Emergency War Surgery NATO Handbook: Part I: Types of Wounds and Injuries: Chapter III: Burn Injury

Endotracheal Intubation

United States Department of Defense

The indications for endotracheal intubation are essentially those that exist in any other surgical patient: namely, acute laryngeal or upper airway edema or obstruction, inability to handle secretions, and associated chest wall injury. Severe smoke inhalation with respiratory insufficiency is another indicator for endotracheal intubation. The presence of inhalation injury and the adequacy of the airway should be assessed by direct examination of the oropharynx and the upper airway using a fiberoptic laryngoscope or bronchoscope.

If the burn patient is to be evacuated and the adequacy of the airway is at all questionable, the caregiver should perform endotracheal intubation or tracheostomy before movement rather than risk the possibility of acute airway obstruction in transit. Three categories of patients are most apt to require endotracheal intubation on the basis of the indications listed: (1) patients with severe head and neck burns, (2) patients with steam burns of the face, and (3) patients burned in a closed space who have inhaled smoke or other noxious products of incomplete combustion.

The severe chemical tracheobronchitis which results from inhalation injury may cause acute respiratory insufficiency. Such patients may have marked hypoxemia persisting for several weeks. Marked bronchospasm and frequent bouts of coughing are common and the patient may raise sputum containing carbonaceous material, confirming the diagnosis of inhalation injury. Conservative therapy with administration of burnidified air or oxygen and nasotracheal aspiration, as indicated, is employed initially. The ability of the patient to clear the tracheobronchial tree and the quality of endobronchial debris will determine whether bronchoscopy is necessary and the frequency with which it should be employed. Endotracheal intubation should be performed for the indications previously noted. Tracheostomy should be carried out only if prolonged mechanical ventilation is necessary or if the endobronchial toilet cannot be adequately performed through an endotracheal tube. Daily chest roentgenograms must be obtained of all patients with significant inhalation injury, with endobronchial cultures obtained if pneumonic infiltrates appear. Antibiotic treatment is guided by the results of the microbiology reports of those cultures. Mucolytic agents and bronchodilators may also be useful. Mechanical ventilatory assistance may be necessary ill the treatment of those patients who have severe bronchospasm, profound hypaxemia, or significant hypercarbia.

Steroids in large doses are employed only in those patients with unrelenting bronchospasm, and such treatment should be terminated at the earliest possible time to minimize the increased risk of infection attendant upon their use.

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Operational Medicine 2001

Health Care in Military Settings

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