Tracheal damage.

Tracheal damage. Blunt/penetrating trauma and inhalation injuries to the trachea can result in acute airway compromise, with life-threatening implications. Early assessment, identification, and prompt and appropriate management are of paramount importance in order to reduce patient morbidity and mortality. Signs and symptoms of these injuries are specific and sometimes subtle, and their seriousness may be obscured by other injuries. Diagnosis can therefore be challenging, requiring a high index of suspicion. Indeed, diagnosis and treatment are often delayed, resulting in attempted surgical repair months or even years after injury. Laryngoscopy, flexible and/or rigid bronchoscopy and computed tomography of the chest are the procedures of choice for a definitive diagnosis. Airway control and appropriate ventilation represent the key aspects of emergency management. Definitive treatment depends on the site and the extent of injury. Surgery, involving primary repair with direct suture or resection and end-to-end anastomosis, is the treatment of choice for patients suffering from tracheal injuries. A conservative approach must be considered for the paediatric population and selected patients with mainly iatrogenic damage. We present a review of the incidence, mechanisms of injury, clinical presentations, diagnosis, initial airway management, anaesthetic considerations and definitive treatment in the case of tracheal damage from blunt/penetrating trauma and inhalation injuries.

[Management of chemical burns and inhalation poisonings in acute medical care procedures of the State Fire Service]. / Oparzenia chemiczne i zatrucia wziewne w procedurach ratowniczych z zakresu kwalifikowanej pierwszej pomocy Panstwowej Strazy Pozarnej.

Emergency Medical Services (EMS) were founded by the government to perform tasks aimed at providing people with help in life-threatening conditions. The system comprises two constituent parts. The first one is public administrative bodies which are to organise, plan, coordinate and supervise the completion of the tasks. The other constituent is EMS units which keep people, resources and units in readiness. Supportive services, which include: the State Fire Service (SFS) and the National Firefighting and Rescue System (NFRS), are of great importance for EMS because they are eligible for providing acute medical care (professional first aid). Acute medical care covers actions performed by rescue workers to help people in life-threatening conditions. Rescue workers provide acute medical care in situations when EMS are not present on the spot and the injured party can be accessed only with the use of professional equipment by trained workers of NFRS. Whenever necessary, workers of supportive services can assist paramedics' actions. Cooperation of all units of EMS and NFRS is very important for rescue operations in the integrated rescue system. Time is a key aspect in delivering first aid to a person in life-threatening conditions. Fast and efficient first aid given by the accident's witness, as well as acute medical care performed by a rescue worker can prevent death and minimise negative effects of an injury or intoxication. It is essential that people delivering first aid and acute medical care should act according to acknowledged and standardised procedures because only in this way can the process of decision making be sped up and consequently, the number of possible complications following accidents decreased. The present paper presents an analysis of legal regulations concerning the management of chemical burn and inhalant intoxication in acute medical care procedures of the State Fire Service. It was observed that the procedures for rescue workers entitled to provide acute medical care should be correlated with the procedures for emergency medical teams.

Inhalation Injury: Which Providers Can Assess the Need for Intubation?

Previous studies have suggested that many burn patients undergo unnecessary intubation due to concern for inhalation injury. We hypothesized that burn surgeons would intubate burn patients at a lower rate than non-burn acute care surgeons (ACSs). We performed a retrospective cohort study of all patients admitted to an American Burn Association-verified burn center who presented emergently following burn injury from June 2015 to December 2021. Patients excluded include polytrauma patients, isolated friction burns, and patients intubated prior to hospital arrival. Our primary outcome was intubation rates between burn and non-burn ACSs. 388 patients met inclusion criteria. 240 (62%) patients were evaluated by a burn provider and 148 (38%) were evaluated by a non-burn provider; the groups were well-matched. In total, 73 (19%) of patients underwent intubation. There was no difference in the rate of emergent intubation, diagnosis of inhalation injury on bronchoscopy, time to extubation, or incidence of extubation within 48 hours between burn and non-burn ACSs. We found no difference between burn and non-burn ACSs in the airway evaluation and management of burn patients. Surgical providers with acute care surgery backgrounds and Advanced Trauma Life Support training are well-equipped for initial airway management in burn patients. Further studies should seek to compare other types of provider groups to identify opportunities for intervention and education in preventing unnecessary intubations.

