What is the best route for securing the airway in a patient with facial, neck, and upper chest burns, inhalation injury, and airway obstruction, who is currently intubated with an airway tube and has hypoxemia?

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, 2

Rationale for Orotracheal Intubation

• The patient presents with classic features of thermally-induced airway obstruction including inhalation injury, airway obstruction, and hypoxemia (SpO2 <90%), which are clear indications for urgent definitive airway management 1
• Face, neck, and upper chest burns suggest potential for progressive airway edema and worsening obstruction, making immediate definitive airway management essential 2
• Modified rapid sequence intubation (RSI) with orotracheal intubation is the most appropriate technique for securing the airway in burn patients with inhalation injury 1, 2

Why Orotracheal Intubation is Superior to Other Options

• Nasotracheal intubation (Option A): Should be avoided in this scenario as facial burns may distort anatomy, and the procedure could cause additional trauma and bleeding in already compromised tissues 1
• Surgical cricothyroidotomy (Option C): Should be reserved as a rescue technique when orotracheal intubation fails, not as a first-line approach in a patient who can still be intubated orally 1, 3
• Tracheostomy (Option D): Too time-consuming for an emergency situation with immediate airway compromise; associated with higher complication rates compared to orotracheal intubation in acute settings 1

Technique Recommendations

• Use videolaryngoscopy if available to increase first-pass intubation success 1, 2
• Position the patient appropriately (head-up if possible) to maximize pre-oxygenation and improve laryngoscopic view 1, 2
• Use a bougie to facilitate intubation if direct laryngoscopy is used 1
• Select an uncut tracheal tube to allow for subsequent facial swelling 1, 2
• Confirm tube placement with capnography and clinical assessment 1

Special Considerations in Burn Patients

• Carbon monoxide and cyanide poisoning may be present, which can worsen tissue hypoxia despite normal oxygen saturation readings on pulse oximetry 1
• Large volume fluid resuscitation will worsen airway swelling, making early definitive airway management crucial 1, 2
• After securing the airway, insert a gastric tube as this may become difficult later due to facial swelling 2
• Avoid succinylcholine from 24 hours post-injury to avoid hyperkalemia 1, 2

Backup Plan

• Have rescue devices and surgical airway equipment immediately available 2, 3
• If orotracheal intubation fails after limited attempts (maximum 3), be prepared to move to a surgical airway (cricothyroidotomy) without delay 1, 3
• Avoid multiple failed intubation attempts as they can cause additional trauma to the upper airways and prolong hypoxia 4