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CASE PRESENTATION

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A 57-year-old man was brought to the emergency department by Emergency Medical Service (EMS) with burns to the head, face, and chest secondary to smoking while on 2 L·min−1 of oxygen via nasal cannula for COPD. There was no reported loss of consciousness. Albuterol was nebulized, an 18-gauge IV was placed and IV fluids and fentanyl administered. Upon arrival to the emergency department, the patient is awake and alert but in obvious pain with mild respiratory distress. He speaks in full sentences with a hoarse voice. His blood pressure is 152/91, with a heart rate of 112 bpm, breathing 26 times per minute, with an oxygen saturation of 97% while receiving oxygen by non-rebreather, and his temperature is 36.8°C. Lungs sounds are remarkable for diffuse wheezing with fair air movement.

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The patient is noted to be 6′3″ tall and weighs 110 kg. Further rapid evaluation reveals deep partial to full thickness burns to the peri-oral region, anterior neck, and upper chest wall. Despite these burns, the patient still has full mouth opening greater than three finger breaths, with a thyromental distance of three finger breaths and the larynx is more than two finger breaths below the hyoid. The Mallampati score is I. The nasal hairs are singed and there is mild erythema to the tongue and posterior pharynx with a small intact blister noted. He has full range of motion of the neck but laryngeal landmarks are difficult to appreciate due to a combination of obesity and burns.

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PATIENT ASSESSMENT

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What Are the Airway Evaluation Considerations in This Patient?

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Airway evaluation and management for the acute burn patient builds on standard airway evaluation and management with the added complexities associated with both inhalational and external burns, as well as the potential for coexisting toxicological injuries from carbon monoxide and cyanide. In addition, it is critical to consider the potential for the dynamic evolution of inhalational and topical burn injury; an airway initially at low risk for difficulty can progress and become very difficult if edema ensues and leads to obstruction.

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This patient currently has predictors of moderate difficulty in all four dimensions of airway management: BMV, direct and indirect laryngoscopy, extraglottic device placement, and surgical airway rescue. The likelihood of toxicological issues is low in this case given there was no prolonged smoke exposure, no loss of consciousness, and mental status is currently normal with relatively reassuring vital signs.

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What Are Signs and Symptoms of Inhalational Injury?

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Inhalational injury is a major contributor to the morbidity and mortality associated with burns and is a critical component to the evaluation and management of the airway. Inhalational injury is primarily associated with fires in enclosed space, especially when there is loss of consciousness. Signs and symptoms of inhalational injury may include dyspnea, hoarseness, hot potato voice, stridor, respiratory ...

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