Airway management for the burn patient

[Ridryder 911]

I agree larger tube size would be nice. But remember we need to think of potential cuff pressure and necrosis to chords as well, secondary to laryngeal edema. These type of patients I highly recommend them getting a trach after the 3'rd day of ventilator therapy.

R/r 911

[Dustdevil]

These type of patients I highly recommend them getting a trach after the 3'rd day of ventilator therapy.

Or on the scene.

Probably half of my crics have been burn patients.

[Spock]

Thanks for the information everybody. I also use 7.5 for women and 8.0 for men. We do not trach our burn patients because the trach is a very good source of infection and these patients are behind the eight ball already. An emergency cric is a different matter. Succinylcholine is safe during the first 24 hours and I use it in the trauma bay in all patients unless they are hyperthermic. Suxs is a triggering agent for malignant hyperthermia so using it on a patient already hyperthermic is risky.

It looks like we have a local problem with the tube size so I plan on discussing it with our prehospital coordinators. Again, thanks for the input.

Live long and prosper.

Spock

[Doczilla]

One thing that many folks don't think of is that the patient may have to have a bronchoscopy in the hospital for diagnosis of some conditions. In our adult hospitals here, because of bronch equipment size, they can't get bronched through any tube smaller than an 8.0 (okay, maybe they can squeeze it through a 7.5, but the pulmonologists REALLY prefer the 8.0, and have told me that on more than one occasion).

A lot of medics reach for the smaller sizes because they pass more easily and success rate is slightly better (anecdotally). I've been encouraging my medics to use the larger sizes if possible. If physiological size, impinging mass, or airway edema makes that impossible, so be it.

'zilla

[Ace844]

Thanks for the information everybody. I also use 7.5 for women and 8.0 for men. We do not trach our burn patients because the trach is a very good source of infection and these patients are behind the eight ball already. An emergency cric is a different matter. Succinylcholine is safe during the first 24 hours and I use it in the trauma bay in all patients unless they are hyperthermic. Suxs is a triggering agent for malignant hyperthermia so using it on a patient already hyperthermic is risky.

It looks like we have a local problem with the tube size so I plan on discussing it with our prehospital coordinators. Again, thanks for the input.

Live long and prosper.

Spock

"Spock,"

Indeed 'Suxs' is known for 'triggering MH', but this is usally only in pts with that 'genetic pre-disposition and or familial hx's'. In general it is a relatively smal concern, as IIRC there is only approximately a 3% incidence of this?!?? For those that don't know, The treatment for 'Suxs' induced MH is Dantrolene.

Hope this helps,

ACE844

[Spock]

If suxs had to go through an FDA evaluation today it would not pass. Treatment for MH involves much more than just dantrolene and you would be hard pressed to find anybody in anesthesia who would give suxs to a hyperthermic patient. Yes MH does have a genetic predisposition but nobody will take the chance on triggering MH.

Doczilla is right about the bronchoscopy. We frequently do a bronch before a thoracotomy and I routinely place a 9.0 tube because I love the look on the surgeon's face when he comes into the room and asks what size tube did you put in.

Live long and prosper.

Spock

[Scaramedic]

Imagine trying to breath through a straw for a few days and you can appreciate what these pts feel.

Another thread I missed, sorry I am late on this.

In my Paramedic program we had to take tubes of various sizes and breath through them to get an idea what it was like. There is an exponential difference in the air you can move thru the various sizes, at least it feels like it.

I am very aggressive when it comes to airway treatment on burns also, that whole swelling of the tissues issue. Burns aside, I don't believe I would intubate that small on a normal adult for any reason, you could provide BVM respiration and move more air than you could through a 6.5 with cuff leakage, not much airway protection there if you ask me.

Peace,

Marty

:joker:

[Ace844]

If suxs had to go through an FDA evaluation today it would not pass. Treatment for MH involves much more than just dantrolene and you would be hard pressed to find anybody in anesthesia who would give suxs to a hyperthermic patient. Yes MH does have a genetic predisposition but nobody will take the chance on triggering MH.

Doczilla is right about the bronchoscopy. We frequently do a bronch before a thoracotomy and I routinely place a 9.0 tube because I love the look on the surgeon's face when he comes into the room and asks what size tube did you put in.

Live long and prosper.

Spock

For those interested in more info on MH here are a few resources for you.

[web:8b5d9c18dd]http://www.mhaus.org/index.cfm/fuseaction/Content.Display/PagePK/ProfessionalInfoCenter.cfm[/web:8b5d9c18dd]

[web:8b5d9c18dd]http://www.mhaus.org/PubData/PDFs/treatmentposter.pdf[/web:8b5d9c18dd]

[web:8b5d9c18dd]http://www.medana.unibas.ch/eng/mh/mhtutori.htm[/web:8b5d9c18dd]

Hope this helps,

ACE844

[aussie_rn]

Where I work, we would use a 7.5 for females and an 8 for males. In burns pts we would use the same size but reinforced tubes, to allow for any oedema. We also use vec instead of sux.

[kevkei]

If they placed a 6.0 ETT, either it was an error of equipment selection or an error of judgement. Realistically, if all they could pass was a 6.0 due to edema, that's fine.

If they were properly prepared, they would have had ETT's of all sizes available. Yes with inhallation burns, aggressive airway management through ETI is important, but you don't need to truly rush and make errors. It is better to plan, prepare and pass (the tube). While doing the laryngoscopy, there is no reason you can't say "hey, I think I can actually pass a 8.0" instead of arbitraily placing a 6.0. Even if they are edematous, you can probably pass 0.5-1.0 size larger than you visualize due to soft edema - provided you can visualize cords.