II. Epidemiology

  1. Leading cause of death from Burn Injury (responsible for 50-80% of burn-related deaths)

III. Pathophysiology

  1. Upper airway is typically affected (except in steam inhalation which can affect sub-glottic airway)
  2. Inhalation injuries are mediated by chemical lung injury (not typically heat)
    1. Results in large volume fluid influx into the lungs

IV. Signs: Findings suggestive of Smoke Inhalation

  1. Full thickness facial burns
  2. Burn Injury occuring in a confined space
  3. Sputum with soot (carbonaceous Sputum)
  4. Hoarseness or Stridor
  5. Bullae in oropharynx or Larynx
  6. Cough

V. Signs: Respiratory distress (late findings)

  1. Dyspnea
  2. Tachypnea
  3. Wheezing
  4. Rhonchi
  5. Nasal flaring or chest retractions

VI. Labs

  1. Arterial Blood Gas
  2. Serum Lactic Acid
    1. Increased with cyanide Poisoning
    2. No specific Cyanide lab testing in most clinical settings
  3. Carboxyhemoglobin level
    1. Increased with Carbon Monoxide Poisoning
  4. Complete Blood Count
  5. Consider serum Troponin
    1. Indicated for Chest Pain, EKG changes or increased cardiovascular risk

VII. Imaging

IX. Complications

  1. Carbon Monoxide Poisoning
  2. Cyanide Poisoning
    1. Results from inhalation of burning materials (e.g. wool, silk, polyurethane, and vinyl)
  3. Methemoglobinemia
  4. Respiratory injury
    1. Causes Hypoxia, airway edema, airway obstruction and ARDS

X. Evaluation

  1. Altered Mental Status
    1. Burn Injury is typically associated with alert, agitated patient in pain
    2. Decreased level of conciousness suggests other cause
      1. Carbon Monoxide Poisoning
      2. Cyanide Poisoning
      3. Trauma

XI. Management

  1. See Burn Injury
  2. Monitoring
    1. Intravenous Access
    2. Oxygen Saturation monitoring
    3. Telemetry monitoring
  3. Interventions: Airway
    1. Supplemental Oxygen 100% Non-Rebreathing Mask
      1. Continue until Carboxyhemoglobin <5%
      2. Carbon Monoxide decreases 50% in 60 minutes on Non-Rebreather Mask
      3. Carbon Monoxide decreases 50% in 30 minutes on 100% oxygen while intubated
    2. Consider hyperbaric oxygen (see indications below)
    3. Consider Advanced Airway and Mechanical Ventilations
      1. Monitor upper airway closely and prophylactically intubate early if airway compromise is suspected
      2. Mechanical Ventilation settings
        1. Keep Tidal Volumes at 3-5 ml/kg
        2. Keep plateau pressures <30 cm H2O
        3. Administer PEEP
      3. Rapid Sequence Intubation precautions
        1. Succinylcholine is safe in acute Burn Injury (Hyperkalemia risk starts at 5 days post-injury)
      4. Endotracheal Tube precautions
        1. Place at least a 7.5 Endotracheal Tube (otherwise more difficult suctioning, bronchoscopy)
    4. Intubation indications
      1. Includes all standard intubation indications
        1. See Advanced Airway
        2. Respiratory failure
        3. Unprotected airway
      2. Expectation of further tracheal edema within next 24 hours
      3. Hoarseness or increasing Stridor
      4. Severe Third Degree Burns to face
      5. Prolonged transport and tenuous airway status
      6. Carbon Monoxide >20% may require intubation due to Hypoxemia
  4. Other interventions
    1. Intravenous crystalloid
      1. See Burn Management (includes Parkland Formula)
      2. Maintain urinary output of 0.5 to 1 mL/kg/hour
    2. Opioid Analgesics
    3. Bronchodilators (e.g. Albuterol) for Asthma Exacerbation (i.e. Wheezing)
    4. Systemic Corticosteroids may be indicated in certain inhalations
      1. Examples: Nitrogen oxide, zinc oxide, sulfur trioxide, titanium tetrachloride
      2. Discuss with poison control, pulmonology or burn center
    5. Cyanokit (IV Hydroxycobalamin)
      1. Indications (Paris Fire Brigade Protocol)
        1. Known Smoke Inhalation in an enclosed space AND
        2. One of the following criteria
          1. Altered Mental Status
          2. Soot in nares or mouth
          3. Full cardiopulmonary arrest (without full body burns incompatible with life)
      2. Dosing
        1. Hydroxycobalamin (Vitamin B12a) 5 grams IV over 15 minutes
      3. Efficacy
        1. Resulted in 50% ROSC rate in full arrest Smoke Inhalation patients
        2. Much safer empiric therapy than the Lily Kit (Methemoglobinemia, Hypotension)
      4. References
        1. Fortin (2006) Clin Toxicol 44 (suppl 1):37-44 +PMID:16990192 [PubMed]
        2. Borron (2007) Ann Emerg Med 49(6): 794-801 +PMID:17481777 [PubMed]