[Clinical, radiological and bronchoscopic evaluation of inhalation injury cases treated at a burn center]. / Yanik merkezimizde takip edilen inhalasyon yanigi olgularinda, klinik, radyolojik ve bronkoskopik degerlendirme.

BACKGROUND: We aimed to introduce inhalation injury, pulmonary complications and mortality-related factors on the basis of clinical, radiological and bronchoscopic findings in patients with inhalation burns. METHODS: Between January 2009 and January 2010, patients hospitalized in the intensive care unit (ICU) of a burn center who were diagnosed as inhalation burn and underwent bronchoscopy were included in the study. Demographic findings, burn type, burn percentage, clinical-laboratory features, chest Xray findings on the first and fifth days, and bronchoscopic lesions were obtained from patient files. Bronchoscopic findings were classified, and bronchoscopic score for each patient was calculated. Clinical, laboratory and radiological findings, length of stay in the ICU, and bronchoscopic scores of patients who were discharged versus of those who died were compared, and mortality-related factors were investigated. RESULTS: Twenty-nine patients (25 male, 4 female; mean age 40.1 +/- 3.4 years) were included. Radiological abnormalities were found in 41.3% and 65.5% of patients on the first and fifth days of hospitalization, respectively. There were no complications related to bronchoscopy. Percentage of burn and duration of stay in the ICU were higher in patients who died than in discharged patients (20.4%-48.5%, p = 0.003; mean: 7.0-13.7 days, p = 0.037, respectively). Of patients who died, 79.1% showed radiological abnormality and 50% had acute respiratory distress syndrome (ARDS) on the fifth day of hospitalization. There were no pathologic findings on chest X-ray and no ARDS was seen on the fifth day in patients who were discharged (p < 0.05). CONCLUSION: Inhalation burns in patients with cutaneous burns cause a high percentage of pulmonary complications and increase mortality. Bronchoscopy must be performed early for diagnosis, and close follow-up of these patients is necessary.

[The structure of non-combat injuries in survivors and victims of maritime disasters of warships in peace-time].

The structure of accidents and injuries in victims of major maritime disasters involving fires and explosions on warships from 1976-2011. It is established that the main damage of the injured are acute inhalation of carbon monoxide poisoning is mild, 33.3%, combined blast and mechanical trauma 25%, the combined mechanical and burn trauma-cold 21.2%, the combined mechanical-burn injury 13.4%, combined blast and cold injuries 5.3%, burns and chemical damage a 1.8%. The main causes of mortality were acute inhalation poisoning with carbon monoxide, severe burns of the upper respiratory tract bums, III and IV 12.4%. Bums I and II degree against carbon monoxide poisoning is mild with drowning as a major cause of death recorded 11.8%; combined mechanical-burn were travmy 19.2%, the combined mechanical-burn-cold injury was 9.4%, combined blast and mechanical trauma 26.3%, combined explosive, mechanical, and cold injuries 14.7%, and chemical burn of 6.2%.

Extensive burns in an elderly man found in a brush fire.

This past spring, a flight team was activated by a rural advanced life support ground service for a scene call approximately 30 minutes from their base for an 80-year-old man found lying in the middle of a brush fire. The ground paramedics did not know how the patient came to this position. During the initial call to the flight service, ground emergency medical services (EMS) reported that the patient had 100% burns that varied in severity from superficial to full thickness. The intercept was requested for emergent transport to a burn center, analgesia, and advanced airway management. On arrival, the flight crew saw that a bag valve mask was being used to ventilate the patient. EMS had placed the patient on a spine board for extrication from the scene. His initial Glasgow Coma Score was noted to be 6 (E1, V1, M4). The flight team noted that the patient occasionally moved his upper extremities and his head. Immediately, there was concern for a compromised airway in the setting, with soot and edema noted in the nares and oropharynx. The ground EMS crew was able to ventilate the patient with difficulty. However, given the severity of the burns and noted trismus, an oral airway could not be placed. Stridor was noted, with obvious swelling of the neck.

