eMedicine Specialties > Emergency Medicine > Environmental

Smoke Inhalation: Follow-up

Author: Keith A Lafferty, MD, Adjunct Assistant Professor of Emergency Medicine, Temple University; Consulting Staff, Department of Emergency Medicine, South West Regional Medical Center
Contributor Information and Disclosures

Updated: Jul 7, 2008

Follow-up

Further Inpatient Care

  • Patients with smoke inhalation should be monitored for 4-6 hours in the ED. While there is no definite criteria for admission, the following patients should be strongly considered for hospitalization:
    • History of closed-space exposure for longer than 10 minutes
    • Carbonaceous sputum production
    • Arterial PO2 less than 60 mm Hg
    • Metabolic acidosis
    • HbCO levels above 15%
    • Arteriovenous oxygen difference (on 100% oxygen) greater than 100 mm Hg
    • Bronchospasm
    • Odynophagia
    • Central facial burns

Further Outpatient Care

  • Although the literature is lacking regarding definite discharge criteria, patients whom otherwise do not meet admission criteria may be sent home after an observation period of 6 hours providing the following criteria are met:
    • Normal vital signs
    • Normal physical examination
    • Short smoke exposure

Transfer

  • Treat patients with isolated smoke inhalation appropriately in any modern intensive care unit. However, transport patients with significant cutaneous burns (who otherwise meet criteria for transfer to a burn center) when stable.
  • Modern burn care has decreased the mortality rate in patients with thermal burns. A large retrospective chart review from 1972-1996 has shown that increasing burn size, older age, inhalation injury, and female sex increase the risk of death, while operative intervention and upper limb burns decrease the risk of death.8

Deterrence/Prevention

  • A study shows that smoke detectors reduce the risk of death by about 60% in all subgroups of people.
    • This is in contrast to past data that suggest that these early warning devices may not be effective in populations that have difficulty responding to an alarm in a timely manner, such as children, older adults, persons with disabilities, or those impaired by alcohol or other drugs.
    • These new data clearly exemplify the point that all homes should have a working smoke detector in every room.
    • Although smoke detectors have been widely adopted by the public, and 93% of US households have one in place, it is estimated that 30-45% of these are not operational, usually due to nonreplacement or removal of batteries.
    • DiGuiseppi et al have shown that just merely giving out free smoke alarms in a deprived, multiethnic, urban community did not reduce injuries related to fire.9 This was because few alarms had been installed or properly maintained.

Complications

  • While the mortality rate for isolated smoke inhalation injury is lower than 10%, the addition of a cutaneous burn could almost quadruple this mortality rate.
  • Subglottic stenosis
  • Bronchiectasis
  • Pulmonary edema (4-9%)
  • Pneumonia (3-23%)
  • Atelectasis (1-5%)
  • After the 1987 California forest fire disaster, local EDs saw a dramatic rise in asthmatic patients.
  • Another study of firefighters showed certain subgroups to have an exaggerated decline in postexposure FEV1 that was not predicted by age, smoking history, intensity of exposure, or the use of self-contained breathing apparatus.
    • Some of these patients, who had no family history of reactive airway disease, went on to need long-term beta-agonist therapy.
    • The many case series in the literature clarify that reactive airway disease, in a small sample of patients with smoke inhalation, is a real potential sequela.

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • As smoke inhalation can lead to serious morbidity and mortality, make every effort to diagnose and treat this condition. Avoid the following potential errors in treating smoke inhalation:
    • Beware that patients may appear asymptomatic on arrival but may develop significant signs and symptoms as long as 36 hours after exposure, especially in fires that produce small particles with low water solubility.
    • Avoid relying on the HbCO level obtained in the ED. This level does not correlate with tissue hypoxia or long-term neurological sequelae. Ideally, an HbCO level at the scene would be most valuable.
    • Be aware of pertinent historical risk factors in treating patients with potential smoke inhalation injury. These include closed-space fires, carbonaceous sputum, elevated CO levels, and central facial burns.
    • While the mortality rate of isolated smoke inhalation injury is lower than 10%, the coexistence of a burn injury may almost quadruple this mortality rate.
    • A significant amount of patients may present with a paucity of upper airway signs or symptoms but still may have serious subglottic injury. The threshold for performing diagnostic bronchoscopy should be low.
 


More on Smoke Inhalation

Overview: Smoke Inhalation
Differential Diagnoses & Workup: Smoke Inhalation
Treatment & Medication: Smoke Inhalation
Follow-up: Smoke Inhalation
References
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References

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Further Reading

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Keywords

smoke inhalation, smoke inhalation injury, cyanide toxicity, CN toxicity, SI, inhalation injury, pulmonary injury, fire-related injury, thermal damage, asphyxiation, pulmonary irritation, CO poisoning, CO toxicity, carbon monoxide toxicity, hyperbaric oxygen therapy, HBO, carbon monoxide poisoning, tissue hypoxia, thermal injury

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Contributor Information and Disclosures

Author

Keith A Lafferty, MD, Adjunct Assistant Professor of Emergency Medicine, Temple University; Consulting Staff, Department of Emergency Medicine, South West Regional 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.

Medical Editor

Daniel J Dire, MD, FACEP, FAAP, FAAEM, Clinical Associate Professor, Department of Emergency Medicine, University of Texas-Houston
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.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

James S Walker, DO, Program Coordinator, Associate Professor, Department of Emergency Medicine, University of Oklahoma Health Sciences Center
Disclosure: Nothing to disclose.

CME Editor

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

Jonathan Adler, MD, Attending Physician, Department of Emergency Medicine, Massachusetts General Hospital; Division of Emergency Medicine, Harvard Medical School
Jonathan Adler, MD is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: eMedicine.com, Inc. Consulting fee Consulting

 
 
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