A 34-year-old man is brought to the emergency department after being rescued from a burning building. His temperature is 36.9 C (98.6 F), blood pressure is 90/60 mm Hg, pulse is 100/min, and respirations are 28/min. Examination shows second and third degree burns over 15% of his body. His oropharynx shows erythema and scattered blisters. His lungs are clear to auscultation and his abdomen is soft and nondistended. His blood carboxyhemoglobin concentration is 20%. Which of the following is the best management for this patient?

Question

A 34-year-old man is brought to the emergency department after being rescued from a burning building.  His temperature is 36.9 C (98.6 F), blood pressure is 90/60 mm Hg, pulse is 100/min, and respirations are 28/min.  Examination shows second and third degree burns over 15% of his body.  His oropharynx shows erythema and scattered blisters.  His lungs are clear to auscultation and his abdomen is soft and nondistended.  His blood carboxyhemoglobin concentration is 20%.  Which of the following is the best management for this patient?

Quizplus · Accepted Answer

Explanation: The initial management of burn injuries is identical to the management of all trauma patients: airway, breathing and circulation must always be secured first. Burn patients are at high risk for respiratory compromise because the supraglottic airway, which efficiently exchanges heat with inhaled air, is very susceptible to direct thermal injury and acute obstruction by edema and blistering. (In contrast, the subglottic airway is protected from injury by reflexive closure of the vocal cords upon exposure to extremely hot air.) Clinical indicators of thermal and smoke inhalation injury include: Burns on the face Singeing of the eyebrows Oropharyngeal inflammation Blistering or carbon deposits Carbonaceous sputum Stridor Carboxyhemoglobin level >10% History of confinement in a burning building. All burn victims should be treated initially with high-flow oxygen via a non-rebreather mask, although caregivers should maintain a low threshold for intubation in any patient with physical evidence of thermal damage to the upper airway. A key reason for early intubation is that progressive airway edema may preclude intubation later in the patient's clinical course, potentially necessitating an emergent surgical airway. (Choice A) High-dose corticosteroids are not used in the acute treatment of burn wounds. The diabetogenic and immunosuppressive effects of systemic steroids make them contraindicated in severely burned patients, who are already at high risk for metabolic derangement and immunosuppression as a result of their injuries. (Choice C) Prophylactic antibiotics are not indicated in the acute management of this patient. While burn patients are at high risk for infection, especially by Pseudomonas aeruginosa, treatment in the acute setting should focus on restoration of airway, breathing and circulation. Pseudomonas aeruginosa (Choice D) Fluid restriction is never indicated in burn patients. Following severe thermal burns, patients require significant volume replacement to compensate for fluid lost through their wounds as well as for a potential injury-related systemic inflammatory response (shock). (Choice E) N-acetylcysteine is the antidote for acetaminophen-induced hepatotoxicity. It is also used as a mucolytic agent in cystic fibrosis. There are case reports to suggest that this agent may also be of value in treating carbon monoxide poisoning, however this intervention would always come second to airway protection by intubation. Educational objective: In burn patients, clinical indicators of thermal inhalation injury to the upper airway and/or smoke inhalation injury to the lungs include burns on the face, singeing of the eyebrows, oropharyngeal inflammation/blistering, oropharyngeal carbon deposits, carbonaceous sputum, stridor, carboxyhemoglobin level >10%, or history of confinement in a burning building. The presence of ≥1 of these indicators warrants early intubation to prevent upper airway obstruction by edema.

A 34-Year-Old Man Is Brought to the Emergency Department After