Clinico-pathological profile and outcome of inhalational burns.

OBJECTIVE: To determine clinico-pathological profile and outcome of inhalational burns in a specialized burns treatment unit. STUDY DESIGN: Case-series. PLACE AND DURATION OF STUDY: The Department of Plastic Surgery and Burns Centre Unit, Combined Military Hospital, Kharian Cantonment in March 2005. METHODOLOGY: Patients of inhalational burns were included and evacuated within 30 hours of accident to the specialized burns centre after immediate resuscitation. Total Body Surface Area (TBSA) involved in burns was calculated. Complete blood count and renal profile along with serum albumin and total proteins was obtained. Portable chest radiographs and bronchoscopic examination was conducted. Escarotomies were carried and wounds were covered with split thickness skin grafts. Ventilatory support was used as needed. Comparison of the clinico-pathological profile of surviving and fatal cases was done for significance using t-test. RESULTS: There were 19 patients of inhalational burns, 8 (42%) of whom expired. The mean percentage of TBSA in 11 surviving patients was 50+/-10.87 and 70+/-15.46 in fatal cases. The mean haemoglobin (Hb) on admission was 15.8+/-1.6 g/dL and after fluid resuscitation it became 11.4+/-1.5 g/dL. The mean Total Leucocyte Count (TLC) in surviving patients was 9.6+/-6.1 x 10(9)/L and 1.5+/-2.3 x 10(9)/L in fatal cases (p=0.001). The mean platelet count of surviving patients was 205+/-63 x 10(12)/L while in fatal cases was 58+/-48 x 10(12)/L (p=0.05). The serum urea levels in surviving patients was 4.3+/-2 mmol/L while in fatal cases was 8.6+/-0.9 mmol/L (p=0.05). The serum creatinine levels were 98.2+/-16.5 micromol/L in the survivor group and 249.5+/-76 micromol/L in the mortality group (p=0.05). The serum total protein in surviving patients was 63+/-8 g/dL while in mortality cases it was 57+/-7 g/L. Serum albumin in the survivor group was 36.7+/-5 g/L and 35+/-4 g/L in fatal cases. Significant in Hb, protein and albumin levels. All the expired patients had acute respiratory distress syndrome while acute renal failure with multi-organ failure co-existed in 6 patients. CONCLUSION: Inhalational burns injury cases multi-system injury with high mortality. Body area involvement, total leucocyte count, platelet count, serum area and serum creatinine are important indicators of survival.

Inhalation Injury: Unmet Clinical Needs and Future Research.

Pulmonary and systemic insults from inhalation injury can complicate the care of burn patients and contribute to significant morbidity and mortality. However, recent progress in diagnosis and treatment of inhalation injury has not kept pace with the care of cutaneous thermal injury. There are many challenges unique to inhalation injury that have slowed advancement, including deficiencies in our understanding of its pathophysiology, the relative difficulty and subjectivity of bronchoscopic diagnosis, the lack of diagnostic biomarkers, the necessarily urgent manner in which decisions are made about intubation, and the lack of universal recommendations for the application of mucolytics, anticoagulants, bronchodilators, modified ventilator strategies, and other measures. This review represents a summary of critical shortcomings in our understanding and management of inhalation injury identified by the American Burn Association's working group on Cutaneous Thermal Injury and Inhalation Injury in 2018. It addresses our current understanding of the diagnosis, pathophysiology, and treatment of inhalation injury and highlights topics in need of additional research, including 1) airway repair mechanisms; 2) the airway microbiome in health and after injury; and 3) candidate biomarkers of inhalation injury.

Preventing Unnecessary Intubations: A 5-Year Regional Burn Center Experience Using Flexible Fiberoptic Laryngoscopy for Airway Evaluation in Patients With Suspected Inhalation or Airway Injury.

