The critical care management of major burns and inhalational injury

This scenario was developed to educate emergency medicine residents on the diagnosis and management of patients with an inhalational airway injury secondary to a house fire. Burn injuries are a common occurrence encountered by the emergency physician. According to the National Hospital Ambulatory Medical Care Survey, around 371,000 patients were treated in emergency departments for fire or burn injuries across the United States in 2020. This represents around 1% of emergency department visits related to injury, poisoning, or adverse effects.1 One of the most dangerous and time critical aspects of managing severely burned patients is inhalation injury. Inhalation injury is a relatively vague term which may refer to pulmonary exposure to a wide range of chemicals in various forms. In the context of burn patients, this is most often smoke exposure. It is critical that the emergency medicine provider rapidly identifies the potential for an inhalational injury in order to determine the need for definitive airway management. It is also important that the provider has the necessary skills and systematic approach to manage what is likely to be a difficult airway. Furthermore, providers must then have the knowledge of how to best manage and resuscitate these severely burned patients post-intubation. At the conclusion of the simulation session, learners will be able to: 1) recognize the indications for intubation in a thermal burn/inhalation injury patient; 2) develop a systematic approach to an inhalational injury airway; and 3) recognize indications for transfer to burn center. This session was conducted using high-fidelity simulation, followed by a debriefing session and lecture on the diagnosis, differential diagnosis, and management of inhalational airway injury secondary to a house fire. Debriefing methods may be left to the discretion of participants, but the authors have utilized advocacy-inquiry techniques. This scenario may also be run as an oral board case. Our residents are provided a survey at the completion of the debriefing session so they may rate different aspects of the simulation, as well as provide qualitative feedback on the scenario. The local institution's simulation center's electronic feedback form is based on the Center of Medical Simulation's Debriefing Assessment for Simulation in Healthcare (DASH) Student Version Short Form2 with the inclusion of required qualitative feedback if an element was scored less than a 6 or 7. Nine learners completed a feedback form. This session received all 6 & 7 scores (consistently effective/very good and extremely effective/outstanding, respectively) other than one isolated 5 score. This is a cost-effective method for reviewing inhalational airway injury diagnosis and management. The case may be modified for targeted audiences, expected resources, and learning objectives, such as removal of a bronchoscope availability in settings which are expected to be resource-limited. Some readers may choose to focus on other aspects of burn management instead of airway securement such as cyanide and/or carbon monoxide toxicity. We encourage readers to limit the number of learning objectives because airway algorithms and troubleshooting for this scenario was a rich, stand-alone debriefing. There was not enough time to review in detail all nuanced aspects of the burned patient, including: Lund-Browder versus rule of 9's, modified Brooke versus Parkland formulas, indications for and completion of escharotomies, and/or identification and treatment of cyanide and carbon monoxide toxicity. Medical simulation, burns, airway emergencies, emergency medicine.

