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Difficulty: MediumInitial Stabilization and Triage

Paramedics rush a 42-year-old man into the resuscitation bay after extricating him from a burning residential garage. En route, the patient was agitated but spontaneously breathing. His wife, who escaped unharmed, reports that he has a history of type 2 diabetes mellitus but is otherwise healthy. Upon arrival, he remains awake but is visibly distressed and clutching his neck. He communicates with a hoarse voice and repeatedly coughs up dark, carbonaceous sputum. Physical examination reveals soot in the posterior oropharynx, singed nasal vibrissae, and partial-thickness burns over the anterior neck and chest. Vital signs include a temperature of 37.1°C (98.8°F), blood pressure of 118/74 mm Hg, heart rate of 115/min, and respiratory rate of 28/min. Pulse oximetry displays 99% on room air. Auscultation of the neck demonstrates audible inspiratory stridor. Which of the following is the most appropriate next step in management?

  1. Perform endotracheal intubationAnswer
  2. B
    Apply 100% oxygen via a non-rebreather face mask and observe
  3. C
    Obtain an arterial blood gas for carboxyhemoglobin analysis
  4. D
    Order a portable chest radiograph to assess for lung injury
  5. E
    Request an urgent otolaryngology consultation for airway evaluation

Answer

The correct action is to perform immediate endotracheal intubation.
The patient's presentation of hoarseness, singed facial hair, carbonaceous sputum, and especially inspiratory stridor strongly indicate severe thermal burns to the upper airway. This results in progressive, massive edema that can rapidly lead to complete airway obstruction. In such cases, the immediate priority is to secure a definitive airway via endotracheal intubation before the swelling worsens and makes the procedure anatomically impossible.

Step-by-Step Solution

1
Evaluate the patient's airway patency and respiratory effort.
The patient exhibits hoarseness, carbonaceous sputum, and inspiratory stridor.
The primary survey begins with the airway (A). These specific physical findings are hallmark signs of thermal inhalation injury to the upper airway.
2
Determine the risk of impending clinical deterioration.
Recognize that thermal injury causes massive, rapidly progressive fluid shifts and mucosal edema.
Although the airway is currently partially patent (the patient is talking), edema can progress in minutes to cause complete occlusion, rendering later intubation attempts impossible.
3
Select the most appropriate initial stabilization intervention.
Definitive airway management via endotracheal intubation is prioritized over all diagnostics.
Airway stabilization must precede imaging, blood tests, and subspecialty consultations in an unstable patient.

Key Concept

Early definitive airway management in thermal inhalation injury
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Topics

Initial Stabilization and Triage

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