The decision to intubate acute burn patients is often based on the presence of classic clinical exam findings. However, these findings may have poor correlation with airway injury and result in unnecessary intubation. We investigated flexible fiberoptic laryngoscopy (FFL) as a means to diagnose upper airway thermal and inhalation injury and guide airway management. A retrospective chart review of all burn patients who underwent FFL from 2013 to 2017 was performed. Their charts were reviewed to determine the indications for FFL including the historical data and physical exam findings that indicated airway injury as well as patient age, TBSA, type and depth of burn injury, carboxyhemoglobin level, and clinical course. Fifty-one patients underwent FFL, with an average TBSA of 6.5% (range 0.5-38.0%) and carboxyhemoglobin level of 3.5%. Burn mechanism was flame (35.3%) or flash (51.0%), with 50% occurring in enclosed spaces. In all cases, the decision to perform FFL was based on physical exam findings meeting criteria for intubation, including facial burns, singed nasal hairs, nasal soot, voice change, throat pain or abnormal sensation, shortness of breath, carbonaceous sputum, wheezing, or stridor. Based on FFL, 9 patients (17.7%) were treated with steroids, 28 patients (54.9%) received supportive care, and 6 patients (11.8%) had repeat FFL for monitoring. One patient was intubated after repeat FFL examination. All patients who underwent FFL met traditional criteria for intubation based on exam, however 98% were monitored without issues based on FFL findings. FFL is a valuable tool that can lead to fewer intubations in acute burn patients with a stable respiratory status for whom history and physical exam suggest upper airway injury.

Pulmonary Tumor Thrombotic Microangiopathy Mimicking Inhalation Lung Injury.

Pulmonary tumor thrombotic microangiopathy (PTTM) is a complication characterized by dyspnea, pulmonary hypertension, and occasionally sudden death. We encountered a man who developed PTTM and had an inhalation history of chemical herbicides and abnormal findings on chest computed tomography, mimicking chemical inhalation lung injury. He was diagnosed with PTTM with adenocarcinoma by a transbronchial lung biopsy and received chemotherapy and anticoagulant therapy. He survived for one month. An autopsy revealed primary gastric cancer with PTTM that can have a presentation similar to diffuse pulmonary diseases, including chemical inhalation lung injury. The examination of a biopsy specimen is crucial in such patients.

Clinical factors affecting mortality in elderly burn patients admitted to a burns service.

INTRODUCTION: The purpose of this retrospective study was to provide basic probabilistic predictors of mortality to assist in determining appropriate therapeutic aggression in elderly burns population. METHOD: Eighty patients over the age of 70 years were admitted to the Victorian Adult Burns Service in Melbourne, Australia, over a period of 4 years. Retrospective data was analysed, taking into account patient demographics, type, site, depth and area of burn, presence of inhalation injury, number of co-morbidities, survival time and the number of operations performed, withdrawal of care and implementation of comfort measures only. RESULTS: Comparing survivors and non-survivors, significant differences were found between age, percentage total burn surface area (TBSA%), percentage full thickness surface area (FTSA%), presence of inhalation injury, site of burn and number of operations. The number of co-morbidities and gender were not significant to outcome. FTSA%, presence of inhalation injury, site of burn, age and number of operations were all significantly related to survival time. When patients who obtained comfort care were excluded from analysis, age and the number of operations were not considered to be significantly related to mortality. CONCLUSION: This study indicates that TBSA%, FTSA%, inhalation injury and age are significant predictors of death in the elderly burns population, although only the first three remain significant when patients who receive comfort care measures only are excluded.

Reliability of the primary triage process after the Volendam fire disaster.

