Literature Review: Are we intubating burn patients inappropriately?

Review at CGD and summary by Dr. Alan Laverty

Romanowski KS, Palmieri TL, Sen S, Greenhalgh DG.
More Than One Third of Intubations in Patients Transferred to Burn Centers are Unnecessary
Journal of Burn Care & Research. 2015 Aug 17

We reviewed the above paper at our Clinical Governance Day on 23 March 2016. Below is the summary of the paper, the issues identified, and observations made by our paramedics, registrars, and consultants.

This was a retrospective chart review of burns patients requiring intubation and transfer to a single burn center. It found 416 patients over 10 years and divided them into appropriate vs non- appropriate groups based on length of intubation (≤2days vs >2days) and compared 16 variables (%TBSA, aetiology, intubating profession, age, distance to hospital etc). Intubation complications (10 total) included cardiac arrest, hypotension, seizure, aspiration and cricothyroidotomy. They concluded that there was a high incidence of unnecessary intubations and that flame burns and burns from enclosed spaces were good indicators of intubation requirement. They proposed guidelines for intubation in the prehospital setting. These included discussion with the burns unit pre-intubation where feasible, and lower need for intubation in non-flame burns, burns in non-enclosed spaces, less than 20% TBSA, no third degree burn to face and <3hour transfer time to burn centre.

Multiple methodological issues were identified which invalidate any robust conclusions from this study. The length of intubation is not a useful surrogate for appropriateness. Multiple confounders to this measure were suggested including concomitant trauma, low GCS, mode of transfer, lung disease, litigation risk, communication difficulties and humanitarian indications. There was no blinding of reviewers, no review of hospital and prehospital protocols for transfer and extubations. The prolonged nature of the study allowed for considerable changes in practice throughout the review period. Patients who subsequently died were not included. The study largely conflated two aetiologies (burns and thermal/inhalational airway burns). At a statistical level the two groups were not independent and a number of the variables were unlikely to be normally distributed which did not appear to have been corrected for with the student t evaluation. While statistical significance was achieved for a number of variables, the large number of variables investigated, the lack of a power calculation, and the overlapping confidence intervals combined with the poor methodology would preclude any strong real world conclusions or application. Any application of conclusions from this study would also fall foul of the fallacy of confusion of the inverse and would need prospective testing.

Group discussion felt that this was a missed opportunity for a useful study. Airway  management will still remain a clinical decision by the provider with the patient. Opportunities for expectant management are more applicable to road transfers than helo. Use of airway examination via our ambu A scope with topical anaesthetic is a good adjunct to standard clinical assessment. Involvement of ENT in the ED and interhospital transfers can lend weight to a decision not to intubate where receiving teams are requesting intubation. Taking photos when assessing the patient is recommended and discussion with the Senior Retrieval Consultant where decision is in doubt. Awareness of the NSW Burns retrieval guideline was highlighted.

NSW Burns Transfer Guidelines



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