Smoke inhalation injury
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
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 arrhythmias
- Delayed onset (2-12 hours) pulmonary edema
- Dyspnea, 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
- Smoke inhalation injury (airway compromise)
- Chemical injury
- Acrolein
- Hydrochloric acid
- Tuolene diisocyanate
- Nitrogen dioxide
- Systemic chemical injury
- Specific types of burns
- Caustic burns
- Airbag-related burns
- Tar burn
- Cement burn
- Electrical injuries
- Caustic burns
- Associated toxicities
Inhalation injury
- Unintentional
- Smoke inhalation injury
- Cyanide
- Carbon monoxide
- Chloramine
- Hydrocarbons
- Sewer gas
- Hydrogen Sulfide
- Ammonia toxicity
- Methane
- Carbon monoxide
- Terrorism
- Pulmonary chemical agents
- Ammonia
- Methyl isocyanate
- methyl bromide
- Hydrochloric acid
- Chlorine
- Phosgene
- Bioterrorism
Evaluation
- Assess ABCs, burns resuscitation
- ABG or VBG, carboxyhemoglobin
- ECG, monitor on telemetry
- Chest x-ray
- Low threshold 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
Disposition
- Respiratory distress or airway compromise will need admission
- Observe for 1-4 hours if no signs or symptoms of inhalation injury develop or if all resolved within 1 hour consider discharging patient home with instructions for return for re-evaluation next day or sooner if pulmonary and/or airway symptoms develop
References
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