Airway Injuries: Smoke Inhalation, Carbon Monoxide, and Cyanide

Emergency Department Management of Smoke Inhalation Injury in Adults

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Table of Contents
About This Issue

When treating patients who have suffered injury in a fire, managing their airway is as critical as treating their burns. Following on the February 2018 issue on Thermal Burns, this issue reviews strategies for diagnosing and treating inhalation injuries in fire-exposed patients.

How is inhalation injury severity measured?

What are the differences between injury to the upper airway, the lower airway, and systemic effects of intoxication?

What are the signs of carbon monoxide and cyanide poisoning, and what are the best treatments?

What kind of diagnostic tests should be done, and what will they tell you?

Blood gas, CO-oximetry, pulse oximetry, and pulse CO-oximetry: when should they be used and when might they be falsely normal?

What are the benefits and limitations of CT, bronchoscopy, and laryngoscopy?

Are prophylactic antibiotics warranted to prevent pneumonia?

What are the optimal methods of airway management when edema and airway obstruction is a threat?

Table of Contents
  1. Abstract
  2. Case Presentations
  3. Introduction
  4. Selected Abbreviations
  5. Critical Appraisal of the Literature
  6. Etiology and Pathophysiology
    1. Upper Airway Thermal Injury
    2. Lower Airway and Lung Parenchymal Injury
    3. Systemic Cellular Dysfunction of Carbon Monoxide and Cyanide Exposure
  7. Differential Diagnosis
  8. Prehospital Care
  9. Emergency Department Evaluation
    1. History
    2. Physical Examination
  10. Diagnostic Studies
    1. Blood Gas and CO-Oximetry
    2. Pulse Oximetry
    3. Noninvasive Pulse CO-Oximetry
    4. Lactic Acid
    5. Cyanide Testing
    6. Other Laboratory Testing
    7. Electrocardiogram
    8. Chest X-Ray
    9. Chest Computed Tomography
    10. Fiberoptic Bronchoscopy
      1. Limitations of Fiberoptic Bronchoscopy
    11. Direct and Fiberoptic Laryngoscopy
    12. Other Clinical Testing
  11. Treatment
    1. Airway Management
    2. Medical Adjuncts
    3. Treatment for Carbon Monoxide Poisoning
    4. Treatment for Cyanide Poisoning
    5. Complications
  12. Special Populations
    1. Pregnant Patients
    2. Geriatric Patients
  13. Controversies and Cutting Edge
    1. Extracorporeal Membrane Oxygenation
    2. Point-of-Care Ultrasound
  14. Disposition
  15. Summary
  16. Risk Management Pitfalls for Smoke Inhalation Injury
  17. Time- and Cost-Effective Strategies
  18. Case Conclusions
  19. Key Points
  20. Clinical Pathway for Management of Smoke Inhalation Injury
  21. Tables and Figures
    1. Table 1. Classification of Inhalation Injury
    2. Table 2. History and Physical Examination Findings Suggesting Inhalation Injury
    3. Table 3. Carboxyhemoglobin Levels and Associated Symptoms
    4. Table 4. RADS Score to Grade Severity of Inhalation Injury on Chest CT
    5. Table 5. Abbreviated Injury Score Grading Scale for Inhalation Injury on Bronchoscopy
    6. Table 6. Long-Term Complications of Smoke Inhalation Injury
    7. Figure 1. Soot and Bronchial Casts From Smoke Inhalation
    8. Figure 2. Computed Tomography Scan Slice With Radiologist’s Score Findings
    9. Figure 3. Fiberoptic Laryngoscopy Views of a Normal Airway and an Edematous Airway
    10. Figure 4. PaO2/FiO2 Ratio in High-Frequency Percussive Ventilation Compared to Low- Tidal-Volume Ventilation
    11. Figure 5. Imaging of Tracheal Wall Thickening on X-Ray, Ultrasound, and Computed Tomography
  22. References


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.


Case Presentations

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...

A little later in your shift, a 27-year-old woman who is 18 weeks’ pregnant is triaged for shortness of breath, cough, lightheadedness, mild confusion, and headache. She was in the same apartment complex fire as your previous 2 patients. She cannot recall all the details because she “fainted,” and she regained consciousness only when the firefighters were evaluating her. The EMS crew mentions that the carbon monoxide meter reading in the apartment was elevated. Her vital signs are within normal limits. You suspect carbon monoxide poisoning, but wonder whether she is a candidate for hyperbaric treatment and whether it is safe for the fetus...



