Respiratory care of the burn patient

The vast majority of respiratory disorders in thermally injured patients arise from associated inhalation injuries. The major forms of these injuries are carbon monoxide poisoning, injury to the upper airway, and pulmonary parenchymal damage. One hundred per cent oxygen, initiated at the scene of the accident, is the single most effective treatment of carbon monoxide toxicity, which must be assessed by carboxyhemoglobin determinations. Respiratory tract damage is identified by fiberoptic bronchoscopy and xenon ventilation-perfusion scintigrams. The compromised airway is protected by tracheal intubation, and respiratory failure is treated with assisted ventilation and supplemental oxygen. Pulmonary infection requires specific antibiotics based on isolated organisms and their sensitivities to antimicrobials. The upper respiratory tract of patients requiring long-term intubation should be assessed by fiberoptic bronchoscopy and other modalities to prevent fatal late airway occlusion.     

Airway and respiratory management following non-lethal hanging

Purpose

To review the literature on airway and respiratory management following non-lethal (suicidal) hanging and to describe the anatomy, mjury and pathophysiological sequelae and their impact on patient care.

Source

A Medline literature search of English-language and English-abstracted papers for 1990–96. Keywords were: hanging; strangulation; airway obstruction; pulmonary oedema. Fitters were applied to limit the search to relevant citations, (i.e., keywords = pulmonary oedema; filters = postobstructive, neurogenic). Citations were then hand-culled to obtain current and relevant papers about an unusual cohort of patients. A hand search of the bibliographies of relevant papers supplemented the Medline search. A review of our expenence at the University of Ottawa adult hospitals over the last decade was also undertaken to determine the relevance of the literature to our clinical expenences.

Principal Findings

Most victims are young men and survivors are uncommon. Laryngo-tracheal injunes, although reported in 20–50% of postmortem examinations, are infrequent in survivors and have little impact on airway management. Spinal injuries are rare in survivors but should be excluded. Pulmonary complications including pulmonary oedema and bronchopneumonia are implicated in most in-hosprtal deaths. Pulmonary oedema is likely due to neurogenic factors or negative intrathoracic pressure. Although neurological injury determines outcome following hanging, initial neurological presentation is of limited prognostic value: a poor initial condition does not exclude a good recovery.

Conclusion

Airway injuries severe enough to interfere with airway management are uncommon after attempted suicide by hanging. Irrespective of the initial neurological assessment, aggressive and early resuscitation to optimize cerebra oxygénation is recommended.     

Airway management in the intensive care unit

Airway management practices in the intensive care unit (ICU) are still evolving, evidenced by an increasing proliferation of guidelines and algorithms in recent years. Specific considerations relate to the out-of-theatre environment and the physiological state in this patient population. Airway management in ICU is ultimately a multifaceted process spanning team training, simulation, preassessment, preparation, positioning of the patient, equipment decisions, guidelines/algorithm adherence and most recently the consideration of the coronavirus disease (COVID-19) pandemic. The use of video laryngoscopy has increased, as have the practices of apnoeic oxygenation and the use of checklists. Emergency front-of-neck access (FONA) should be taught to all staff and standardized equipment made available. This article highlights the factors a multidisciplinary team must navigate when approaching airway management in the ICU.     

Airway management in the transfer of the unconscious patient.

Thirty-one consecutive unconscious patients admitted to a specialist neurosurgical centre for computerised axial tomography and further management were reviewed with emphasis upon initial airway management. Fourteen patients had inadequate airway control on arrival and needed immediate intubation. Six of this group developed pulmonary complications. The implications of this are discussed and certain recommendations made.     

Airway management of post burn contracture neck – An anaesthesiologist's challenge

Airway management is a challenge to anaesthesiologist owing to fixed flexion deformity resulting in nonalignment of oral, pharyngeal and laryngeal planes for intubations. The Ovassapian fibreoptic intubating airway, Williams airway intubator and the Berman oropharyngeal airway may provide a conduit for the bronchoscope. We present the successful anaesthetic management of a patient with obliteration of nasal passages, microstomia and severely limited neck extension by awake oral fibreoptic intubation aided by Berman's airway.     

The care of the burn patient in the rehabilitation center

The rehabilitation of a patient with serious burns involves several disciplines. The initial objective is to reduce the appearance or evolution of functional sequelae. The patient's future will depend on the quality of this rehabilitation.     

Airway management of a patient with Weill-Marchesani syndrome

Weill-Marchesani syndrome is a genetically determined rare systemic connective tissue disorder consisting of brachymorphy, brachydactyly, aortic stenosis, and ophthalmologic abnormalities, such as ectopia lentis, microspherophakia, and secondary glaucoma. The primary lesion is fibrous tissue hyperplasia. Airway control and intubation may be difficult in patients with WMS because of stiff joints, poorly aligned teeth, and maxillary hypoplasia with a narrow palate. We describe the successful airway management of a patient with WMS and laryngeal stenosis, using an intubating laryngeal mask following failed conventional laryngoscopic intubation.     

Airway management of a patient with facial trauma

Airway management in patients with facial trauma is usually challenging. In this case, we report the airway management of a patient who had multiple midface fractures and a two-inch tree limb implanted into his face.     

