Management of inhalation injury and its effect on patients’ outcome in burns unit Kenyatta national hospital

Abstract

Background: Smoke inhalation is responsible for pulmonary injury common in burn victims and is a major contributing factor to the morbidity and mortality of burn victims both in the hospital and at incident sites. Inhalation burn injury predisposes burn victims to a major risk for permanent pulmonary dysfunction and however small, should be central to the management of burns. Cleaning up of the patients’ lungs after smoke exposure is not a priority yet it may be of significant value in preventing progress of inhalation injury and mortality following the rising incidents of fire disasters and high mortality recently reported in Kenya. Much of the care given to burns patients in Kenya has overlooked the inhalation injury and concentrated on airway maintenance as in general critical care patients. Endotracheal intubation traumatizes the airway of patients with inhalation injury more easily than it would to an intact airway. This calls for attention even after extubation since it might be a contributing factor to high mortality among burns patients. Occurrence of tracheal stenosis post extubation was reported 3(7.9%; n=38) and its prevention requires attention. Main objective: The aim of this study was to determine the relationship between the management of inhalation injury and the outcome of patients in Burns Unit, KNH. Study design: This was a longitudinal descriptive study with both quantitative and qualitative components. A sample size of 84 patients with inhalation injury was purposively selected from Burns unit, KNH and study duration was three months. Key informants were purposively selected and interviewed for in-depth information on management of inhalation injury. A checklist of variables, a questionnaire and an interview guide were used. Data was managed using SPSS soft ware version 20.0 while statistical inferences were based on p-values and ODDS ratio. Results: Diagnosis of inhalation injury was mainly clinical, based on history of the incidence and presenting signs and symptoms. Other parameters like chest X-ray were primarily used to confirm position of central lines and only 7 (8.3%) patients had this done. Grading inhalation injury and determining levels of toxicity were not part of the diagnosis. Purpose of intubation was to secure the airway and tracheal lavage for removing excess secretions. However,12 (64.7%) nurses reported using tracheal lavage to remove smoke from the lungs while 5 (29.4%) reported smoke is never removed. Literature recommends broncho alveolar toileting for smoke removal and as such tracheal lavage (dry or wet) is not effective to remove soot and carbonaceous particles from the base of lungs. This might explain the deranged arterial blood gas results reported in majority 23 (39.4%) of the patients who died during research period.Majority 27 (69.2%) of deaths occurred during the first week and arterial blood gas analysis showed 13 (15.5%; n=84) of patients with hypoxemia. Intubation was found to be significant in relation to mortality with (p-value 0.0001) but in relation with other significant interventional parameters, it was not significant (p-value 0.63). Use of steroids had no significant relationship with mortality (p-value 0.322). Assessment of carbon monoxide blood levels was recommended as a guide to oxygenation of individual patients in managing inhalation injury. Also, a documented standardized protocol of managing inhalation injury was recommended to enhance uniformity in decision making and reduce personal discretions.