients, positive signs on conventional physical examinations may not always be predictive of inhalation injury and the need for endotracheal tube intubation in the ED. More attention should be given to facial burn patients with shortness of breath and a high TBSA. Airway protection is needed in facial burn patients without inhalation injuries because of their associated injuries and treatments.

Inhalation Injury

“…Providers should have a higher suspicion for inhalation injury in circumstances such as a house fire, an enclosed space, or forest fire where they were trapped in the middle of the blaze. 13…”

“…However, the diagnosis of inhalation injury should be guided by the deep understanding of the pathophysiology of inhalation injury, and it should consider serious complications such as pneumonia. 5,13 When a burn patient presents for initial assessment, a primary survey is paramount. Examining whether a patient can maintain their airway is an initial concern.…”

“…There used to be an urgency to intubate patients who had burns on their face or singed hair with mild hoarseness, but these sequelae are not sensitive nor are they specific for inhalation injury. 11,13 If the burn patient has full-thickness burns on their face, dyspnea, or altered mental status, these would lead to a higher inclination to secure the patient's airway. Providers should have a higher suspicion for inhalation injury in circumstances such as a house fire, an enclosed space, or forest fire where they were trapped in the middle of the blaze.…”

Airway Management for Acute and Reconstructive Burns: Our 30-year Experience

“…22 23 This direct examination of the airway allows us to immediately decide if intubation is warranted. 12 21 24…”

Expansion potential of auxetic prosthetic skin grafts: a review

“…Lyons et al [22] investigated the difference in meshing ratios with different skin graft meshers [12,23] (e.g., BioPlasty, Zimmer, Collins) and compared their expected ratio (1, 1.5, 2, 3, 4) and actual meshing ratio [6,12,24]. Cadaveric skin specimens were meshed and stretched, to study the expansions.…”