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Difficulty: MediumSurgical and Procedural Interventions

An emergency medical services unit brings a 36-year-old male to the trauma center following prolonged extraction from a burning residential building. On primary survey, the patient is highly agitated and in severe respiratory distress, demonstrating vigorous accessory muscle use and audible biphasic stridor. His voice is notably hoarse, and there is visible carbonaceous material within the oropharynx. Physical examination reveals leathery, contracted, and painless full-thickness burns circumferentially involving his entire anterior and posterior chest wall, as well as both upper extremities. Vital signs are temperature 37.1°C (98.8°F), heart rate 132/min, blood pressure 88/58 mm Hg, and respiratory rate 36/min. Pulse oximetry shows 91% on a 15 L/min non-rebreather mask. Radial pulses are absent on the left and evaluated only by Doppler ultrasound on the right. His chest excursion is severely limited during maximal inspiratory effort, resulting in shallow tidal volumes. Which of the following procedural interventions are emergently indicated? (Select all that apply)

  1. Endotracheal intubationAnswer
  2. Bedside escharotomy of the chest and upper extremitiesAnswer
  3. C
    Bilateral upper extremity fasciotomies
  4. D
    Transfer to a hyperbaric oxygen chamber
  5. E
    Computed tomography angiography of the chest and neck

Answer

The emergently indicated procedural interventions are endotracheal intubation and bedside escharotomy of the chest and upper extremities.
The correct procedural choices directly address the patient's immediate life threats. Stridor and hoarseness in the setting of a house fire indicate supraglottic thermal injury and impending airway obstruction, making endotracheal intubation an immediate necessity. Furthermore, the leathery, circumferential full-thickness burns of the chest act as a tourniquet, severely restricting chest wall expansion and preventing adequate tidal volumes. This restrictive physiology, combined with the loss of distal pulses in the arms, makes bedside escharotomy (incising the burnt tissue to allow expansion) the essential concurrent procedural intervention.

Step-by-Step Solution

1
Evaluate the patient's airway and breathing status.
The patient exhibits stridor, hoarseness, carbonaceous sputum, and respiratory distress.
These findings indicate upper airway edema from thermal inhalation injury, necessitating immediate endotracheal intubation to secure the airway before complete obstruction occurs.
2
Assess chest wall mechanics and peripheral perfusion.
The patient has circumferential chest burns causing severely limited chest excursion, and circumferential arm burns with absent/weak distal pulses.
Full-thickness thermal burns form an inelastic eschar. On the chest, this creates a restrictive defect preventing ventilation despite intubation. On the extremities, it causes secondary ischemic compromise. Both require emergent bedside escharotomy.

Key Concept

Immediate procedural management of severe thermal inhalation injury and circumferential full-thickness burns requires rapid airway securement (intubation) and mechanical release of restrictive eschar (escharotomy) to restore ventilation and perfusion.
Estimated Time:1m 30s
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Topics

Surgical and Procedural Interventions

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