FDIC 2024 Preview: Through the Fire and Flames: Stabilizing the Burn Patient

The author poses for a headshot. She has dyed blonde hair and is wearing dress clothing.
Debbie Harrell, MSN, RN, NE-BC

Abstract

Inhalation injuries present a significant challenge for first responders due to their rapid onset and potential for severe consequences. The American Burn Association states that 75% of burn deaths occur on scene or during transport, thus the recognition of these injuries early is essential for prompt intervention and improved outcome.1

This article explores the multifaceted index of suspicion for inhalation injuries in burn patients, focusing on key components such as the location of the fire, physical assessment, respiratory assessment and mental status. The index of suspicion puzzle can be a helpful and practical tool to apply when assessing a patient for airway compromise from an inhalation injury. The BLS and ALS provider can “put the pieces” together rapidly to assist the provider in making a critical decision.2

Understanding the Index of Suspicion

Inhalation injuries in patients are often associated with exposure to hot gases, smoke, and toxic fumes, primarily resulting from structure fires. Timely recognition of these injuries is critical for optimal management and improved patient outcomes. The index of suspicion serves as a vital tool for first responders to assess the likelihood of inhalation injuries and the complications it can cause.

This article aims to provide an in-depth analysis of the index of suspicion, utilizing the inhalation puzzle emphasizing the importance of evaluating the location of the fire, physical assessment, respiratory assessment, and mental status assessment to enhance the recognition of these injuries.3

The Fire’s Location

The location of the fire is a pivotal factor in evaluating the index of suspicion for the potential of an inhalation injury.

  1. Outside fires: These account for many outdoor injuries and flash injuries. When assessing, consider whether this is a flash burn or whether the person actually caught on fire. Breathing in heat for an extended period increases the risk of upper-airway swelling.
  2. Enclosed spaces: Fires that occur in enclosed spaces with poor ventilation increase the risk of inhalation injuries due to the rapid accumulation of smoke and heat. If possible, determine the time of exposure in a confined area during the fire, as this significantly elevates the likelihood of exposure.
  3. Industrial or recreational fires: These fires present the potential for exposure to toxic fumes in non-residential settings, such as industrial accidents or recreational activities involving fires. Gather information about the type and duration of exposure in these scenarios.

Physical Assessment

A comprehensive physical assessment is central to the index of suspicion for inhalation injuries. Here’s a look at the factors it considers.

  1. Burns to the face with the presence of singed nasal hair and eyebrows. But a decision on an inhalation injury does not stop here. Many people have significant inhalation injuries with no burns to their face, just as many people have burned faces with no airway compromise.4 Burns to the face would be one piece of the puzzle.
  2. Soot or carbonaceous material. The presence of soot or carbonaceous material in the nasal passages, mouth, or on the skin may be an indicator of possible inhalation injury. Pay close attention to these areas during the physical examination, especially in cases without visible burns.4

Respiratory Status Assessment

The respiratory status assessment is a fundamental component of the index of suspicion for inhalation injuries. Here are key factors it considers.

  1. Assessing for an upper airway injury. This may be as easy as talking to the patient or listening to the sound of the cry of nonverbal patients. Hoarse and raspy cries may be an indicator of upper airway edema. This would call for placement of a non-rebreather mask with humidification if possible.3
  2. Stridor. Severe inhalation injuries may result in stridor, a high-pitched sound during inhalation that indicates airway obstruction. Recognize stridor as a red-flag; it’s a sign of serious airway edema.3

Mental Status Assessment

Evaluating an individual’s mental status is crucial in the index of suspicion for inhalation injuries. Considerations include the following:

  1. Altered mental status. Carbon monoxide exposure can lead to an increased carboxyhemoglobin-causing hypoxia, which can lead to changes in mental status. Be vigilant for signs of irritability, confusion, drowsiness, or a decreased level of consciousness. Altered mental status may be the earliest indicator of inadequate oxygenation.
  2. Communication challenges. Nonverbal patients may have difficulty describing their symptoms accurately. Assess for any cognitive impairment that may impede effective communication. This is particularly relevant in younger children.

Diagnostic Considerations

In addition to the components of the index of suspicion discussed above, healthcare providers should consider utilizing diagnostic tools to aid in confirming the diagnosis of inhalation injury in pediatric patients. These include the following:

  1. Pulse oximetry. Continuous monitoring of oxygen saturation using pulse oximetry is a valuable diagnostic tool. It detects hypoxia promptly but will not be an indicator of high exposure to carbon monoxide.3
  2. CO-oximetry. The pulse produces concurrent 02 saturation and COHb levels. This will assist in the evaluation of the levels of O2– or CO-rich hemoglobin.
  3. Blood gas analysis. Arterial blood gas analysis provides essential information about oxygenation, acid-base status, and carbon monoxide levels, aiding in the assessment and management of inhalation injuries.
  4. Chest X-ray. While not always diagnostic, chest X-rays often appear normal in the early stages of an inhalation injury.

Key Takeaways

A comprehensive approach to the index of suspicion for inhalation injuries in patients involves evaluating the location of the fire, physical assessment, respiratory status assessment, and mental status assessment. Integrating these key components into the assessment process will enhance the recognition of airway compromise secondary to an inhalation injury.

Early identification is crucial for timely intervention, as it can significantly affect outcomes and reduce the risk of complications. Healthcare providers must diligently consider these elements in their clinical evaluation to ensure the best possible care for patients at risk of inhalation injuries. Recognizing the intricate pieces of the puzzle for inhalation injury is essential to providing optimal care and ensuring the well-being of these vulnerable patients.

References

  1. “Burn incidence and Treatment in the United States,” 2016 – ABA Fact Sheet, American Burn Association. bit.ly/3I1KWNY.
  2. Romanoski, K. S., Palmieri, T.L., Sen, S., Greenhalgh, D.G. “More Than One-Third of Intubations in Patients Transferred to Burn Centers Are Unnecessary: Proposed Guidelines for Appropriate Intubation of the Burn Patient,” Journal of Burn Care & Research, Volume 37, Issue 5, 2016, pp. e409-14. bit.ly/3SHYwL4.
  3. Advanced Burn Life Support Course Provider Course, American Burn Association, January 2023. bit.ly/3HZPGn7.
  4. Herndon, David W., Total Burn Care, Elsevier, 2018.

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