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Difficulty: MediumInitial Stabilization and Triage

Emergency medical services bring a 35-year-old man to the emergency department after he was rescued from a closed-space house fire. The paramedics report that he was trapped in a smoke-filled room for several minutes before being extricated. Upon arrival, the patient is agitated, has a hoarse voice, and is coughing up carbonaceous sputum. Vital signs are temperature 37.2°C (99.0°F), blood pressure 118/76 mm Hg, pulse 112/min, and respirations 26/min. Pulse oximetry shows 98% on 15 L/min of oxygen via a non-rebreather mask. Physical examination reveals singed nasal hairs and soot in the oropharynx. The lungs are clear to auscultation bilaterally. There are superficial burns on his bilateral forearms, accounting for approximately 9% of his total body surface area. Which of the following is the most appropriate next step in the management of this patient?

  1. Endotracheal intubationAnswer
  2. B
    Measurement of arterial carboxyhemoglobin
  3. C
    Transfer to a regional burn center
  4. D
    Fiberoptic bronchoscopy
  5. E
    Portable chest radiography

Answer

Endotracheal intubation
The correct answer is endotracheal intubation. The primary survey in any trauma or burn patient begins with assessing the airway. This patient exhibits multiple high-risk indicators of upper airway thermal injury, including a closed-space fire exposure, hoarseness, singed nasal hairs, and carbonaceous sputum. Thermal injury to the supraglottic structures causes progressive edema that can rapidly lead to complete airway obstruction. Because swelling can make later intubation extremely difficult or impossible, the standard of care is early, prophylactic endotracheal intubation while the airway is still patent, regardless of the patient's current oxygen saturation.

Step-by-Step Solution

1
Identify the patient's mechanism of injury and presenting symptoms.
The patient was in a closed-space fire and presents with agitation, a hoarse voice, singed nasal hairs, and carbonaceous sputum.
These findings are classic clinical indicators of upper airway thermal injury.
2
Evaluate the patient's current hemodynamic and respiratory status.
The patient is tachycardic and tachypneic, but currently maintaining oxygen saturation on high-flow oxygen.
Although the airway is currently patent, thermal injury causes progressive, severe edema that can rapidly lead to complete airway obstruction.
3
Determine the priority of intervention based on the primary trauma survey (ABCs).
Airway management is prioritized before any diagnostic testing or disposition decisions.
Prophylactic intubation must be performed early, as delaying until stridor or respiratory failure develops can result in a lost airway requiring emergent surgical intervention.

Key Concept

Patients with clinical signs of inhalation injury (e.g., hoarseness, singed nasal hairs, carbonaceous sputum) require early, prophylactic endotracheal intubation to secure the airway before progressive thermal edema causes complete obstruction.
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Topics

Initial Stabilization and Triage

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