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Difficulty: MediumInitial Stabilization and Triage

A 3434-year-old firefighter is brought to the emergency department after being extricated from an enclosed structural fire. He was trapped for approximately 1515 minutes. The patient is visibly agitated and has a hoarse voice with a brassy cough. Examination reveals singed nasal vibrissae and carbonaceous sputum in the oropharynx. There are full-thickness burns involving the anterior chest, abdomen, and bilateral upper extremities, covering approximately 36%36\% of his total body surface area. Vital signs include a blood pressure of 88/5688/56 mm Hg, a pulse of 132132/min, and respirations of 2828/min. Pulse oximetry shows 94%94\% on a non-rebreather mask. Which of the following interventions are indicated immediately? (Select all that apply)

  1. Perform prompt endotracheal intubationAnswer
  2. Initiate aggressive intravenous crystalloid resuscitationAnswer
  3. C
    Arrange immediate transfer to a regional burn center prior to further intervention
  4. D
    Administer intravenous furosemide to mitigate the risk of pulmonary edema
  5. E
    Obtain a computed tomography scan of the chest to evaluate the extent of inhalation injury

Answer

Perform prompt endotracheal intubation AND Initiate aggressive intravenous crystalloid resuscitation.
The correct answers address the patient's two immediate life-threatening issues: impending airway loss and severe shock. The patient exhibits classic signs of a thermal inhalation injury (hoarseness, singed nasal hairs, carbonaceous sputum, and entrapment in an enclosed fire). Inhalation injuries cause progressive upper airway edema that can rapidly result in complete airway obstruction; therefore, securing a definitive airway via prompt endotracheal intubation is the immediate priority. Simultaneously, the patient's extensive full-thickness burns and hemodynamic instability (hypotension, tachycardia) indicate burn shock, necessitating immediate, aggressive intravenous fluid resuscitation with crystalloids (e.g., lactated Ringer solution) to restore and maintain tissue perfusion.

Step-by-Step Solution

1
Assess the patient's airway and risk for impending compromise.
Hoarse voice, brassy cough, singed vibrissae, and carbonaceous sputum strongly indicate inhalation injury.
Thermal injury to the upper airway leads to progressive edema, which can rapidly obliterate the airway, making later intubation impossible.
2
Evaluate the patient's hemodynamic status.
Hypotension (88/5688/56 mm Hg) and tachycardia (132132/min) in the setting of extensive full-thickness burns indicate severe burn shock.
Massive fluid shifts occur immediately following severe burn injuries due to increased capillary permeability, requiring urgent volume replacement.
3
Determine the appropriate immediate interventions based on the primary survey (ABCs).
Both airway protection and circulatory support must be initiated simultaneously.
Delaying either of these initial stabilization steps increases the risk of mortality in major polytrauma and burn presentations.

Key Concept

Initial stabilization of severe thermal and inhalation injuries requires simultaneously securing a definitive airway to prevent obstruction from edema and initiating aggressive intravenous fluid resuscitation to treat burn shock.
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Topics

Initial Stabilization and Triage

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