A 34-year-old man is brought to a rural emergency department after being rescued from a burning building where he was trapped for a prolonged period. The patient reports a headache and dizziness. Temperature is 36.9 C (98.6 F), blood pressure is 90/60 mm Hg, pulse is 100/min, and respirations are 26/min. Oxygen saturation is 100% on a nonrebreather mask. The patient is awake and alert. Diffuse blistering of the oropharyngeal mucosa is present. Mild wheezing is noted to auscultation of the lungs. Deep partial- and full-thickness burns are present over 45% of the body, including the face, neck, arms, and legs. There is a circumferential deep partial-thickness burn to the left lower arm. Radial pulses are present. The abdomen is soft and nondistended. Blood carboxyhemoglobin concentration is 35%. Intravenous fluid resuscitation is initiated per standard burn protocol. Which of the following is the best next step in management of this patient?
Inhalation injury | |
Pathophysiology |
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Concerning |
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Strong indicators |
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Management |
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CO = carbon monoxide. | |
Management of patients with burn injury begins with stabilization of the airway and breathing. For those in fires, this includes immediate administration of 100% oxygen to treat presumed carbon monoxide (CO) poisoning and early assessment for inhalation injury because thermal injury to the airway can lead to progressive airway edema that may eventually preclude intubation. This patient has several features concerning for inhalation injury, including:
Other concerning features include singed hair and carbonaceous sputum.
The presence of concerning features should prompt careful examination for findings such as oropharyngeal blistering and respiratory distress, which are strong indicators of airway injury, concerning for high risk for progressive airway edema. This patient has diffuse oropharyngeal blistering consistent with severe airway injury; therefore, he should receive endotracheal intubation now, before it becomes more difficult or, potentially, impossible. (In stable patients with concerning features but no strong indicators, bedside fiberoptic laryngoscopy can be considered to better visualize the airway.)
An additional consideration is this patient's need for transfer to a facility that can provide treatment for his symptomatic (eg, headache, dizziness) and severe (eg, carboxyhemoglobin level >25%) CO poisoning. Severe CO poisoning typically requires hyperbaric oxygen therapy, which should be administered quickly (goal: <6 hr) to decrease myocardial injury and long-term neurologic sequalae. Transfers take time, when airway edema and obstruction can occur, so endotracheal intubation should be performed prior to transfer (Choice E).
(Choice A) Patients with burns are at high risk for infection, especially by Pseudomonas aeruginosa. However, systemic antibiotics are not used prophylactically, even in severe burns, because they do not prevent burn sepsis and may instead select for more aggressive, antibiotic-resistant bacteria.
(Choice B) Burn wound débridement should eventually be performed, but airway management (eg, intubation) is a higher priority in this patient with strong evidence of airway injury (eg, diffuse oropharyngeal blistering). In addition, débridement likely requires significant sedation and opioid administration, which could further compromise his airway.
(Choice D) A left arm escharotomy may eventually be indicated given this patient's circumferential left arm burn. However, the arm is currently well perfused (eg, normal radial pulse), and it generally takes hours to days for enough edema to develop beneath the constrictive eschar such that it compromises perfusion. Securing the airway takes priority.
Educational objective:
Initial management of patients with burns includes administration of 100% oxygen and early assessment of the airway. In patients with strong indicators of inhalation injury (eg, oropharyngeal blistering), endotracheal intubation should be performed.