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

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Points

  • 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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Pearls

  • 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

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.
 
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Publication Information
Authors

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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