From the Guidelines
Paramedics managing potential intubation smoke inhalation should immediately prioritize preparation, wear appropriate personal protective equipment (PPE), and focus on prompt and reliable airway management to minimize risk to both staff and patients. When managing potential smoke inhalation, it is crucial to assess for signs of upper airway burns, including facial burns, singed nasal hairs, carbonaceous sputum, and stridor 1.
Key Recommendations
- Prepare for airway management by having a strategy in place, involving the smallest number of staff necessary, and wearing appropriate PPE 1.
- Use techniques that are known to work reliably across a range of patients, including videolaryngoscopy for tracheal intubation and a second-generation supraglottic airway device for airway rescue 1.
- Avoid aerosol-generating procedures wherever possible, and if aerosol generation takes place, use airborne precaution PPE and deep clean the room after 20 minutes 1.
- For rapid sequence intubation (RSI), consider using etomidate or ketamine for induction, followed by succinylcholine or rocuronium for paralysis, as recommended for emergency tracheal intubation 1.
- Select an appropriate endotracheal tube size, considering the patient's anatomy and the potential for airway edema, and maintain ventilation with low tidal volumes and consider albuterol nebulization for bronchospasm.
Airway Management
- Meticulous pre-oxygenation with a well-fitting mask for 3-5 minutes is essential before attempting intubation 1.
- Place a heat and moisture exchange (HME) filter between the catheter mount and the circuit to minimize the risk of aerosol generation 1.
- Ensure full neuromuscular blockade before attempting tracheal intubation, and consider using a peripheral nerve stimulator or waiting 1 minute to confirm blockade 1.
Post-Intubation Care
- Monitor oxygen saturation, end-tidal CO2, and assess for carbon monoxide poisoning using pulse CO-oximetry if available 1.
- Maintain ventilation with low tidal volumes (6-8 ml/kg) and consider albuterol nebulization (2.5-5 mg) for bronchospasm.
- These interventions are critical because smoke inhalation can cause rapid airway compromise through thermal injury and chemical irritation, while toxic gases like carbon monoxide and hydrogen cyanide can cause systemic effects requiring prompt treatment.
From the Research
Immediate Recommendations for Paramedics
Paramedics managing potential intubation smoke inhalation should consider the following:
- Ensure the airway allows adequate oxygenation and ventilation 2
- Avoid ventilator-induced lung injury and substances that may complicate subsequent care 2
- Consider intubation if signs of respiratory distress, stridor, hypoventilation, use of accessory respiratory muscles, blistering or edema of the oropharynx, or deep burns to the face or neck are present 2
- Provide a high concentration of supplemental oxygen to quickly reverse hypoxia and to displace carbon monoxide from protein binding sites 2
Predictors of Intubation Need
The need for intubation can be predicted by:
- Physical examination findings of soot in the oral cavity, facial burns, and body burns 3
- Fiberoptic laryngoscopic findings of edema of either the true vocal folds or the false vocal folds 3
- Patients with these findings should be monitored closely as they indicate a higher likelihood of laryngeal edema and the need for intubation 3
Respiratory Management
Respiratory management plays a vital role in the treatment of smoke inhalation injury, including: