Management of blast and inhalation injury

Key points

• All patients with facial burns may be suspected of having ‘difficult-to-control’ airways owing to smoke inhalation injury (SII). Many of them either have an incorrect diagnosis, or mild-to-moderate injury with unrecognised aggravating respiratory failure.

• For a diagnosis of inhalation injury, it is necessary to follow the patient closely for >48 h.

• Inhalation injury is a condition with different clinical presentations. Clinical follow-up is necessary to improve patient care, to help guide treatment and to provide clues for therapeutic interventions.

• Notwithstanding intensive care treatment including airway intubation and mechanical ventilation, many patients with severe inhalation injury remain under-treated.

Educational aims

• To discuss the initial approach and assessment of a patient with SII.

• To help the reader recognise different clinical pictures of inhalation injury.

• To outline management and discuss treatment.

Summary “Inhalation injury” describes a variety of insults caused by the aspiration of superheated gases, steam or noxious products of incomplete combustion. Inhalation injury involves the entire respiratory system. Early diagnosis based on history and physical examination, in addition to careful monitoring for respiratory complications, is mandatory. As there is no specific treatment for inhalation injury, management involves providing the necessary degree of support required to compensate for upper airway swelling and impairment in gas exchange. Airway intubation and mechanical ventilation may be required while the endobronchial and alveolar mucosa are regenerating.

Primary blast injury (BI) is caused by immediate pressure variations, which are the product of rapid sequences of compression and decompression. Secondary and tertiary BI include lesions caused when the subject is thrown against rigid structures or is hit by flying objects. Its diagnosis and therapy follows guidelines for emergency care.