In a major incident, correct triage is crucial to emergency treatment and transportation priority. The aim of this study was to evaluate the triage process pursued at the site of the fire disaster in Volendam, the Netherlands on January 1, 2001. On-site (OS) and Emergency Department (ED) data regarding total body surface area burned (TBSA) and inhalation injury (INH) were compared with the final (FIN) assessment of these two parameters after hospital admission. Finally, the effect of OS intubation and the time of arrival at a hospital were evaluated. There were 245 injured. Mean age was 17.3 years. Final median TBSA was 12%; 96 patients (39%) had inhalation injury. Agreement between TBSA-OS (n = 46) and TBSA-FIN was poor (Pearson's correlations coefficient [PCC] = 0.77; R(2) = 0.60). TBSA-ED (n = 78) was more accurate (PCC = 0.96; R(2) = 0.93). INH-OS (n = 79, sensitivity 100%, specificity 24%) and INH-ED (n = 198, sensitivity 99%, specificity 36%) were sensitive but not specific. Eight patients were intubated on-site. No differences in outcome were found between this group and the patients who were intubated in the hospital. There was no difference in time of arrival at a hospital (p = 0.55). TBSA was not estimated reliably in a non-clinical environment. The diagnosis of inhalation injury was adequate but resulted in over-triage on-site and at the ED. Triage did not lead to transport priorities for the severely wounded. In a major burn accident, a field triage protocol for rapid evaluation of burn injuries may be useful. Detailed assessment of injuries of burn casualties is practical only in a specialized clinical setting.

Determining the role of nasolaryngoscopy in the initial evaluation for upper airway injury in patients with facial burns.

BACKGROUND: Upper airway injuries can be fatal in burn patients if not recognized, a scenario that causes a significant amount of anxiety for physicians providing initial assessment of burn patients. Early elective intubation is often performed; sometimes unnecessarily. However, some providers employ nasolaryngoscopy for patients presenting with facial burns or signs/symptoms of upper airway injury in order to assess the need for intubation, but this practice is not considered standard of care and may also be unnecessary. Evidence is currently lacking about the utility of nasolaryngoscopy as an adjuvant assessment during evaluation of potential upper airway burn injuries. The objective of this study was to determine if nasolaryngoscopy provides additional information to the history and physical in making the decision to electively intubate patients with facial burns. METHODS: This study was a retrospective analysis of all patients who underwent fiberoptic nasolaryngoscopy after facial burn injury to evaluate for upper airway injury associated with burns over a 2 year period at a regional burn center. During this time period, all patients who presented with facial burns, soot, or carbonaceous sputum underwent nasolaryngoscopy to look for upper airway injury regardless of mechanism of injury. Patients intubated prior to arrival were excluded from the study. Patients were considered to have signs/symptoms of airway injury (symptomatic) if they presented with dyspnea, tachypnea, hypoxia, or significant burns to buccal mucosa. Procedure notes were used to determine if supraglottic/glottic injury (erythema or edema) was present on nasolaryngoscopy. Presence of pathologic changes and whether they led to intubation were evaluated in the asymptomatic and the symptomatic groups of patients. Select individual records were inspected further to help determine if the nasolaryngoscopy findings altered management plans and if intubation was ultimately necessary based upon the presence or absence of a cuff leak and the duration of intubation. RESULTS: Twenty-two patients were symptomatic upon presentation, 14 of which had positive findings on laryngoscopy and 7 (50%) were intubated. One-hundred and eighty-eight patients were asymptomatic, 58 (31%) of which had either erythema or edema or carbonaceous debris on nasolaryngoscopy, and only 2 (1%) were intubated. These patients were both extubated within two days. None of the 130 asymptomatic patients with negative nasolaryngoscopy were intubated. CONCLUSIONS: This study showed disparity between signs and symptoms of airway injury and nasolaryngoscopy findings. Asymptomatic patients showed pathologic changes in 30% of scopes, but this finding only changed management 1% of the time. Furthermore, the two patients in this group were extubated quickly, suggesting they may have been suitable for observation without intubation. These results indicate that the presence of erythema or edema is of questionable clinical significance in asymptomatic patients and nasolaryngoscopy is of limited benefit in this group. Only 50% of the symptomatic patients with airway injury evident on nasolaryngoscopy were actually intubated, also bringing into question the significance of the pathologic changes in this group. However, negative nasolaryngoscopy may have had some benefit in preventing intubation in a few, select symptomatic patients. This study suggests that a thorough history and physical is the best tool to identify patients at higher risk of upper airway injury who need intubation, but this should be further studied in prospective trials to determine the definitive role of nasolaryngoscopy.

