1. Airway and Respiratory Support in Inhalation Injury

Inhalation injury is a dynamic process that evolves over the first 24 hours, characterized by progressive airway edema, bronchospasm, and the deposition of soot and debris. Proactive assessment and early, decisive airway control are critical to prevent the need for emergent, high-risk surgical airways and to mitigate downstream complications like ventilator-associated pneumonia and ARDS.

1.1 Indications for Endotracheal Intubation and Cricothyrotomy

The decision to intubate is clinical and should not be delayed for definitive diagnostic tests. Key indications for early intubation include:

• Physical signs: Significant facial or neck burns, singed nasal hairs, or soot in the oropharynx.
• Functional signs: Hoarseness, stridor, dyspnea, or wheezing.
• Physiologic compromise: Hypoxemia (SpO₂ < 90% on high-flow oxygen), altered mental status, or hemodynamic instability requiring resuscitation.

Cricothyrotomy is a rescue procedure reserved for the “cannot intubate, cannot ventilate” (CICV) scenario, which can occur when massive edema completely obstructs the laryngeal view.

1.2 Advanced Ventilation Strategies

Standard lung-protective ventilation (tidal volume ≤ 6 mL/kg predicted body weight, plateau pressure ≤ 30 cm H₂O) is the initial approach. However, severe inhalation injury can lead to refractory hypoxemia or barotrauma, necessitating advanced strategies:

• High-Frequency Oscillatory Ventilation (HFOV): Delivers very small tidal volumes at extremely high rates (3–15 Hz). It can improve oxygenation in refractory ARDS but requires specialized equipment and expertise.
• Airway Pressure Release Ventilation (APRV): Maintains a continuous high airway pressure with brief, periodic releases. This allows for spontaneous breathing, which can preserve diaphragmatic function and reduce sedation needs.
• Extracorporeal Membrane Oxygenation (ECMO): A rescue therapy for patients with life-threatening hypoxemia (e.g., PaO₂/FiO₂ < 80 mm Hg) or severe acidosis (pH < 7.20) despite maximal ventilator support. Its use requires careful consideration of the high bleeding risk from systemic anticoagulation.

1.3 Weaning Protocols and Pulmonary Hygiene

As airway edema subsides (often indicated by a cuff leak), a structured approach to weaning and pulmonary clearance is vital to prevent complications and expedite liberation from the ventilator.

• Weaning Readiness: Assess daily with spontaneous breathing trials (SBTs) on minimal pressure support (5–8 cm H₂O). Respiratory muscle strength can be assessed with a negative inspiratory force (NIF) measurement (goal > –30 cm H₂O). Consider early tracheostomy for patients expected to require prolonged ventilation (>14 days).
• Aggressive Pulmonary Hygiene: This is crucial for clearing soot and preventing airway cast formation. Key components include regular chest physiotherapy, deep suctioning, patient mobilization, and nebulized therapies. A common regimen is nebulized heparin (5,000 IU) and albuterol (2.5 mg) administered every 4 hours to reduce fibrin cast formation and bronchospasm.

2. ICU Prophylaxis and Infection Control

The profound hypermetabolic and hyperinflammatory state following a major burn creates a high risk for venous thromboembolism (VTE), stress-related mucosal disease, and invasive infections. Prophylactic strategies must carefully balance efficacy against the risks of bleeding and the development of antimicrobial resistance.

2.1 VTE Prophylaxis

Burn patients are hypercoagulable and often immobilized, mandating VTE prophylaxis. The choice of agent depends on renal function and bleeding risk.

2.2 Stress Ulcer Prophylaxis (SUP)

Large burns are a major risk factor for stress-related gastrointestinal bleeding. Prophylaxis should be initiated promptly but discontinued once the primary risk factor resolves.

• Proton Pump Inhibitors (PPIs): Agents like pantoprazole (40 mg IV daily) provide potent acid suppression but have been associated with a higher risk of C. difficile and pneumonia with long-term use.
• H₂ Receptor Blockers (H₂RAs): Agents like famotidine are also effective and may carry a lower risk of nosocomial infections.
• De-escalation: The initiation of enteral nutrition provides physiologic protection to the gastric mucosa. SUP should be discontinued once the patient is tolerating goal enteral feeds.

2.3 Topical and Systemic Infection Control

A cornerstone of modern burn care is preventing infection through meticulous wound care and antimicrobial stewardship.

• Topical Antimicrobials: The burn wound is managed with topical agents like silver sulfadiazine cream or silver-impregnated dressings. These are applied using aseptic technique and changed regularly to control local bacterial burden.
• Systemic Antibiotics: Systemic antibiotic prophylaxis is not recommended and promotes resistance. Systemic agents should be reserved for patients with clear clinical signs of invasive infection (e.g., cellulitis, hemodynamic instability, worsening organ dysfunction) and guided by culture data. Empiric therapy should cover common burn pathogens like Pseudomonas aeruginosa and Staphylococcus aureus, with rapid de-escalation based on sensitivities.
• Wound Management: Early surgical excision and grafting of full-thickness burns is a critical infection control measure, as it removes the necrotic tissue that serves as a nidus for infection.

