EARLY VS LATE INTUBATION OF BURNS

iPhoneIcon_BigWe are taught to intubate victims with inhalational injury early. If we delay for too long the tongue, epiglottis and other structures can swell and cause airway obstruction, forcing an emergency intubation that is more likely to be difficult or failed. A french study in AJEM looks at the incidence of difficult intubations in patients with face and neck burns and the possible consequences of airway tardiness.

Background
Mortality in patients with major burns is decreasing. Burn shock, which used to account for 20% of burn deaths is very rare these days thanks to aggressive fluid resuscitation. Burn wound sepsis used to be the other leading killer, but has been brought under control  thanks to antibiotics and improved surgical management. Inhalation injury has emerged as the most frequent cause of death in burns victims. Victims with inhalational injury often require intubation to prevent airway obstruction but also for mechanical ventilation, bronchoscopy and other lung management.

The study
The study retrospectively looks at the incidence of difficult intubations in victims with facial or neck burns (FNB).  The study included victims with second or third degree FNB who were admitted to a specialised burns unit and were intubated within 24h of injury. Difficult intubation was defined as intubations requiring three or more intubation attempts, requiring two or more intubators and/or a Cormack-Lehane score of 3 to 4.

Results
134 FNB victims were included. The overall incidence of difficult intubation was 15 11,2% (15).  The authors then noted how the majority of difficult intubations (n=13) happened at the burns centre while only 2 of pre-burns centre intubations were recorded to be difficult, perhaps confirming how these patients should be intubated early rather than late.

Take-home message
Intubating patients with FNB is more likely to be difficult. The overall incidence of difficult emergency intubations is (for physiscians) often reported to be in the 5% range. For FNB victims the incidence might be double. The study might also confirm recommendations to intubate these patients early.

Study lives here:
http://www.ncbi.nlm.nih.gov/pubmed/25151328Am J Emerg Med. 2014 Oct;32(10):1174-8. Tracheal intubation difficulties in the setting of face and neck burns: myth or reality ?Esnault P, Prunet B, Cotte J, Marsaa H, Prat N, Lacroix G, Goutorbe P, Montcriol A, Dantzer E, Meaudre E.

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