Fire and Smoke Injuries

Introduction Inhalation injuries from burns are associated with worse patient outcomes including increased risk of pneumonia and progression to multisystem organ failure. Increased concentrations of several pro- and anti-inflammatory cytokines have been found in non-survivors of inhalation injuries compared to survivors. The aim of this study was to examine how the inflammatory profile of burn patients with inhalation injuries differs from those without inhalation injuries. It is hypothesized that patients with inhalation injuries will demonstrate a different cytokine profile to burn patients without inhalation injuries. Methods After obtaining IRB approval, adipose tissue was collected from adult burn patients presenting to an ABA-Verified Burn Center from 2022-2024 during initial excision. Thermal, electrical and chemical burns were included, as well as burn patients with concomitant trauma. Adipose-derived stem cells (ADSCs) were extracted and the supernatant was collected. Cytokine analysis was performed using a 10-analyte multiplex assay. The cytokines studied were IFN-γ, IL-1β, IL-4, IL-6, IL-10, IL-13, IL-17A, TGF-α, TNF-α, FGF-2, MCP-1 and VEGF. Patients were stratified based on the presence of inhalation injury. Statistical analysis was performed using the Mann-Whitney U test. Results Of the 28 patients studied, 15 patients (54%) sustained inhalation injuries. No significant differences in age, body mass index, sex, % total body surface area burn, blood alcohol level on admission, smoking status or mortality were observed between groups (p>0.05). In patients with inhalation injuries, IL-8 was significantly decreased as compared to patients without inhalation injury (p=0.03). No significant differences in the other cytokines analyzed were identified between groups (p>0.05). Conclusions This study suggests that adipose derived stem cells from burn patients with inhalation injury produce decreased levels of IL-8 in adipose tissue. IL-8 is a pro-inflammatory cytokine that activates neutrophils and is involved in angiogenesis and cell growth. Elevated plasma IL-8 is implicated in development of sepsis following burn injuries and positively correlates with inhalation injury severity. It is possible that IL-8 produces a different effect in adipose tissue compared to plasma. Ultimately, investigating the cytokine profile of adipose tissue following concomitant inhalation and burn injury may further elucidate the role the local inflammatory response plays in the systemic inflammatory response seen in major burn injury. Applicability of Research to Practice Studying the cytokine profile of ADSCs may help broaden our understanding of the often detrimental systemic inflammatory response produced in response to major burn injury. Funding for the Study AAST Trauma Research Scholarship

The management of acute orofacial burns and inhalational injury can be extremely challenging and emotive, requiring a calm but expeditious systematic, multidisciplinary approach. Airway interventions necessitate involvement of a skilled, senior anaesthetist and, therefore, must be carefully timed with a full array of difficult airway equipment immediately available. This chapter describes the principles in managing any emergency admission with major burns with a special focus upon the specific issues and treatment strategies associated with severe facial burns and inhalational injury. The importance of thorough assessment, resuscitation, fluid and temperature management, and analgesia are highlighted in the context of the pathophysiological changes that occur. Priorities for intraoperative and intensive care management are also discussed, as well as the challenges these patients pose for repeated surgical procedures.

Critical care management of severe burns and inhalational injury

Fluid resuscitation mediates the association between inhalational burn injury and acute kidney injury in the major burn population

Patients with severe burn injuries pose significant challenges for the intensivist. Though average burn sizes have decreased over time, severe burn injuries involving greater than 20% of the total body surface area still occur. Verified burn centers are limited, making the management of severely burn injured patients at nonspecialized ICUs likely. Current practices in burn care have increased survivability even from massive burns. It is important for intensivists to be aware of the unique complications and therapeutic options in burn critical care management. This review critically discusses current practices and recently published data regarding the evaluation and management of severe burn injury. Burn patients have long, complex ICU stays with accompanying multiorgan dysfunction. Recent advances in burn intensive care have focused on acute respiratory distress syndrome from inhalation injury, acute kidney injury (AKI), and transfusion, resulting in new strategies for organ failure, including renal replacement therapy and extracorporeal life support. Initial evaluation and treatment of acute severe burn injury remains an ongoing area of study. This manuscript reviews current practices and considerations in the acute management of the severely burn injured patient.

Critical care management of inhalational injury and severe burns

Care of the severely injured patient with burn requires correct diagnosis, appropriately tailored resuscitation, and definitive surgical management to reduce morbidity and mortality. Currently, mortality rates related to severe burn injuries continue to steadily decline due to the standardization of a multidisciplinary approach instituted at tertiary health care centers. Prompt and accurate diagnoses of burn wounds utilizing Lund-Browder diagrams allow for appropriate operative and nonoperative management. Coupled with diagnostic improvements, advances in resuscitation strategies involving rates, volumes, and fluid types have yielded demonstrable benefits related to all aspects of burn care. More recently, identification of comorbid conditions such as inhalation injury and malnutrition have produced appropriate protocols that aid the healing process in severely injured patients with burn. As more patients survive larger burn injuries, the early diagnosis and successful treatment of secondary and tertiary complications are becoming commonplace. While advances in this area are exciting, much work to elucidate immune pathways, diagnostic tests, and effective treatment regimens still remain. This review will provide an update on the critical care management of severe burns, touching on accurate diagnosis, resuscitation, and acute management of this difficult patient population.

