Management of Smoke Inhalation Injury
The management of smoke inhalation injury requires immediate assessment of airway patency, oxygen administration, and consideration of hydroxocobalamin only in cases of suspected severe cyanide poisoning. 1, 2
Initial Assessment and Management
- Assess for signs of airway compromise including voice modification, stridor, laryngeal dyspnea, and monitor oxygen saturation 2
- Look for signs of smoke inhalation: soot on face/in nares, dysphonia, dyspnea, wheezing, and/or blackish sputum 1, 2
- Provide immediate supplemental oxygen to all patients with suspected smoke inhalation, regardless of oxygen saturation readings (which may be falsely normal in carbon monoxide poisoning) 3, 4
- Remove all burning materials and flammable substances from the patient 2
- For external burns, cool thermal burns with clean running water for 5-20 minutes 1
Airway Management
Perform immediate intubation if the patient shows any of the following 1, 2:
- Severe hypoxia or hypercapnia
- Altered mental status or coma
- Signs of airway obstruction (stridor, hoarseness)
- Severe respiratory distress
- Deep burns to face or neck
- Blistering or edema of the oropharynx
For patients without immediate indications for intubation, closely monitor and regularly reassess airway status as edema may develop progressively 2, 5
Carbon Monoxide and Cyanide Management
Administer 100% oxygen to all patients with suspected carbon monoxide exposure to displace carbon monoxide from hemoglobin binding sites 4, 5
Hydroxocobalamin should not be routinely administered after smoke inhalation 1
Consider hydroxocobalamin administration only in:
- Adults with smoke inhalation and high suspicion of severe cyanide poisoning (cardiac/respiratory arrest, shock, coma) 1
- Children with smoke inhalation and signs of moderate cyanide poisoning (confusion, stridor, hoarse voice, dyspnea) or severe poisoning 1
- Consider plasma lactate levels to guide treatment (values >8 mmol/L correlate with cyanide poisoning) 1
- Adult dosage: 5g (10g for cardiac arrest); pediatric dosage: 70 mg/kg (maximum 5g) 1
Hyperbaric Oxygen Therapy (HBOT)
- Hyperbaric oxygen therapy should not be routinely administered for suspected carbon monoxide poisoning after smoke inhalation 1
- Consider HBOT on a case-by-case basis, particularly for:
Respiratory Support
- Maintain bronchial hygiene through therapeutic coughing, chest physiotherapy, and deep breathing exercises 6
- Consider bronchodilators (beta-2 agonists) to improve oxygenation 6, 7
- Use lung-protective ventilation strategies if mechanical ventilation is required 4, 7
- Perform bronchoscopy at a burn center to assess the severity of inhalation injury 1, 2
Referral to Specialized Care
- Seek referral to a burn specialist to determine whether the patient should be admitted to a burns center 1
- Consider telemedicine to improve initial assessment if burn specialists are not readily available 1
- If indicated, admit the patient directly to a burns center rather than transferring through intermediate facilities 1
- Consider escharotomy if deep burns induce compartment syndrome affecting airways, respiration or circulation 1
Monitoring and Follow-up
- Monitor for delayed complications, including progressive airway edema 2, 5
- Watch for development of acute respiratory distress syndrome, which may occur hours to days after the initial injury 6, 7
- Maintain vigilance for signs of systemic effects that may affect multiple organ systems 6
Common Pitfalls to Avoid
- Delaying intubation when signs of airway compromise are present 2
- Performing bronchoscopy in the field, which may delay transfer to a burn center 2
- Relying solely on oxygen saturation readings, which can be falsely elevated in carbon monoxide poisoning 3, 4
- Routine administration of hydroxocobalamin without clear indications of cyanide toxicity 1