The emergency department receives a call from the emergency medical services (EMS) about a burn victim coming to your facility in about 5 minutes. In an attempt to take his own life, a 40-year-old man, while locked inside his vehicle, set himself on fire with gasoline. The patient's arrival at hospital was delayed due to a prolonged extrication and transport time of about 1 hour. He had significant burns to the anterior trunk, thighs, head, and neck. The EMS personnel advise that a difficult airway ought to be anticipated.
Attempts to examine his airway, establish intravenous (IV) access, and oxygenate are foiled by his severely agitated and uncooperative state.
23.2.1 How Can Airway Assessment and Management, Resuscitation, Patient Comfort, and Cooperation Be Achieved?
The evaluation of the airway in a burn victim is crucial to patient management. Difficulties with bag-mask-ventilation (BMV), the use of extraglottic devices, laryngoscopy, and surgical airways may all be present and should be anticipated.
Despite extensive burns, these patients are often awake, alert, and in severe pain. They are likely to require significant fluid resuscitation early in the course of their care. However, unless there are associated injuries, the immediate priorities for burn victims are early airway control, fluid resuscitation, and pain management. Accurate assessment of the airway and the patient's underlying physiological status may be impossible, until control of pain and agitation is achieved. Immediate IV access is desirable to facilitate this. But, access may also be restricted by the location of the burns.
In this case, the patient arrived very agitated, in severe pain, and without IV access. Haldol and morphine were given intramuscularly to achieve cooperation. Due to the location of his burns, access was restricted to his lower extremities and groin, areas which were spared due to his seated position. While nursing staff attempted peripheral IV access in his feet, a right femoral venous catheter was placed under ultrasound guidance.
Limited IV access requires that conditions be used to optimize success. It is recommended that the most experienced practitioners be assigned to provide vascular access using ultrasound guidance through unburned skin. Attention to sterile technique is particularly important in this population as delayed infections represent a serious risk. Intravenous access through an overlying burn is not contraindicated, but is more difficult to locate landmarks, can be challenging to secure, and may become dislodged with subsequent tissue edema. An intraosseous line is an alternative access option in an emergency situation when intravenous access cannot be achieved.
23.2.2 Are There Difficulties with Bag-Mask-Ventilation that Might Be Anticipated in This Patient?
Anatomical features predictive of difficult BMV may be present as well in burn victims, although other barriers to effective ventilation with a bag-mask must be considered. This patient is not obese, not elderly, and there is no facial hair or edentulous state to ...