Airway management of a patient with Forestier's disease

Forestier's disease, also called diffuse idiopathic skeletal hyperostosis (DISH), is a noninflammatory enthesopathy, ossifying the anterolateral spine and sparing the disc and joint space in elderly men, mostly at thoracic levels. Intubation difficulty and spinal cord injury are potential problems when managing the airway in DISH patients. We report a patient with Forestier's disease who was admitted for osteophyte resection. After taking a detailed history, we evaluated the airway carefully. Also, preparation for difficult intubation was done. After a rapid sequence induction, we performed mask ventilation and laryngoscopy without hyperextension of the neck, to prevent spinal cord injury. Although the worldwide standard for management of the airway in DISH patients is awake fiberoptic intubation, we chose conventional laryngoscopy because a fiberoptic bronchoscope was not available.     

End of life decisions and care of the adult burn patient

Introduction

Despite advancements in the provision of burn care, there is still a significant cohort of patients who fail to respond to therapy or for whom treatment is deemed futile. The decision to withdraw support from, or to implement a Do-Not-Resuscitate (DNAR) order in, such patients can be challenging. Our aims were to review the withdrawal of life-sustaining treatment, issuing of DNAR orders and end of life care in burn patient deaths.

Methods

A retrospective case notes review was undertaken, for all burn in-patient deaths from 1st April 2001 to 31st December 2007.

Results

Following exclusions, 63 patients were included in our study, with a median age of 56 years (21-94). End of life decisions in younger patients (under 65 years) were more often due to burn severity. In those over 65 years, reasons were due to co-morbidities, and these decisions were made late in the patient's admission. In 34% of patients, end of life care was not comprehensively documented.

Conclusion

A coherent, decisive approach should be adopted and adhered to by all members of the multi-disciplinary team, with clear, standardised documentation in place.     

Airway management for patient safety: preface and comments

Maintenance of patent airway has an essential role in respiratory management. The management of difficult airway is one of problems associated with the maintenance of airway patency. "Cannot intubate, cannot ventilate (CICV)" scenario is rare, but it usually leads to serious morbidity and mortality related to anesthesia. A wide variety of equipments and anesthetic techniques can be used to deal with this emergency situation. However, the recent practice of airway management seems to be very complex, depending on the introduction of new airway devices including laryngeal mask airway (LMA). In order to provide the reader with valuable information as to the new devices and airway-associated problems, five experts in this field contributed to this special issue of difficult airway problems.     

Advances in fluid therapy and the early care of the burn patient

The resuscitation and early care of the burn patient has been placed on a more sound physiologic basis as a result of recent studies of the pathologic effects of thermal injury and the clinical application of technological advances. Whichever resuscitation formula is employed, its application should be guided by the patient's response to treatment. The surgeon must preserve vital organ function while taking advantage of compensatory mechanisms to minimize the deleterious effects of both the injury and the therapy. Resuscitation using only balanced salt solution in the first 24 hours, and reserving colloid-containing fluids for the second 24 hours, is clinically effective in the vast majority of burn patients, but should be altered in terms of volume and composition to meet the particular needs of any given burn patient. Repeated planned monitoring of cardiopulmonary function and of the peripheral circulation is mandatory to achieve maximum survival of unburned tissue and to reduce mortality. Careful fluid management, including daily assessment of fluid balance, is required from the time of admission until the burn wound has healed or been grafted.

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Résumé Les recherches récentes sur la pathologie des brûlures et les progrès techniques ont amélioré la réanimation et le traitement précoce des brûlés. Il existe divers schémas de réanimation: quelle que soit la technique employée, dans la pratique il faut toujours se guider sur la réponse du patient à la thérapeutique. Le chirurgien doit préserver les fonctions vitales tout en profitant des mécanismes compensatoires pour réduire les effets nocifs du traumatisme aussi bien que du traitement. Dans la majorité des cas, la réanimation est efficace si elle utilise uniquement des solutions électrolytiques équilibrées pendant les premières 24 heures et si elle réserve les colloïdes pour le 2ème jour. Mais il faut savoir, selon les besoins particuliers de chaque patient, changer les volumes et la composition des liquides perfusés. Les fonctions cardiopulmonaires et la circulation périphérique doivent être surveillées en permanence pour assurer une viabilité optimale des tissus non brûlés et réduire la mortalité. Des bilans journaliers doivent contrôler l'équilibre hydrique, jusqu'au moment où les brûlures sont guéries ou greffées.

     

Airway management in a patient with Williams syndrome

Williams syndrome is characterized by the triad of supravalvular aortic stenosis (SAS), mental retardation and elfin facies. Generally, difficult airway is expected in patients with Williams syndrome by characteristic face. A 26-year-old female with Williams syndrome was scheduled for abdominal myomectomy under general anesthesia. Difficult mask ventilation and tracheal intubation were anticipated because of micrognathia, mandibular retrusion, and a Mallanpati class III airway. Before induction of anesthesia the patient breathed 100% oxygen for 3 minutes. Anesthesia was induced and maintained with propofol, remifentanil and rocuronium bromide. Mask ventilation was easily performed. The direct laryngoscopic view was Cormack grade I and there was no difficulty in the tracheal intubation. After induction of anesthesia, anesthetic course was uneventful. According to the most previous clinical reports in patients with Williams syndrome in Japan, mask ventilation and tracheal intubation were performed easily contrary to preoperative airway assessment. In view of SAS, mental retardation, airway deformity and airway assessment in previous clinical reports, we should select the optimal strategy for airway management in patients with Williams syndrome.