XII. Disposition

  1. Monitor in Emergency Department for at least 4-6 hours
    1. Observe with serial exams, Vital Signs and diagnostics
    2. Discharge with close interval follow-up if normal observation without significant airway symptoms
  2. Hospitalization indications
    1. Enclosed space inhalation exposure for >10 minutes
    2. Sputum with soot
    3. pAO2 <60 mmHg
    4. Metabolic Acidosis
      1. Increased Anion Gap and Lactic Acidosis with cyanide Poisoning
    5. Carboxyhemoglobin >15%
    6. A-a Gradient >100 mmHg on 100% Supplemental Oxygen
    7. Significant symptoms or signs (Central facial burns, painful swallowing or bronchospasm)
  3. Hyperbaric oxygen therapy indications
    1. Base Excess < -2 mmol/L
    2. Carboxyhemoglobin >25% (or >15% in pregnancy, in which fetal Hemoglobin is more CO avid)
    3. Cerebellar symptoms (e.g. Ataxia)
    4. Pulmonary edema
    5. Cardiac arrhythmia or Acute Coronary Syndrome
    6. Very young or very old

XIII. References

  1. Lafferty in Alcock (2013) Smoke Inhalation Injury, Medscape EMedicine (accessed 12/11/2013)
  2. Latenser in Bope (2011) Burn Treatment Guidelines, Conn's Current Therapy, Elsevier, p. 1151
  3. Schwartz in Cydulka (2011) Tintinalli's Emergency Medicine 7ed, McGraw Hill, New York (accessed 12/11/2013)
    1. http://www.accessmedicine.com/content.aspx?aID=6385384

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Ontology: Smoke Inhalation Injury (C0037367)

Definition (MSH) Pulmonary injury following the breathing in of toxic smoke from burning materials such as plastics, synthetics, building materials, etc. This injury is the most frequent cause of death in burn patients.
Concepts Injury or Poisoning (T037)
MSH D015208
ICD10 T59.81 , J70.5
SnomedCT 426936004, 212861004, 35844001, 212863001, 366957009, 367182000
English Inhalation Injuries, Smoke, Inhalation Injury, Smoke, Injuries, Smoke Inhalation, Injury, Smoke Inhalation, Smoke Inhalation Injuries, Smoke inhalation, INHAL INJ SMOKE, SMOKE INHAL INJ, INJ SMOKE INHAL, Smoke inhalation injury (disorder), Smoke inhalation injury, Smoke Inhalation Injury, Smoke Inhalation Injury [Disease/Finding], smoke inhalation injury, inhalation smoke, smoke inhalation, smoke inhalation injuries, Smoke inhalation NOS, Smoke Inhalation, Smoke inhalation (event), Smoke inhalation (disorder), Smoke inhalation (finding), Inhalation;smoke
Dutch rookinhalatie, Rookinhalatietrauma, Trauma, rookinhalatie-
French Inhalation de fumée, Lésion par inhalation de fumées, Blessure par inhalation de fumée, Lésion par inhalation de fumée, Lésions d'inhalation de fumée
German Rauchinhalation, Rauchgasverletzung, Vergiftung, Rauchgas-
Italian Inalazione di fumo, Lesione da inalazione da fumo
Portuguese Inalação de fumos, Lesão por Inalação de Fumaça
Spanish Inhalación de humo, lesión por inhalación de humo, lesión por inhalación de humo (trastorno), inhalación de humo, inhalación de humo (trastorno), Lesión por Inhalación de Humo
Japanese 煙の吸引, ケムリノキュウイン, 煤煙吸入傷害, 吸入傷害-ばい煙, ばい煙吸入傷害, 有毒ガス吸入障害, 煤煙吸入損傷
Swedish Inhalationsskador, rök
Czech kouř - poranění inhalací, Vdechnutí kouře
Finnish Savuinhalaatiovamma
Russian INGALIATSIIA DYMOM, TRAVMA, DYMA VDYKHANIE, INGALIATSIONNYE TRAVMY, INGALIATSIONNYE TRAVMY DYMOM, DYMA VDYKHANIE, DYKHATEL'NYE RASSTROISTVA, ДЫМА ВДЫХАНИЕ, ДЫХАТЕЛЬНЫЕ РАССТРОЙСТВА, ДЫМА ВДЫХАНИЕ, ИНГАЛЯЦИОННЫЕ ТРАВМЫ, ИНГАЛЯЦИОННЫЕ ТРАВМЫ ДЫМОМ, ИНГАЛЯЦИЯ ДЫМОМ, ТРАВМА
Croatian DIM, OŠTEĆENJE INHALACIJOM
Polish Urazy wziewne, Uszkodzenia wywołane wdychaniem dymu
Hungarian Füst inhalatioja
Norwegian Røykskade, Inhalasjonsbrannskader, røyk