Inhalation Injuries

Title of Guideline (must include Inhalation Injuries in the Paediatric Patient

the word Guideline (not
protocol, policy, procedure etc)
Contact Name and Job Title Dr J A Davies Consultant Burns Anaesthetist
(author)
Directorate & Speciality Family Health: Burns
Date of submission December 2014
Date on which guideline must be December 2016
reviewed (one to five years)
Explicit definition of patient group Inhalation injury can be defined as the aspiration of
to which it applies (e.g. inclusion superheated gas and toxic products of incomplete
and exclusion criteria, diagnosis) combustion. The type of injury sustained consists of
three distinct phases:-
Thermal
Chemical
Toxic.

Abstract All burn injuries should be approached with a view

to excluding an inhalation injury. It is paramount to
gain as much history as possible surrounding the
events and environment of the burn injury (e.g.
ignition source, temperature, concentration and
solubility of gases involved, enclosed space and
duration of exposure). Entrapment and decreased
sensory awareness (e.g. drugs or alcohol) will
increase likelihood.

Key Words Paediatric Child Inhalation Burn Injuries

Statement of the evidence base of the guideline has the guideline been peer reviewed
by colleagues?
1a meta analysis of randomised controlled
trials
2a at least one well-designed controlled study
without randomisation
2b at least one other type of well-designed
quasi-experimental study
3 well designed non-experimental
descriptive studies (ie comparative /
correlation and case studies)
4 expert committee reports or opinions and / X
or clinical experiences of respected
authorities
5 recommended best practise based on the X
clinical experience of the guideline
developer
Consultation Process
Target audience Staff within Nottingham Childrens Hospital
This guideline has been registered with the trust. However, clinical guidelines are
guidelines only. The interpretation and application of clinical guidelines will
remain the responsibility of the individual clinician. If in doubt contact a senior
colleague or expert. Caution is advised when using guidelines after the review
date.

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Document Control

Document Amendment Record

Version Issue Date Author Description

V1 August 2014 Dr John Davies

General Notes:

Summary of changes for new version:

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Background

Inhalation injury can be defined as the aspiration of superheated gas and toxic products of
incomplete combustion. The type of injury sustained consists of three distinct phases:-
Thermal
Chemical
Toxic.

Inhalation injury can be classified by the anatomical distribution of the injury, (and the phases
mentioned above can be typically mapped to these sites):-

1. Airway injury above the larynx (Thermal).

2. Airway injury below the larynx (Chemical).
3. Systemic effects of inhalation injury (Toxic).

In airway injuries above the larynx, the injury is produced by the inhalation of hot gases
leading to the same changes as a thermal injury to the skin (oedema=>swelling). This can
then lead to obstruction of the childs airway and hypoxia. It is most likely to occur if the
patient was in an enclosed space, trapped in a fire or with steam inhalation. Since the space
in the oro-pharynx and the airways is much smaller in children, it doesnt require much
swelling to cause significant obstruction.

Airway injuries below the larynx arise from the inhalation of products of combustion. Fire
causes the oxidation and reduction of compounds containing carbon, sulphur, phosphorous
and nitrogen. The resultant various chemical compounds produced will then dissolve in the
water of the respiratory mucous and tissue fluids producing different acids & alkalis which
then cause a direct chemical injury to the respiratory mucosa. This leads to swelling and
impairment of gas exchange.

Systemic intoxication occurs following the production and inhalation of various toxic
compounds found in smoke (e.g. carbon monoxide, hydrogen cyanide), which acutely
produce cellular hypoxia, and can cause lung injury by inflammatory cascades.

History and Examination

All burn injuries should be approached with a view to excluding an inhalation injury. It is
paramount to gain as much history as possible surrounding the events and environment of
the burn injury (e.g. ignition source, temperature, concentration and solubility of gases
involved, enclosed space and duration of exposure). Entrapment and decreased sensory
awareness (e.g. drugs or alcohol) will increase likelihood.

