Points and Pearls Digest | Management of Smoke Inhalation Injury in Adults

Emergency Department Management of Smoke Inhalation Injury in Adults

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  • Upper airway injuries are due to thermal burns from heat transfer, while lower airway injuries are secondary to chemical and particulate irritants.
  • Airway edema, carbonaceous sputum, soot in the nares or oropharynx, facial burns, and singed nasal hairs all indicate potential inhalation injury.
  • The diagnosis and prognostication of the course of inhalation injury is challenging, since much of the damage is not visible upon initial presentation.
  • A complete physical examination, including a primary and secondary survey, is essential to rule out other acute injuries.
  • Pulse oximetry may be falsely normal despite significant carbon monoxide (CO) poisoning.
  • Check a glucose fingerstick, lactic acid level, troponin, pregnancy test, and a chest x-ray in all smoke inhalation victims.
  • Consider obtaining an electrocardiogram if there is concern for CO exposure, since CO toxicity increases the risk of dysrhythmias and myocardial ischemia.
  • A venous blood gas may be used in lieu of an arterial sample to determine a carboxyhemoglobin level. Levels correlate loosely with symptoms.
  • An elevated lactic acid level in a smoke inhalation victim should raise concern for cyanide toxicity.
  • Checking a cyanide level is not recommended for management in the ED.
  • Consider a trial of noninvasive positive-pressure ventilation for patients with mild symptoms and no contraindications.
  • The use of hyperbaric oxygen therapy for CO poisoning is controversial and remains a Level B recommendation. Normobaric 100% FiO2 remains the standard of care.
  • Bronchodilators, inhaled epinephrine, inhaled nitric oxide, inhaled heparin, inhaled N-acetylcysteine, and inhaled anticoagulants may all play a role in managing patients with smoke inhalation injuries. Further studies are needed.
  • Mechanical ventilation is an independent predictor of mortality and can also worsen lung injury.
  • Pneumonia and acute respiratory distress syndrome (ARDS) are both common complications of inhalation injury.
  • Up to 33% of burn patients require intubation. Of those, 33% to 54% develop ARDS.
  • All patients for whom there is concern for potential inhalation injury should be closely observed in a monitored setting for 24 hours, with a low threshold for intubation.
  • The presence of inhalation injury is one of the American Burn Association criteria for burn center referral.

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  • For suspected cyanide poisoning, hydroxocobalamin 5 g IV should be administered immediately.
  • Caution must be used when resuscitating smoke inhalation patients, as over-aggressive IV fluids can worsen airway edema.
  • There is no conclusive evidence supporting the use of corticosteroids to reduce airway edema in smoke inhalation victims.
  • Endotracheal intubation is indicated for patients with deep burns to the face and neck, blistering or edema of the oropharynx, hoarseness or stridor, or large cutaneous burns greater than 40% of total body surface area.


Table 1. Classification of Inhalation Injury

Table 1. Classification of Inhalation Injury

Access more tables and figures here



MDCalc Score Calculators
Radiologist’s Score for Inhalation Injury:
Abbreviated Injury Score Calculator:

Reader Comments

Last month’s issue was on Thermal Burns. (www.ebmedicine.net/Burns) When we asked, “What changes do you anticipate making in your practice as a result of this activity?” your colleagues said:
  • Use initial cool water therapy and provide more evidence to my colleagues to stop using silver dressings on wounds.
  • Use the Lund & Browder chart when I can.
  • Pay more attention to clinical parameters and urine output when assessing fluid needs.
  • Use lactated Ringer’s instead of normal saline.
  • I now have a better idea of when I should consider transfer to a burn center and indications for emergent treatment prior to transfer.
Most Important References
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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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