A 45-year-old man is rescued from a house fire. He has facial burns, singed nasal vibrissae, carbonaceous sputum, a hoarse voice, and has developed inspiratory stridor. His SpO2 is 96% and chest is clear. The most appropriate immediate management step is:

• A Early endotracheal intubation ✓
• B Nebulised bronchodilators and observe for 24 hours
• C Heliox therapy via face mask
• D Fibreoptic laryngoscopy only if stridor worsens

Explanation

Hoarseness, stridor, singed nasal hair and carbonaceous sputum indicate thermal and smoke injury to the upper airway. Oedema progresses rapidly over hours and can cause sudden complete obstruction, so early endotracheal intubation is indicated once hoarseness or stridor appears, before oedema makes intubation difficult. Oxygen saturation is unreliable here because carbon monoxide poisoning keeps pulse oximetry falsely reassuring. Observation, heliox or delayed laryngoscopy risk a lost airway.

Reference: ATLS Student Course Manual, American College of Surgeons, 10th ed.

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Written and medically reviewed by the StethoPrep medical team.