Emergency Department Management of Smoke Inhalation Injury in Adults -
Publication Date: March 2018 (Volume 20, Number 3)
Karalynn Otterness, MD
Clinical Assistant Professor of Emergency Medicine, Stony Brook School of Medicine, Stony Brook, NY
Christine Ahn, MD
Clinical Assistant Professor, Residency Assistant Program Director, Department of Emergency Medicine, Stony Brook School of Medicine, Stony Brook, NY
Alex Manini, MD, MS, FACMT, FAACT
Professor of Emergency Medicine, Icahn School of Medicine at Mount Sinai, Elmhurst Hospital Center, New York, NY
Lewis S. Nelson, MD
Professor and Chair, Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, NJ
Smoke inhalation injury portends increased morbidity and mortality in fire-exposed patients. Upper airway thermal burns, inflammation from lower airway irritants, and systemic effects of carbon monoxide and cyanide can contribute to injury. A standardized diagnostic protocol for inhalation injury is lacking, and management remains mostly supportive. Clinicians should maintain a high index of suspicion for concomitant traumatic injuries. Diagnosis is mostly clinical, aided by bronchoscopy and other supplementary tests. Treatment includes airway and respiratory support, lung protective ventilation, 100% oxygen or hyperbaric oxygen therapy for carbon monoxide poisoning, and hydroxocobalamin for cyanide toxicity. Due to its progressive nature, many patients with smoke inhalation injury warrant close monitoring for development of airway compromise.
Excerpt From This Issue
A 48-year-old man presents after being rescued from a burning apartment. He complains of shortness of breath and chest tightness. He is coughing up carbonaceous sputum, has soot in his nares, and has 15% total body surface area burns. He is mildly tachypneic, with an oxygen saturation of 92%, and is wheezing. As you continue your primary survey, you wonder what the indications are for intubation in smoke inhalation, and the best approach to this patient’s management...
As you are finishing your evaluation, the patient’s 72-year-old mother is brought in from the same fire. She is obtunded, with 30% total body surface area burns on her torso, extremities, and face. EMS reports that her vital signs are: blood pressure, 100/65 mm Hg; pulse, 105 beats/min; respiratory rate, 16 breaths/min; oxygen saturation, 90% on nonrebreather mask. She does not respond to voice, although she moans and localizes to painful stimuli. As the nurse is checking a fingerstick glucose and placing her on a monitor, you begin your primary survey. You ask your resident to describe the differential diagnosis for altered mental status in a patient with smoke exposure, while in the back of your mind, you begin to weigh the testing and management priorities...
Excellent review with nice cutting-edge concepts as well Kelly K, MD - 09/07/2018
It's good to know that facial burns w/o mucosal injury, or even just simple soot in the nares doesn't immediately equal an intubation. Bronchodilators just might help if pt looks otherwise OK. Chuang-Yuan L. L., MD - 09/03/2018
This was useful and relevant to my practice. I'll now have a lower threshold for treating suspected CN toxicity. And I have more confidence in ventilator settings for inhalation injury. Jennifer P. - 07/23/2018
This was a terrific review with a lot of new information. I will now try 100% o2 first with these patients. I did not know that lactic acid levels were predictive of cyanide toxicity. I was unaware of anticoagulation therapy to reduce fibrin casts. Sherry Hill, MD - 03/14/2018
Good article! I will now try 100% o2 first with these patients. I did not know that lactic acid levels were predictive of cyanide toxicity. I was unaware of anticoagulation therapy to reduce fibrin casts. Sherry Hill, MD - 03/14/2018
Great article! I now feel more confident about when to intervene in the airway. William E Franklin, DO - 03/14/2018
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