IntroductionInhalational injury significantly alters the clinical course of burn patients. In addition to increasing the volume of fluid required for adequate resuscitation, inhalation injury places patients at risk of prolonged mechanical ventilation, pneumonia, and acute respiratory distress syndrome. To combat the deleterious effects of inhalational trauma, therapeutic strategies consisting of nebulized medications have been used. Nebulized heparin attenuates pulmonary edema and reduces formation of intraluminal fibrin. NAC provides anti-inflammatory benefits in addition to a mucolytic. Albuterol functions as a bronchodilator. We sought to perform a pilot study at our institution. We hypothesized that adjunctive heparin and NAC would decrease ventilator dependence and in-hospital mortality.MethodsIndividual cases were reviewed and only those confirmed by fiberoptic bronchoscopy were included. The final study population consisted of patients with Grade II and III injury patterns. The protocol consists of 10,000 units of nebulized heparin, 3 ml of 20% nebulized NAC, and 3 ml of 0.083% nebulized albuterol all given every 4 hours for either 7 days or until extubation. Demographics, injury characteristics, and hospital outcomes were compared between the treatment and control groups. Wilcoxson rank-sum test and Pearson’s chi-square statistic were used for numerical and categorical variables respectively. For all analyses, p < 0.05 was considered statistically significant.Results40% of initial cohort suffered from Grade II or Grade III injury patterns and were included in the final study population. Of these, 47.5% were treated with the inhalation injury protocol, with the remaining 52.5% serving as historical controls. Patients receiving adjunctive nebulized therapies had similar outcomes compared to historical controls. Hospital length of stay as well as time in the intensive care unit did not differ. Likewise, there was no statistically significant decrease in days of ventilator dependence. Ultimately, mortality rates did not differ for patients receiving nebulized therapies.ConclusionsThe results of our pilot study demonstrated no difference in ventilator dependence or in-hospital mortality with the utilization of nebulized heparin, NAC, and albuterol in adult burn patients suffering inhalational trauma. Despite disagreeing with the findings of previous studies, these results should not deter the current use of nebulized therapies which have been deemed “appropriate” for use in the management of inhalation injury by an international panel. However, these results stress the need for a vigorous, multicenter effort to perform a randomized control trial.Applicability of Research to PracticeThis study is directly applicable to bedside practice and management of intubated patients with inhalational burn injuries in an attempt to improve patient outcomes with nebulized therapiesFunding for the StudyN/A

Burn injuries are often associated with profound physiologic derangements due to the nature of the underlying injuries and the overwhelming inflammatory response that ensues. In recent decades, a number of advancements have been made in the management of thermal burns. Inhalation injury frequently occurs in patients with thermal burns and can be a significant source of morbidity and mortality. Due to the intense inflammatory response that occurs after a burn injury, early aggressive volume resuscitation is necessary to minimize the risk of developing multiorgan dysfunction. Adequate sedation and analgesia, early enteral nutrition, physical rehabilitation, excision and grafting, and other supportive measures are also critically important to promoting healing and improving long-term outcomes. This review outlines a general approach to the management of patients with burn and inhalation injuries and highlights some of the recent advances in the care of these patients.

