Smoke Inhalation Clinical Presentation

  • Author: Keith A Lafferty, MD; Chief Editor: Rick Kulkarni, MD   more...
 
Updated: Jun 30, 2010
 

History

  • Fires in closed spaces significantly increase the risk of smoke inhalation.
  • Particular materials in fires may contain dangerous asphyxiants.
  • Polyurethane, wool, and silk increase the patient's risk of CN toxicity.
  • Conditions at the scene may yield critical information, such as loss of consciousness or deaths in the same environment.
  • CO measurement at the scene correlates much better with toxicity than does the measurement in the ED.
  • A history of respiratory illnesses, such as asthma or chronic obstructive pulmonary disease (COPD), predisposes patients to respiratory insufficiency.
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Physical

Inhalation injury can range from an immediate threat to a patient's airway and respiratory status to only minor mucosal irritation. Follow a trauma management protocol.

  • Primary survey
    • Assess patency of the airway.
    • Maintain cervical immobilization in any patient who is obtunded, has distracting injuries, has been involved in a significant mechanism of injury, has bony tenderness, or complains of neck symptoms.
    • Assess breathing by respiratory rate, chest wall motion, and auscultation of air movement.
    • Assess circulation by level of consciousness, pulse rate, blood pressure, capillary refill, and by symmetry and strength of pulses.
    • Perform a brief neurological evaluation including a determination of the Glasgow Coma Scale, pupil size and reactivity, and any focal findings.
    • Remove all clothing to expose traumatic injuries/burns and to prevent ongoing thermal injury from smoldering clothes. Evaluate patient's back and perform a log roll if appropriate.
  • Respiratory
    • Identification of impending respiratory failure is paramount.
    • Smoke inhalation and burns to the upper airway trigger the inflammatory cascade with associated vasodilation and capillary leak. Treat any signs or symptoms of airway compromise early and aggressively before rapid progression to upper airway obstruction ensues.
    • Hoarseness, change in voice, complaints of throat pain, and/or odynophagia indicate an upper airway injury that may be severe.
    • Carbonaceous sputum should be regarded as a marker of exposure. Transportation to a burn center with such findings should lower one’s threshold for early endotracheal security.
    • Tachypnea may be present.
    • Wheezing, rales and rhonchi, and use of accessory respiratory muscles may be noted.
  • Patients with facial burns should be carefully evaluated for smoke inhalation.
    • One study has shown a 59% incidence of respiratory injury with burns involving the nose, lips, brows, and neck area compared with a 22% incidence in patients with either peripheral or no facial burns.
    • Again, early airway security is paramount before edema and airway compromise develop.
    • Patients with facial burns showed an increased mortality and more of a need for ventilatory support.
  • Large cutaneous burns indicate an inability to escape flame and a risk for smoke inhalation injury.
  • The secondary survey continues in a complete head-to-toe examination as in any other trauma evaluation.
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Causes

Based on a study looking at the characteristics of survivors and casualties of fire fatalities, specific risk factors seem to elevate the rate of mortality.[12]

  • Age is an important predictor, with elderly persons (>64 y) and young persons (< 10 y) being the most likely to die as a result of a fire.
  • Persons having a physical or cognitive disability have a higher mortality rate than matched controls, as do persons under the influence of alcohol or other drugs. For these vulnerable populations, if a nonvulnerable potential rescuer was present, the fatality rate dropped from 49% to 39%.
  • The absence of a functioning smoke detector increases the risk of death in a fire by about 60%.
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Contributor Information and Disclosures
Author

Keith A Lafferty, MD  Adjunct Assistant Professor of Emergency Medicine, Temple University School of Medicine; Medical Student Director, Department of Emergency Medicine, Gulf Coast Medical Center

Keith A Lafferty, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Medical Association, and Pennsylvania Medical Society

Disclosure: Nothing to disclose.

Coauthor(s)

Harry J Goett, MD  Assistant Professor of Emergency Medicine, Department of Emergency Medicine, Temple University Hospital

Harry J Goett, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Daniel J Dire, MD, FACEP, FAAP, FAAEM  Clinical Professor, Department of Emergency Medicine, University of Texas Medical School at Houston; Clinical Professor, Department of Pediatrics, University of Texas Health Sciences Center San Antonio

Daniel J Dire, MD, FACEP, FAAP, FAAEM is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Emergency Medicine, American Academy of Pediatrics, American College of Emergency Physicians, and Association of Military Surgeons of the US

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

James Steven Walker, DO, MS  Clinical Professor of Surgery, Department of Surgery, University of Oklahoma College of Medicine

James Steven Walker, DO, MS is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Osteopathic Emergency Physicians, and American Osteopathic Association

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD  Attending Physician, Department of Emergency Medicine, Cambridge Health Alliance, Division of Emergency Medicine, Harvard Medical School

Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: WebMD Salary Employment

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