Emergency Treatment of Severely Burned Pediatric Patients: Current Therapeutic Strategies

Gerd G. Gauglitz; David N. Herndon; Marc G. Jeschke

Disclosures

Pediatr Health. 2008;2(6):761-775. 

In This Article

Inhalation Injury

Even though mortality from major burns has significantly decreased during the past 20 years, inhalation injury still constitutes one of the most critical concomitant injuries following thermal insult. Approximately 80% of fire-related deaths result not from burns, but from the inhalation of the toxic products of combustion, and inhalation injury has remained associated with an overall mortality rate of 25-50% when patients require ventilator support for more than 1 week following injury.[39,40] Therefore, the early diagnosis of bronchopulmonary injury is critical for survival and is primarily conducted clinically, based on a history of closed-space exposure, facial burns and carbonaceous debris in mouth, pharynx or sputum.[41] Evidence-based experience on diagnosis of inhalation injury, however, is rare. Chest x-rays are routinely normal until complications, such as infections, have developed. Hence, bronchoscopy of the upper airway should be the standard diagnostic method used on every burn patient. Gamelli and others established a grading system of inhalation injury (0, 1, 2, 3 and 4) derived from findings at initial bronchoscopy and based on Abbreviated Injury Score criteria.[42] Bronchoscopic criteria that are consistent with inhalation injury included airway edema, inflammation, mucosal necrosis, presence of soot and charring in the airway, tissue sloughing or carbonaceous material in the airway. The treatment of inhalation injury should start immediately with the administration of 100% oxygen administered via a face mask or nasal cannula. Maintenance of the airway is critical. As mentioned previously, if early evidence of upper airway edema is present, early intubation is required because the upper airway edema normally increases over 9-12 h. However, prophylactic intubation without good indication should not be performed.

Advances in ventilator technology and treatment of inhalation injury have resulted in some improvement in mortality. A multicenter, randomized trial in patients with acute lung injury and acute respiratory distress syndrome demonstrated that mechanical ventilation with a lower tidal volume than that traditionally utilized resulted in decreased mortality and increased the number of days without ventilator use.[43] Pruitt's group demonstrated that since the advent of high-frequency ventilation, mortality has decreased to 29% from 41% reported in an earlier study.[44] The management of inhalation injury consists of ventilatory support, aggressive pulmonary toilet, bronchoscopic removal of casts and nebulization therapy.[14] Nebulization therapy can consist of heparin, α-mimetics or polymyxin B and is applied between two- and six-times daily. Pressure-control ventilation with permissive hypercapnia is a useful strategy in the management of these patients, and pCO2 levels of as much as 60 mmHg can be well tolerated if arrived at gradually. Prophylactic antibiotics are not indicated, but imperative with documented lung infections. Clinical diagnosis of pneumonia includes two of the following:[36] chest x-ray revealing a new and persistent infiltrate, consolidation or cavitation; sepsis (as defined in Box 1 ) and/or a recent change in sputum or purulence in the sputum, as well as quantitative culture. Clinical diagnosis can be modified after utilizing microbiologic data into three categories according to the ABA Consensus Conference to Define Sepsis and Infection in Burns.[36] Empiric choices for the treatment of pneumonia prior to culture results should include coverage of methicillin-resistant Staphylococcus aureus and Gram-negative organisms such as Pseudomonas and Klebsiella.[45]

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