Soot, Stridor, and a Tight Airway at a House Fire
At 02:10, you are dispatched to a residential fire in Salmiya. A 42-year-old man was rescued from a smoke-filled bedroom by firefighters. He is seated on the curb, hoarse, repeatedly coughing, with black soot around his mouth and nose. Vital signs: RR 26 and labored, SpO2 91% on 15 L/min non-rebreather, HR 118, BP 138/86, GCS 14 (E3 V4 M6). He has singed nasal hairs, facial flushing, and a dry cough. You hear inspiratory stridor that worsens when he lies back. He has 18% TBSA partial-thickness burns to the face, anterior chest, and both forearms. There is no audible wheeze. The nearest hospital is 9 minutes away without ENT or anesthesia coverage; the burn center is 35 minutes away. Your service carries ketamine, rocuronium, video laryngoscopy, and supraglottic airways. The patient is anxious but cooperative and refuses a mask over his face.
1. What airway finding worries you most, and what is your airway plan for the next 10 minutes?
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The stridor, hoarseness, soot, and singed nasal hairs indicate impending upper airway obstruction from thermal and chemical edema. Stridor is an ominous late sign; waiting for complete obstruction would be a fatal error. Keep him upright, give 100% oxygen by non-rebreather if tolerated, and monitor continuously. Do not force him supine. Prepare for early RSI with a plan A/B/C/D: video laryngoscopy as plan A, supraglottic airway as rescue (though it will not bypass supraglottic edema), and surgical cricothyrotomy as failed-airway rescue. Use ketamine 1.5 mg/kg IV, reducing to 1 mg/kg if shock is present, and rocuronium 1.2 mg/kg. Preoxygenate for 3 minutes with BVM if he will tolerate it, suction secretions, and open the cricothyrotomy kit before the first attempt. If intubation fails after one optimized attempt, proceed to surgical airway rather than repeated attempts. Do not delay transport for the burn center before the airway is secure; if you cannot intubate, move rapidly to the nearest ED with anesthesia.
2. How would you ventilate him after intubation, and what targets would you use?
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Ventilate gently with a target SpO2 of 94-98%, ETCO2 35-40 mmHg, and tidal volume 6-8 mL/kg predicted body weight. Avoid hyperventilation: it reduces venous return and can worsen hypotension, and there is no evidence it improves outcome in inhalation injury. Do not target 100% SpO2 indefinitely, but in suspected carbon monoxide poisoning initial 100% oxygen is appropriate and pulse oximetry may read falsely normal, so treat on suspicion. If wheezing develops, give salbutamol through the circuit. If he remains acidotic, hypotensive, or has altered mental status after an enclosed-space fire with soot, consider cyanide toxicity and give hydroxocobalamin if available. Monitor for falling compliance or rising peak pressures, which may signal bronchospasm, edema, or pneumothorax. Secure the tube and confirm with waveform capnography.
3. Where should he be transported, and what are the key handover points?
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With a secure airway and no refractory shock, transport to the burn center because progressive airway edema and burn expertise outweigh the extra 26 minutes. If he becomes unstable or you cannot secure the airway, go to the nearest ED and arrange transfer after stabilization. Handover should include exposure time, enclosed-space fire, soot, stridor before intubation, intubation grade and tube size/depth, oxygen saturation and ETCO2, suspected CO or cyanide toxicity, TBSA and depth, fluid given by Parkland formula, tetanus status, and analgesia/sedation plan. Also report the inspiratory stridor and hoarseness so the receiving team anticipates a difficult airway and possible reintubation.