As these cases highlight, it is not uncommon for multiple patients who have been exposed to a serious fire to present to the emergency department (ED) simultaneously, requiring urgent evaluation and stabilization. Inhalation injuries contribute significantly to morbidity and mortality in fire-exposed patients, and their injuries can range in severity from minimal symptoms to life-threatening injuries. The presence of smoke inhalation injury (SII) is an independent predictor of mortality, and it worsens the prognosis compared to patients of similar age and burned total body surface area (TBSA) without SII.1-3 In patients with cutaneous burns, the presence of a concomitant SII increases fluid requirements, pulmonary complications, and overall mortality.4 Likewise, patients with SII have increased mortality when cutaneous burns are present.5 Data suggest that 5% to 10% of patients hospitalized for burns have a concomitant SII, and that the presence of inhalation injury portends a 20% increased mortality, which increases to 60% higher mortality if secondary pneumonia develops.6 For these reasons, inhalation injury is one of the criteria for transfer to a burn center.7 The diagnosis and prognostication of SII can be challenging due to the lack of standardized severity scoring.1,8 Additionally, it is often difficult to predict severity in the acute phase, since much of the damage is not visible upon initial presentation.9 Various proposed grading schemes have not reliably predicted patient outcomes.6

The insidious nature of SII, both in its delayed development and associated poisoning exposures, cannot be underestimated. The emergency clinician’s ability to suspect, diagnose, and expertly manage SII is crucial. Management is mainly supportive, and some management strategies—such as hyperbaric oxygen, proactive airway management, and ventilation techniques—remain controversial. Standardized diagnostic criteria for SII are lacking, treatment strategies are suboptimal, and morbidity and mortality remain high. This issue of Emergency Medicine Practice presents a comprehensive review of the existing literature, offers best-practice recommendations on the management of patients with SII, and highlights areas where further research is necessary. For information about assessing and treating patients with thermal burns, see the February 2018 issue of Emergency Medicine Practice, “Emergency Department Management of Patients With Thermal Burns,” available at


Selected Abbreviations

ALI Acute lung injury
ARDS Acute respiratory distress syndrome
COHb Carboxyhemoglobin
CO Carbon monoxide
CN Cyanide
FiO2 Fraction of inspired oxygen
PaO2 Partial pressure of oxygen, arterial
SII Smoke inhalation injury
TBSA Total body surface area


Critical Appraisal of the Literature

A literature search was performed via PubMed using the following main search terms: inhalation injury, burns, inhalation, inhalation exposure, smoke inhalation, chemical inhalation, carbon monoxide, carbon monoxide poisoning, hydrogen cyanide, and cyanide. Additional MeSH pairings were used to expand and include airway management strategies, ED patient population, and to limit the studies to those with adult patients and published in English. Once a list of pertinent studies was obtained, we selectively reviewed reference lists to find additional relevant articles. Overall, 1098 articles were identified and 87 were deemed applicable to be included. Many of the identified articles were retrospective studies, case reports, and literature reviews. Some prospective studies exist, but overall, we found a paucity of prospective, blinded, randomized controlled trials pertaining to fire-related inhalation injury.


Risk Management Pitfalls for Smoke Inhalation Injury

3. “The patient had normal vitals and appeared well, so I didn’t anticipate airway compromise.”

The onset of SII can occur in the absence of clinical signs or symptoms, as laryngeal edema can take 24 hours to develop. An extended period of observation is therefore recommended, and if any concerning signs or symptoms of inhalation injury are present, the patient should be admitted to a burn unit for close monitoring and possible bronchoscopy.

6. “When the patient presented with altered mental status, I assumed it was due to hypoxia and chemical toxicity.”

The approach to burn patients should be similar to that of trauma patients, as concomitant traumatic injury is common. Patients should be assessed with a primary survey, followed by a secondary survey. Once the patient is stabilized, occult trauma should be considered in the workup of the patient, especially in the setting of signs such as altered consciousness or pain.

10. “The patient had only mild respiratory distress initially, so I discharged him after 2 hours of observation in the ED.”

Patients should be discharged from the ED only if they are completely asymptomatic, without concerning history for potential SII. Otherwise, if any degree of inhalation injury is suspected, the patient should be transferred to a burn center and admitted for close monitoring and possible bronchoscopic evaluation.


Tables and Figures

Table 1. Classification of Inhalation Injury



Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of patients. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study is included in bold type following the reference, where available. In addition, the most informative references cited in this paper, as determined by the authors, are noted by an asterisk (*) next to the number of the reference.

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Publication Information

Karalynn Otterness, MD; Christine Ahn, MD

Peer Reviewed By

Alex Manini, MD, MS, FACMT, FAACT; Lewis S. Nelson, MD

Publication Date

March 1, 2018

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