一名大面積燒燙傷（TBSA 40%）病患在受傷後最初 24 小時（急診期）內，下列哪項評估結果最需要立即介入？
Which assessment finding in a client with a major burn injury (40% Total Body Surface Area) during the first 24 hours (emergent phase) requires the most immediate intervention?
- ASinged nasal hairs and hoarse voice✓ 正解鼻毛燒焦及聲音嘶啞
- BComplaints of pain rated 9 out of 10主訴疼痛程度為十分中的九分
- CUrine output of 20 mL/hr尿量為 20 mL/hr
- DPotassium level of 5.2 mEq/L鉀離子濃度為 5.2 mEq/L
燒燙傷照護的 ABC 原則中，C（Airway）永遠是第一位。鼻毛燒焦與聲音嘶啞是吸入性損傷（Inhalation Injury）的典型徵兆，預示著呼吸道可能在短時間內因水腫而完全阻塞。即使病患目前 SpO2 尚可，也必須立即準備氣管插管。雖然尿量過低（C）提示休克需要補液，高血鉀（D）是組織破壞的常見結果，疼痛（B）需緩解，但這些都排在呼吸道喪失之後。在燒傷急診期，隱形的呼吸道熱損傷是致死率最高且最不可預測的威脅。
Within the ABCs of burn care, C (airway) always comes first. Singed nasal hairs and a hoarse voice are classic signs of inhalation injury and warn that the airway may become completely obstructed within a short time due to edema. Even if the client's SpO2 currently appears adequate, preparation for endotracheal intubation must begin immediately. Although low urine output (C) suggests inadequate fluid resuscitation, hyperkalemia (D) is a common result of tissue destruction, and severe pain (B) needs to be relieved, all of these are secondary to airway compromise. In the emergent phase of burns, the hidden thermal injury to the airway has the highest mortality and is the least predictable threat.
美國燒傷病房常使用 Parkland Formula 嚴格計算補液，且對吸入性損傷的插管指標非常果斷；台灣臨床實務中，對於可疑吸入性損傷病人，通常會儘早會診胸腔科或麻醉科進行纖維支氣管鏡檢查。