Physical features that may be present include:- Facial/oropharyngeal burns, singed nasal
and/or facial hair, hoarseness of voice, brassy cough, productive cough, sooty sputum, croup-
like breathing, difficulty in breathing, flaring of nostrils and stridor). However there is no single
diagnostic indicator.

Management of airway injury above the larynx

Maintain the airway (with/without airway adjuncts e.g. oro-pharyngeal airway).

High flow oxygen (ideally 100% at the scene) via a non-rebreathing reservoir oxygen mask.
Nurse the patient sitting up (to try and reduce swelling).

Frequent re-assessment of the airway.

Consider securing the airway early with an endotracheal intubation (using an uncut
endotracheal tube to allow for swelling), whilst maintaining cervical spine stabilisation if any
suspicion of trauma. This will usually be performed by the most senior available anaesthetist
and should be done in a controlled timely manner, rather than in extremis. Once the child is
intubated, the child will need to be transferred to the nearest Paediatric Intensive Care Unit
(PICU) which has an associated burns service. If it is likely that the child will require less than

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24 hours of ventilation, then it may well be appropriate to admit the child to PICU at
Nottingham University Hospitals (NUH). However there should be discussion between our
burns service and that at Birmingham Childrens Hospital (BCH). If likely to be intubated and
ventilated for longer than 24 hours, steps should be taken to transfer to BCH if they have a
bed available since they are our local Burn Centre.

Management of airway injury below the larynx

Oxygen.

Consider endotracheal intubation if increasing oxygen requirement or work of breathing.

Intermittent Positive Pressure Ventilation (IPPV) if intubation required.

N.B. Likely to have significantly increased fluid requirements for the %TBSA burn present.
In this instance they are almost certainly going to require ventilation for >24 hours, and should
be transferred out to the nearest Paediatric Burn Centre with PICU on site (as above).

Management of systemic intoxication

This should follow an ABC supportive approach with high-flow oxygen via a non-rebreathing
reservoir mask. If suspecting carbon monoxide (CO) poisoning then dont rely on SaO2
readings, since they may appear artificial high (carboxyhaemoglobin and oxyhaemoglobin
have similar degrees of absorption for the wavelengths of light used in oxygen saturation
monitors). Get an early carboxyhaemoglobin (COHb) level to help guide duration of oxygen
therapy. There is currently insignificant evidence to support the use of hyperbaric oxygen
therapy in carbon monoxide poisoning.

If suspecting cyanide (HCN) poisoning, then again a supportive ABC approach with high-flow
oxygen should be used, and empirical treatment commenced with an antidote. There is no
quick laboratory test currently available for measuring cyanide levels. Available antidotes are
hydroxycobalamin (Cyanokit), sodium thiosulphate or sodium nitrite (Nithiodote).
Where the child should be admitted will depend on other injuries sustained and level of
support required. If the child is suitable for admission at NUH, there should still be a
discussion with the burns team at BCH.

Summary

The majority (>2/3) of burn injuries in the paediatric population are scald injuries, and so the
incidence of inhalation injury is far less than that seen in adults. However any burn injury
should still be approached with the view to excluding it. Frequent re-assessment of the childs
airway and work of breathing, along with a detailed history should alert to the possibility of an
inhalation injury. Those caring for the child need to ensure that appropriate personnel (e.g.
senior anaesthetist) are called early to help secure the airway in a timely manner and transfer
to a PICU with an associated burns service is arranged.

References

1. Midlands Burns Operational Delivery Network (2013) Midland Burn ODN Guidelines for
the Admission and Transfer of Burns Patients in the Midlands.
http://www.midlandsburnnetwork.nhs.uk/Library/MBCNThresholdsFinalDocument.pdf

2. Emergency Management of Severe Burns (EMSB) Course Manual, Australia and New
Zealand Burns Association (ANZBA) & British Burn Association (BBA) 15th edition, 2012.
http://www.britishburnassociation.org/emsb

3. British National Formulary for children August 2014. http://www.bnf.org/bnf/index.htm

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