Inhalational injury and the larynx: A review

Burn mortality statistics are influenced by age and degree of total surface body burn. The addition of an inhalation injury to a cutaneous burn results in a significant increase in mortality rate. Nine hundred fourteen patients with acute thermal injury were screened for positive history of burn in a closed space, facial or oropharyngeal burn, singed nasal vibrisae, carbonacious sputum, and clinical signs of upper airway involvement. On admission, 84 patients (9.2%) had more than one of the previously mentioned factors. They were prophylactically intubated and placed on optimum level of continuous positive airway pressure (CPAP) and intermittent mandatory ventilation (IMV). The mortality rate among patients without inhalation injury was 7.1%, while 54.7% of patients with inhalation injury died. Comparison of burn patients with inhalation injury to those without pulmonary involvement at the same age group and with the same percentage of burn showed significantly higher mortality rate in patients with inhalation injury. The main cause of death in the first 72 h postburn (stage 1) in patients without inhalation injury was peripheral shock (10.1%) and in patients with inhalation injury was peripheral shock (15.2%) and cardiac failure (10.8%). No pulmonary related death occurred in this stage. In 3-10 days postburn period (stage 2), burn wound sepsis (10.1%) and cardiac failure (11.8%) were the major causes of death in patients with inhalation injury. In patients with inhalation injury, pulmonary sepsis (26%) was the major cause of death in this stage. Major causes of death after 10 days postburn (stage 3) in patients without inhalation injury were pulmonary sepsis (20%) and burn wound sepsis (22%). In patients with inhalation injury, burn wound sepsis (21.7%) was the main cause of death. These data suggest that prophylactic intubation and CPAP therapy in burn patients with suspected inhalation injury prevent pulmonary related death in early stage of burn. Irrespective of presence of inhalation injury, sepsis originating from the wound or respiratory tract is the main cause of death in the late stage of burn.

Inhalation injury is respiratory injury caused by inhalation of substances such as toxic gas, fire fumes and chemical products. It can lead to hypoxia, ventilation dysfunction, increased airway resistance, and massive pulmonary edema. Immediate intervention is crucial for inhalation injuries. Current management strategies include endotracheal intubation, tracheostomy, fluid resuscitation, mechanical ventilation, and treatment of systemic toxicity. Many factors can affect the outcomes of inhalation injury such as age, severity of inhalation injury, and total body surface area burned. The following databases were used in systematic research: Medline (PubMed), Web of Science, and Scopus till 22 December 2024. Inclusion criteria is any study that discusses management of inhalation injuries in emergency and critical care and their outcomes and published in peer-reviewed journals was included with the inclusion of full-text articles, abstracts, and case series with the related topics are included. All languages are included. Animal studies, case reports, letters and comments were excluded. Endotracheal intubation, mechanical ventilation, and tracheostomy are considered important interventions in the inhalation injury emergency setting. However, studies reported poor long-term outcomes of these interventions. The objective of this review is to discuss the different approaches of management of inhalation injuries in emergency department and the obtained outcomes.

The objective of this study was to present data that showed high frequency percussive ventilation (HFPV) was superior to traditional mechanical ventilation for the treatment of children with inhalation injuries. Inhalation injuries continue to be the number one cause of death of patients with thermal injuries in the United States. Therapy for this condition has consisted of conservative pulmonary toilet and mechanical ventilation. Despite improvements in the management of burn injury, patients with inhalation injury develop pneumonia and pneumothorax, leading to adult respiratory distress syndrome. Unfortunately, inhalation injury that is complicated by pneumonia has been shown to increase mortality by 60% in these patients. Cioffi has shown that prophylactic use of HFPV in adult patients with inhalation injury has been a successful method of reducing the incidence of pneumonia and mortality. The effects of HFPV on the incidence of pneumonia, peak inspiratory pressures, and arterial partial pressure of oxygen/fraction of inspired concentration of oxygen (P/F) ratios were retrospectively studied in 13 children with inhalation injuries and compared with historic controls treated with conventional mechanical ventilation. All patients were treated with our standard inhalation injury protocol and extubated when they met standard extubation criteria. Patients ranged in age from 6 to 9 years, and most had burns covering greater than 50% of their total body surface areas. No deaths occurred in either group, but the patients who were treated with HFPV had no cases of pneumonia (P < .05), better P/F ratios (P < .05), lower peak inspiratory pressures, and less work of breathing (P < .05) as compared with our control group. On the basis of our clinical experience and data, the use of HFPV seems to be an effective treatment for the reduction of pulmonary morbidity in pediatric patients with inhalation injuries.