107 The FLAMBE (Factors Leading to Airway Management in Burn Emergencies)

Abstract

It is commonly taught that inhalation injuries require rapid invasive airway management. Previous studies have reported that the mortality rate associated with inhalational injuries is 45-78% and that the risk of mortality is 20% higher in patients with combined inhalation injury and cutaneous burns than in those with cutaneous burns alone. Although these statistics are alarming, they may not be applicable to all patients presenting to the emergency department (ED) with inhalational injuries. Numerous indications for invasive airway management have been documented in the literature ranging from cyanosis and stridor to full thickness burns of the face. The indications for invasive airway management and the definition of inhalation injury share distinct similarities. This coincides with the common teaching that all patients with inhalation injuries require invasive airway management; however, there is little data supporting this invasive strategy. No study has included nasopharyngeal irritation, singed eyebrows, singed nasal hairs, or soot in the proximal airway as an indication for intubation. There is no data on patients presenting to the ED or trauma bay with these findings regarding the necessity of invasive airway management. To date there are no retrospective studies identifying the presence or absence of the study indications for intubation in patients presenting to the emergency department or trauma bay with suspected inhalational injuries. We believe that this data will help in risk stratifying this patient population and avoid unnecessary invasive airway management and intensive care unit (ICU) admission. Invasive airway management has known complications in burn patients, including increasing the incidence of nosocomial pneumonia, damage to the airway resulting in tracheal stenosis, and secondary complications related to sedation. This data may allow us to develop a clinical prediction score for invasive airway management and test this score prospectively in the ED. This is a retrospective chart review evaluation of a cohort of patients presenting to the UCSD emergency department or trauma bay with inhalational injury and facial burns. These patients will be identified via ICD-9 codes. Exclusion criteria include any patient that did not present to the ED or trauma bay, and any patient without the potential ICD-9 diagnosis. The presence of study indications for intubation will be evaluated. Thus far 45 patients who presented to the UCSD emergency department or trauma bay with inhalation injury and/or facial burn were analyzed. Preliminary data is showing only three of the patients from this cohort required endotracheal intubation while 12 presented with clear indication for intubation, and 12 presented with the aforementioned study indications for intubation. Over 70% of patients with clearly established indications for intubation, as well as over 70% of patients the study indications for intubation avoided an expected airway intervention. This discrepancy challenges the current dogma of invasive airway management in the face of inhalation injury and facial burn, and suggests that clinic gestalt trumps the studied indications for intubation.