41- year-old woman is brought to the emergency department after a fire at the apartment building where she lives. She was trapped for several minutes by the fire and had to be rescued by fire fighters. She complains of pain in her face, neck and arms. Her only medical problem is GERD. Temperature is 37.4C (99 F), blood pressured is 138/80mmHg, pulse is 125/min, and respirations are 20/min. Pulse oximetry is 100% on a nonrebreather mask. She is awake, alert, and oriented. There are some superficial partial-thickness burns to the patient’s face, anterior neck, and bilateral upper extremities. Her hair is singed. Her voice is normal, her lungs are clear, and no stridor is present. Pulses are normal. Carboxyhemoglobin level is 15%. Intravenous fluids and opioids are administered.
What is the best next step in management of this patient?
A) Perform bedside fiberoptic laryngoscopy
B) Perform bedside tracheostomy
C) Perform immediate orotracheal intubation
D) Wean oxygen to maintain oxygen saturation < 92%
This patient should undergo a bedside fiberoptic laryngoscopy as she shows signs concerning for inhalation injury. Fiberoptic laryngoscopy uses a flexible and thin laryngoscope and can be performed rapidly without sedation. This would allow for visualization of supraglottic structures. If blistering, oropharyngeal erythema, or soot is present, intubation would be strongly considered. If all are absent, continue observation and supportive care.
Concerning features of inhalation injury include smoke exposure in enclosed space, singed hair, facial burns, carbonaceous sputum, or wheezing. Strong indicators for airway injury include: oropharyngeal blistering or edema, retractions, respiratory distress, or hypoxia.
These patients are managed by 100% oxygen to displace CO. Stable patients with concerning features, but not strong indicators of inhalation injury should have a bedside fiberoptic laryngoscopy. Finally unstable patients should undergo endotracheal intubation. Tracheostomy may be indicated in burn patients if long-term mechanical ventilation is anticipated. Oxygen is to be weaned to <92% for burn patient is at risk for ARDS, however it is important to initially have 100% oxygenation to treat carbon monoxide poisoning. There is no role for NIPPV in this patient.
Key Learning Point
Fiberoptic laryngoscopy should be considered prior to intubation for patients with concerning features of inhalation injury and stable.
