What is the most appropriate route for securing the airway in a patient with face, neck, and upper chest burns, inhalation injury, and airway obstruction, presenting with hypoxemia (oxygen saturation less than 90%)?

Airway Management in a Burn Patient with Inhalation Injury

Orotracheal intubation (Option B) is the most appropriate route for securing the airway in this burn patient with inhalation injury, airway obstruction, and hypoxemia. 1

Rationale for Orotracheal Intubation

• Orotracheal intubation is considered the gold standard for emergency airway control in burn patients with inhalation injury, providing definitive airway management in the face of progressive airway edema 1, 2
• The patient's presentation with face, neck, and upper chest burns, inhalation injury, airway obstruction, and hypoxemia (SpO2 <90%) indicates an urgent need for definitive airway management to prevent further deterioration 1
• Modified rapid sequence intubation (RSI) via the orotracheal route allows for controlled, rapid securing of the airway while minimizing the risk of aspiration in this emergency situation 1

Technical Considerations

• An uncut tracheal tube should be used to accommodate subsequent facial swelling that will likely develop in this burn patient 1
• Videolaryngoscopy, if available, is recommended to increase first-pass success in this challenging airway scenario 1
• A bougie should be used to facilitate intubation if direct laryngoscopy is employed 1
• The patient should be positioned with the head elevated if possible, followed by thorough pre-oxygenation before proceeding with the modified RSI 1

Why Other Options Are Less Appropriate

• Nasotracheal intubation (Option A) is not recommended in this emergency scenario due to potential trauma to the nasal passages, increased risk of bleeding, and technical difficulty in an emergency situation 2
• Surgical cricothyroidotomy (Option C) should be reserved as a rescue technique when orotracheal intubation fails, not as a first-line approach 1, 3
• Tracheostomy (Option D) is more technically complex, time-consuming, and carries higher complication risks compared to orotracheal intubation in an emergency setting 4, 3

Special Considerations

• Having rescue devices and surgical airway equipment (for cricothyroidotomy) immediately available is essential as backup in case orotracheal intubation fails 1
• Carbon monoxide and cyanide poisoning may be present in this fire victim, which can worsen tissue hypoxia despite normal oxygen saturation readings 1
• Large volume fluid resuscitation will likely worsen airway swelling, making early definitive airway management crucial 1
• After securing the airway, a gastric tube should be inserted as this may become difficult later due to facial swelling 1
• Succinylcholine should be avoided from 24 hours post-injury to prevent hyperkalemia 1

Management Algorithm

1. Position the patient appropriately (head-up if possible) 1
2. Pre-oxygenate thoroughly 1
3. Proceed with modified RSI for orotracheal intubation 1
4. If orotracheal intubation fails after multiple attempts, proceed to surgical airway (cricothyroidotomy) 1, 3
5. After securing the airway, insert a gastric tube 1
6. Continue with burn management protocols including fluid resuscitation 1