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Difficulty: EasyInitial Stabilization and Triage

A 55-year-old man is brought to the emergency department by firefighters after being rescued from an enclosed structural house fire. The patient complains of a severe sore throat, painful swallowing, and shortness of breath. Vital signs are temperature 37.2°C (99.0°F), blood pressure 135/85 mm Hg, pulse 115/min, and respirations 24/min. Oxygen saturation is 96% on room air. Physical examination reveals singed facial hair, carbonaceous sputum in the oropharynx, and bilateral scattered wheezes. When the patient speaks, his voice is noticeably hoarse, and audible inspiratory stridor is present. Which of the following is the most appropriate next step in the management of this patient?

  1. Perform immediate endotracheal intubationAnswer
  2. B
    Obtain a portable chest radiograph
  3. C
    Administer 100% oxygen via non-rebreather mask and admit to the intensive care unit
  4. D
    Obtain an arterial blood gas to assess for carbon monoxide toxicity
  5. E
    Administer nebulized racemic epinephrine

Answer

The most appropriate next step in management is to perform immediate endotracheal intubation.
The correct response involves immediately securing a definitive airway. This patient presents with multiple classic signs of thermal upper airway injury resulting from smoke and heat inhalation, including singed facial hair, carbonaceous sputum, a hoarse voice, and inspiratory stridor. Thermal injury causes massive and rapid upper airway edema. When a patient develops stridor, it indicates that the airway is already significantly narrowed and complete obstruction is imminent. Because the swelling is progressive, early endotracheal intubation is required to secure the airway before it becomes completely occluded and impossible to intubate.

Step-by-Step Solution

1
Assess the patient's airway patency and respiratory status as the primary survey.
The patient demonstrates singed facial hair, carbonaceous sputum, hoarseness, and inspiratory stridor.
These findings are pathognomonic for upper airway thermal injury and severe mucosal edema.
2
Determine the immediate threat to life.
The presence of stridor and hoarseness indicates impending complete airway obstruction.
Thermal injury causes progressive edema that can rapidly completely occlude the airway, making later intubation impossible.
3
Select the most appropriate initial stabilization intervention.
Immediate endotracheal intubation is required.
A definitive airway must be established prior to diagnostic testing or secondary interventions.

Key Concept

Patients with thermal inhalation injury presenting with high-risk signs (hoarseness, stridor, singed facial hair, carbonaceous sputum) require early, prophylactic endotracheal intubation to prevent complete airway obstruction from progressive edema.
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Topics

Initial Stabilization and Triage

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