Respiratory management of inhalation injury.

Advances in the care of patients with major burns have led to a reduction in mortality and a change in the cause of their death. Burn shock, which accounted for almost 20 percent of burn deaths in the 1930s and 1940s, is now treated with early, vigorous fluid resuscitation and is only rarely a cause of death. Burn wound sepsis, which emerged as the primary cause of mortality once burn shock decreased in importance, has been brought under control with the use of topical antibiotics and aggressive surgical debridement. Inhalation injury has now become the most frequent cause of death in burn patients. Although mortality from smoke inhalation alone is low (0-11 percent), smoke inhalation in combination with cutaneous burns is fatal in 30 to 90 percent of patients. It has been recently reported that the presence of inhalation injury increases burn mortality by 20 percent and that inhalation injury predisposes to pneumonia. Pneumonia has been shown to independently increase burn mortality by 40 percent, and the combination of inhalation injury and pneumonia leads to a 60 percent increase in deaths. Children and the elderly are especially prone to pneumonia due to a limited physiologic reserve. It is imperative that a well organized, protocol driven approach to respiratory care of inhalation injury be utilized so that improvements can be made and the morbidity and mortality associated with inhalation injury be reduced.

Fibreoptic bronchoscopy in routine clinical practice in confirming the diagnosis and treatment of inhalation burns.

Fibreoptic bronchoscopy has been recently introduced to our practice, its value in the diagnosis and management of respiratory tract burns has been well established. The aim of the prospective study was to ascertain whether, in our routine clinical practice, a correlation could be shown between clinical and bronchoscopic diagnosis. The outcome of the study could support a rationale for introduction of this tool in other centers in Poland. In the period between 1 October 2001 and 30 June 2004, of the 1247 burn patients, that were hospitalized in our centre and admitted directly after burn, N=292 patients (59 women and 233 men) were included in the study. For clinical diagnosis, a clinical pathway was used, which includes a questionnaire probing for signs and symptoms of inhalation trauma. When on initial assessment there was a suspicion of inhalation trauma (>3/11 points), a prompt fibreoptic bronchoscopy was performed. Diagnoses of an inhalation burn was confirmed in 261/292 patients, of whom upon initial assessment an inhalation trauma was suspected. Clinical assessment showed that 62/261 scored 5/11, 57/261 scored 6/11, 122/261 had a score of 7/11 and 20/261 scored >7/11. In this group an upper respiratory tract burn was diagnosed in 111/261 cases, damage of the main respiratory tract in 130/261 cases, and an inhalation trauma of the lower respiratory tract was confirmed in 20/261 cases. Based on our findings we concluded that fibreoptic bronchoscopy was shown to be a useful method in our routine clinical practice to confirm diagnosis and treatment of inhalation burns. The high agreement between the clinical suspicion of inhalation injury and the incidence confirmed by bronchoscopy and biopsies, suggest that the clinical indicators we use are reliable. We noted that performing fibreoptic bronchoscopy in patients with acute breathing insufficiency, who are intubated and require high concentrations of oxygen, is not recommended.

Inhalation Injury: State of the Science 2016.

This article summarizes research conducted over the last decade in the field of inhalation injury in thermally injured patients. This includes brief summaries of the findings of the 2006 State of the Science meeting with regard to inhalation injury, and of the subsequent 2007 Inhalation Injury Consensus Conference. The reviewed studies are categorized in to five general areas: diagnosis and grading; mechanical ventilation; systemic and inhalation therapy; mechanistic alterations; and outcomes.

Inhalation Injury: Pathophysiology, Diagnosis, and Treatment.

The classic determinants of mortality from severe burn injury are age, size of injury, delays of resuscitation, and the presence of inhalation injury. Of the major determinants of mortality, inhalation injury remains one of the most challenging injuries for burn care providers. Patients with inhalation injury are at increased risk for pneumonia (the leading cause of death) and multisystem organ failure. There is no consensus among leading burn care centers in the management of inhalation injury. This article outlines the current treatment algorithms and the evidence of their efficacy.