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Predictors of Inhalation Injury in Burn‐Injured Patients Before Arrival At Emergency Medicine Australasia (2020) doi: 10.1111/1742-6723.13604 ORIGINAL RESEARCH To intubate or not to intubate? Predictors of inhalation injury in burn-injured patients before arrival at the burn centre Kylie DYSON ,1,2 Paul BAKER,3 Nicole GARCIA,3 Anna BRAUN,3 Myat AUNG,4 David PILCHER,4 Karen SMITH,2 Heather CLELAND3,5 and Belinda GABBE1,6 1Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia, 2Centre for Research and Evaluation, Ambulance Victoria, Melbourne, Victoria, Australia, 3Victorian Adult Burns Service, Alfred Hospital, Melbourne, Victoria, Australia, 4Intensive Care Unit, Alfred Hospital, Melbourne, Victoria, Australia, 5Central Clinical School, Monash University, Melbourne, Victoria, Australia, and 6Health Data Research UK, Swansea University Medical School, Swansea, UK Abstract injury was 11%. Increasing %TBSA Key findings burned, flame, enclosed space, face Objective: Inhalation injury occurs burns, hoarse voice, soot in mouth and • Eleven percent of burn-injured in approximately 10–20% of burn shortness of breath were predictive of patients in our study had con- patients and is associated with inhalation injury. The model provided firmed inhalation injury. increased mortality. There is no clear excellent discrimination (area under • The mortality rate of patients method of identifying patients at risk fi curve 0.87, 95% con dence interval with inhalation injury was of inhalation injury or requiring – 0.84 0.91). A lower proportion of 16%. intubation in the pre-hospital setting. patients intubated at a non-burn centre • Increasing percentage of total Our objective was to identify pre- had an inhalation injury (33%) com- burn centre factors associated with pared to patients intubated by emer- body surface area burned, fl inhalation injury confirmed on bron- gency medical services (54%) and in the ame, enclosed space, face choscopy, and to develop a prognos- burn centre (58%). burns, hoarse voice, soot in tic model for inhalation injury. Conclusions: A model to predict inha- mouth and shortness of Methods: We analysed acute admis- lation injury in burn-injured patients breath were predictive of sions from the Victorian Adult Burns was developed with excellent discrimi- inhalation injury. Service and Ambulance Victoria elec- nation. This model requires prospective • A lower proportion of tronic patient care records for 1 July testing but could form an integral part patients intubated at a non- 2009 to 30 June 2016. We defined of clinician decision-making. burn centre had an inhalation inhalation injury as an Abbreviated injury (33%) compared to Injury Scale of >1 on bronchoscopy. A multivariable logistic regression Key words: burn, endotracheal intu- patients intubated by EMS prediction model was developed bation, inhalation injury, pre- (54%) and in the burn based on pre-burn centre factors. hospital. centre (58%). Results: Emergency medical services transported 1148 patients who were Introduction oedema in the airway and subse- admitted to the burn centre. The quent obstruction. Early identifica- median age of patients was 39 years Inhalation injury occurs in approxi- tion of inhalation injury enables – and most patients had <10% total mately 10 20% of burn patients and early intubation to occur, preventing body surface area (%TBSA) burned. is associated with increased mortal- airway occlusion or technically diffi- fi 1,2 The prevalence of con rmed inhalation ity. Inhalation injury can cause cult intubation because of oedema.1,2 Although early intubation can be a Correspondence: Dr Kylie Dyson, Department of Epidemiology and Preventive Medi- lifesaving intervention and is advised cine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia. for all patients with inhalation Email: [email protected] injury,2,3 many patients undergo this Kylie Dyson, PhD, Adjunct Research Fellow; Paul Baker, MBChB, Burn Fellow; high-risk procedure4,5 unnecessarily, Nicole Garcia, MD, Physician; Anna Braun, MD, Physician; Myat Aung, MBBS, often in an uncontrolled environment – Anaesthetic Fellow; David Pilcher, MBBS, Intensivist; Karen Smith, PhD, Director of by inexperienced intubators.6 8 More Centre for Research and Evaluation; Heather Cleland, MBBS, Director of Victorian evidence is needed to safely guide cli- Adult Burns Service; Belinda Gabbe, PhD, Head of Pre-hospital, Emergency and Trauma Research. nicians about which patients will benefit from intubation.7 Accepted 22 July 2020 © 2020 Australasian College for Emergency Medicine 2 K DYSON ET AL. Clinicians often rely on clinical population of 6.5 million.21 Victoria however, the Victorian Ambulance signs, such as hoarse voice or singed is serviced by a single emergency med- Clinical Information System does nasal hairs, to determine which ical service (EMS), AV who provide have minimum requirements for data patients are at risk of inhalation road and air (fixed wing and helicop- entry by paramedics. We extracted injury. However, none of these signs ter) transport of patients. It is a two- variables from all