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* It’s 3:30 a.m. when a 52 year old male arrives to your academic ED, from the scene, with lethargy and facial burns. By report from paramedics, he was smoking in bed last night around midnight, wearing nasal oxygen (he has a history of COPD on continuous home oxygen) and suffered flash burns to his face. The patient did not notify EMS; however, his roommate called after smelling “something burning upstairs” and found him in bed. Per paramedics, he was arousable to physical stimuli only. No signs of blunt trauma. They did not place him in cervical precautions. They applied facemask oxygen with a bag reservoir at 10L/min flow. Vitals upon arrival: HR 104, RR 8, BP 132/75, Afebrile, Sa02 96%. He is somnolent and will not comply with verbal commands. Quick inspection reveals second degree burns over 80% of his anterior face and upper neck. Parts of his bushy beard have "melted" but much of it remains. His eyebrows, and nasal hairs are burned and the skin over both lips is peeling. His lung sounds are coarse with rhonchi bilaterally and a slightly prolonged expiratory phase. Upper airway auscultation reveals intermittent inspiratory noise, unclear whether it represents stridor. Oral examination is difficult as he bites down reflexively on anything place near his tongue and he won’t open his mouth on command. An IV is started and he is placed on the monitor. A portable CXR is pending. You think he needs intubation and request the difficult airway equipment be brought to the bedside (flexible bronchoscope, I-LMA, cricothyrotomy kit and a GlideScope are all available). The trauma surgeons arrive and request a 7.5 ETT be placed to facilitate bronchoscopy in the ICU. You examine his nares carefully and discover a deviated septum. You think the best way to intubate is fiberoptically through the nose. You apply afrin and topical anesthetic to both nostrils. Gentle attempts to pre-load a 7.5 and 7.0 ETT meet early, firm resistance although a 6.5 ETT squeezes through.

Of the choices provided, what is the best approach?

Don't be too cavalier! He may not require intubation at all. Request BL-PAP, wait to obtain an ABG and carboxyhemoglobin to confirm elevated CO2 and carbon monoxide levels before making final plans. At this point, only intubate if he becomes a "crash" airway.

I’m a skilled laryngoscopist and not concerned about airway difficulty. Plan is orotracheal intubation with rapid sequence intubation using a Mac 4 blade, an I-LMA and cricothyrotomy as back-up.

Fiberoptic orotracheal intubation. Prepare the airway with a 4% aqueous lidocaine neb and atomized lidocaine. Then, since he resisted oral examination, sedate with midazolam 4mg IV.

Fiberoptic nasal evaluation. Prepare the airway with glycopyrolate IV, intranasal afrin, 4% lidocaine neb, followed by atomized lidocaine to each nostril. Place 6.5 ETT in the right nare and perform fiberoptic evaluation of the airway passing the scope through the ETT. If the airway is swollen, attempt intubation with 6.5 ETT using the bronchoscope. If the airway is not swollen, pull out and perform orotracheal intubation with the GlideScope in order to place a larger ETT.

Too difficult and pressed for time. Immediate cricothyrotomy.

Blind intubation through I-LMA. Start a 4% aqueous lidocaine neb, atomized lidocaine, sedate with midazolam 4mg IV. Place I-LMA with blind attempt at intubation through the LMA.