Scenario – A 34 year old male has suffered injuries to his face following an explosion from a BBQ gas cannister in a difficult to access location some hours drive from the nearest hospital.
 
Scene – Team winched in due to poor access. Arrived with stretcher, primary packs, monitoring and O2 cylinder. Single road crew had accessed patient c.5mins prior to our arrival. Single male casualty lying semi-recumbant near an unlit BBQ with debris strewn nearby. The incident occured more than an hour ago. Paramedic is applying cool water dressings and O2 via a NRB mask.
 
Patient – GCS 15, in pain, agitated. Extensive full thickness and partial thickness burns to face, neck and upper chest covering c.40% BSA. Dysphonia, stridor and wheeze audible. Soot, singing and erythema in evidence to face and mucosal surfaces. RR 20, sO2 90% on 8L oxygen, HR 140, BP 165/85. Poor chest expansion.
 
Challenges – Pain management. Patient desaturates if laid flat. Need for airway securing recognised but with recognition of both potential difficult anatomy due to oedema and soiling and liklihood of rapid desaturation on induction. Briefing of Plans A, B and C with marking of airway and both LMA and surgical airway kit opened and laid ready. Intubation impossible orally, LMA failing to ventilate, patient becomes bradycardic and hypoxic before airway secured with scalpel-finger-bougie-cricothyroidotomy technique performed.

Learning points from debrief for clinical practice :

The rare but significant population of patients in whom a surgical airway is both likely to be more difficult AND more likely to be required due to progressing pathology, distance to hospital and austere location devoid of additional help/resource.

The decision to use a depolarising relaxant may lead to problems following a failed oral intubation. Consideration given to primary use of non-depolarising relaxant at induction when there is no timely alternative to tracheal intubation before transporting the patient.

Communicate early with all involved the likely trajectory of your patient and what your plans and alternate plans will be as the airway management progresses.

Discussion given to eventual need for escharotomies but in this patient the airway presenting the single most important threat of ventilatory failure, and the unlikelihood of performing an escharotomy on the awake patient!

Thanks to Chloe(doc), Hugh(para), Andrew(actor), Brian (SRC), Luke (STAR)