ePCRs that could accurately identify inhalation injury tiered service, where intensive care be matched to the VABS cohort for – before arrival at the burn centre3,9 13 paramedics can perform endotracheal their burn injury event. Paramedics and an evidence-based tool for clini- intubation. Intensive care paramedics use paper PCRs when the computer cian decision support is yet to be are authorised to perform endotra- is faulty or unavailable and these developed.8 Numerous studies have cheal intubation using rapid sequence cases were excluded (estimated attempted to identify criteria for the induction for patients with suspected <10% of all patient encounters). early diagnosis of inhalation injury airway burns and a Glasgow Coma but many of these studies had a Scale (GCS) score less than 10, or – small sample size,14 18 focused on patients with a GCS ≥10 under con- Methods and measurements whether the patient was sultation with the burn centre ED.22 The degree of inhalation injury was intubated,14,16 or how quickly the Patients with suspected inhalation determined using the AIS gradation – patient was extubated,6 8,19 rather injury can be intubated either at the of inhalation injury ranging from than an objective diagnostic measure scene, at the initial assessing hospital 1 to 5, with 1 corresponding to no of inhalation injury, such as bron- (if not directly admitted to the burn evidence of inhalation injury, and choscopy.20 Accurate prediction of centre) or in the ED at the burn 5 corresponding to the most severe the likelihood of inhalation injury in centre. form of injury (Table S1). A score of the pre-burn centre setting may assist zero means that the bronchoscopy paramedics and non-burn centre findings were not further specified. physicians with the early diagnosis Data sources The AIS gradation of inhalation of inhalation injury and the decision The VABS registry collects informa- injury evaluates the extent of inhala- to intubate. tion on all patients who are admitted tion injury visualised, including Our objective was to identify pre- to the Alfred Hospital burn unit. mucosal erythema and oedema, blis- burn centre factors associated with The VABS registry includes data on tering, ulceration or bronchorrhea, inhalation injury confirmed on bron- the characteristics of the burn injury, fibrin casts or evidence of charring. choscopy, and to develop a prognos- the treatment provided to patients Bronchoscopy is performed within tic model for inhalation injury. while in hospital and their admission the first 24 h of admission to the outcomes. We extracted all patients burn centre as part of a standardised from the VABS registry who were ICU admission protocol to assess Methods admitted from the scene of injury or inhalation injury and recorded using We performed a retrospective analy- referred from another hospital with a template in the patient’s hospital sis of acute ambulance transport and a new burn injury. For all patients in record. secondary transfers admitted to the this cohort who were admitted to the We defined inhalation injury as an Victorian Adult Burns Service ICU, or had pre-burn centre intuba- AIS severity score of >1 on bron- (VABS). We examined 7 years of tion we examined their hospital choscopy. Where the patient was not data (1 July 2009–30 June 2016) records to determine if a bronchos- intubated or bronchoscopy was not from the VABS registry to identify copy was performed and where performed we considered the patient pre-burn centre predictors of inhala- available we recorded the Abbrevi- not to have an inhalation injury. tion injury confirmed on bronchos- ated Injury Scale (AIS) severity grada- Where a bronchoscopy was per- copy. To determine symptoms of tion of inhalation injury (Table S1). formed and the presence or absence inhalation injury before arrival at To examine the characteristics of of inhalation injury was clearly the burn centre, we linked the VABS patients before they arrived at the documented but the score could not data with the Ambulance Victoria burn centre, we extracted data from be located in the patient notes, we (AV) electronic patient care records the AV ePCRs for both primary based the presence of inhalation (ePCRs). The present study was transports and secondary transfers. injury on the documentation (n = 5). approved by the Alfred Hospital Paramedics record all patient assess- In addition, for patients who under- Ethics Committee (project number: ments and interventions on a laptop went nasal endoscopy, pan- 232/15). using the Victorian Ambulance Clin- endoscopy or an unknown ical Information System software procedure, and the presence or developed by AV.23 The ePCRs are absence of inhalation injury was Study design and setting uploaded wirelessly and are stored in clearly documented, we based the The Alfred is the only adult burn the AV Clinical Data Warehouse presence of inhalation injury on the centre in the Australian state of where they can be searched and documentation (n = 10, n = 5 with Victoria. The catchment area for extracted. The ePCR data is prospec- documented inhalation injury).
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