3. Management of Iatrogenic Fluid-Related Complications

Aggressive fluid resuscitation is life-saving in the first 24-48 hours, but it inevitably leads to “fluid creep”—massive interstitial edema that can cause devastating complications. Vigilant monitoring for and prompt management of fluid overload are essential during the post-resuscitation phase.

3.1 Recognition and Treatment of Fluid Overload

Fluid overload should be suspected when the cumulative fluid balance becomes excessively positive (e.g., >250 mL/kg or >5 L in 24-36 hours) and is accompanied by signs of organ dysfunction.

• Recognition: Clinical signs include worsening pulmonary edema, rising central venous pressure (CVP), tense abdominal distension (indicating elevated intra-abdominal pressure), and circumferential extremity edema threatening perfusion.
• Diuretic Therapy: Once hemodynamically stable and post-resuscitation, diuretic therapy with loop diuretics like furosemide (IV bolus or continuous infusion) is the first-line treatment to mobilize interstitial fluid.
• Ultrafiltration: For patients with refractory fluid overload or concomitant acute kidney injury (AKI), continuous renal replacement therapy (CRRT) with slow continuous ultrafiltration (SCUF) allows for precise, controlled fluid removal without causing hemodynamic instability.

3.2 Electrolyte Imbalances

Massive fluid shifts, renal dysfunction, and cellular injury cause profound electrolyte disturbances that require frequent monitoring and careful replacement.

• Sodium: Both hyponatremia and hypernatremia are common. The rate of correction should be limited to ≤ 8 mEq/L over any 24-hour period to prevent osmotic demyelination syndrome.
• Potassium: Hypokalemia is frequent due to renal losses and intracellular shifts. Intravenous replacement should not exceed 10 mEq/hour via a peripheral line. Always correct hypomagnesemia concurrently, as it is required for renal potassium reabsorption.
• Phosphate, Calcium, Magnesium: Hypophosphatemia, hypocalcemia, and hypomagnesemia are common and can cause neuromuscular weakness, cardiac arrhythmias, and respiratory muscle failure. Follow institutional protocols for aggressive replacement.

3.3 Catheter-Related Bloodstream Infections (CRBSI)

Critically ill burn patients require multiple indwelling catheters, placing them at high risk for CRBSI. Prevention relies on strict adherence to evidence-based bundles.

• Insertion Bundle: Strict adherence includes hand hygiene, maximal sterile barriers during insertion, chlorhexidine skin preparation, and optimal site selection (preferring subclavian or internal jugular over femoral access).
• Maintenance Bundle: This includes a daily review of line necessity (“do we still need this catheter today?”), prompt removal of unnecessary lines, and aseptic technique for all dressing changes and access.
• Surveillance and Management: For any new, unexplained fever or sign of sepsis, paired blood cultures (one from the catheter, one from a peripheral site) should be drawn. If CRBSI is suspected, the catheter should be removed immediately and appropriate antibiotics initiated.

4. Multidisciplinary Goals-of-Care and Ethical Framework

The management of severe burns often involves high-risk, burdensome interventions. Transparent, compassionate communication that integrates prognosis, patient values, and ethical principles is essential to ensure that the intensity of care aligns with appropriate goals.

4.1 Risk–Benefit Analysis of High-Risk Interventions

Decisions to initiate or continue life-sustaining therapies like ECMO or CRRT require a formal, multidisciplinary review. This process should consider:

• Prognostic Factors: Objective factors include burn severity (TBSA), presence of inhalation injury, patient age, and pre-existing comorbidities. Survival scores can help inform, but should not dictate, decisions.
• Multidisciplinary Input: The burn surgeon, intensivist, pharmacist, palliative care specialist, and ethicist should collaborate to weigh the potential benefits of an intervention against its risks and burdens (e.g., bleeding on ECMO, immobility).
• Dynamic Reassessment: These discussions are not a one-time event. The patient’s clinical status and goals of care should be revisited regularly as their condition evolves.

4.2 Communication Strategies with Patients, Families, and Team

Structured communication frameworks can facilitate difficult conversations and ensure all parties have a shared understanding of the clinical situation and care plan.

• SPIKES Framework: A useful model for breaking bad news: Setting, Perception, Invitation, Knowledge, Empathy, Summary.
• Pharmacist’s Role: The clinical pharmacist plays a key role in clarifying complex medication regimens, explaining potential side effects, and outlining the monitoring plan for patients and families.
• Scheduled Conferences: Regular, scheduled family conferences with the entire multidisciplinary team promote consistency in messaging, build trust, and support shared decision-making.

4.3 Integration of Palliative and Supportive Care Principles

Palliative care is not synonymous with end-of-life care. Its early integration can improve quality of life for all severely ill patients, regardless of prognosis.

• Concurrent Care: Palliative care should be involved early to focus on aggressive symptom management (pain, anxiety, delirium) alongside curative-intent medical treatment.
• Transitioning Goals: When treatments are no longer providing benefit or are inconsistent with the patient’s goals, the focus may shift to comfort. This involves prioritizing symptom relief with therapies like continuous opioid and anxiolytic infusions.
• Ethical Foundation: All care decisions must be grounded in core ethical principles: respecting patient autonomy, promoting beneficence (acting in the patient’s best interest), and avoiding non-maleficence (avoiding harm from nonbeneficial treatments).