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Smoke inhalation injury
From WikEM
(Redirected from Smoke inhalation)
Contents
Background
- Main cause of mortality in fire-related death
- Associated with closed-space fires, especially when patient has decreased mental status (e.g. substance use, head injury)
- Thermal injury:
- Due to inhaling superheated gases in an enclosed space
- Direct thermal trauma and associated edema usually limited to upper airway, but lower respiratory tract may be injured if steam inhaled
- Chemical injury:
- Direct toxicity to airways and lung parenchyma from noxious chemicals combusted
Clinical Features
Thermal injury
- Soot around nares or in mouth
- Carbonaceous sputum
- Singed nasal or facial hair
- Dyspnea, stridor, drooling, dysphonia, respiratory distress
Chemical injury
Varies depending on substance burned in fire
- Acrolein: found in wood and petroleum
- Pulmonary edema, bronchorrhea, bronchospasm, VQ mismatch which can cause hypoxemia
- Tearing, conjunctivitis
- Hydrochloric acid: product of polyvinyl chloride (structural component of high-rise buildings, plastics) combustion.
- Can persist in air up to an hour after fire extinguished
- PVCs and other arrythmias
- Delayed onset (2-12 hours) pulmonary edema
- Dypsnea, chest pain
- Tuolene diisocyanate: seat cushions, carpet, insulation
- Severe bronchospasm
- Nitrogen dioxide: fires involving automobiles, agrecultural waste
- Uncommon but brief exposure can be lethal
- Severe bronchospasm, laryngospasm, pulmonary edema
- Later: interstitial lung disease
Systemic chemical injury
Differential Diagnosis
Burns
- Burn
- First degree
- Second degree
- Third degree
- Fourth degree
- Smoke inhalation injury (airway compromise)
- Chemical injury
- Acrolein
- Hydrochloric acid
- Tuolene diisocyanate
- Nitrogen dioxide
- Systemic chemical injury
- Electrical injury
Evaluation
- Assess ABCs, burns resuscitation
- ABG or VBG, carboxyhemoglobin
- ECG, monitor on telemetry
- Chest x-ray
- Low threshhold for direct or video laryngoscopy, fiberoptic airway eval
Management
AIRWAY
- Intubate if:
- Respiratory distress, respiratory depression, or altered mental status
- Progressive hoarseness
- Supraglottic or laryngeal edema/inflammation on bronchoscopy or NPL
- Full thickness burns to face or perioral region
- Circumferential neck burns
- Major burns over 40-60% of body surface area
Remember, the intubation will only get more difficult as edema worsens!
- Bronchodilators if evidence of bronchospasm
- See Carbon monoxide toxicity
- See Cyanide toxicity