What are the next steps for a patient presenting with symptoms of smoke inhalation, including coughing and weakness?

Immediate Management of Smoke Inhalation in a Firefighter

Administer 100% oxygen immediately via non-rebreather mask, assess for signs requiring immediate intubation (severe respiratory distress, stridor, altered mental status, or severe facial burns), and arrange urgent transfer to a burn center or emergency department for definitive evaluation and monitoring. 1, 2, 3

Immediate On-Site Actions

Oxygen Therapy - First Priority

• Start 100% oxygen via non-rebreather mask immediately without delay 1, 3
• Continue high-concentration oxygen for 6-12 hours minimum if carbon monoxide poisoning is suspected 1
• Titrate to maintain oxygen saturation ≥90%, but do not withhold oxygen even if CO₂ retention develops 3
• Normal oxygen saturation does NOT exclude serious inhalation injury and should not provide false reassurance 4

Airway Assessment - Critical Decision Point

Intubate immediately if ANY of the following are present: 2, 4

• Severe respiratory distress with hypoxia or hypercapnia 2, 3
• Altered mental status or coma 2, 3
• Stridor or signs of upper airway obstruction 2, 4
• Severe facial burns or deep circular neck burns 2, 4
• Inability to protect airway 2

For this firefighter with cough and weakness but no immediate airway compromise:

• Do NOT routinely intubate based on smoke exposure alone 2
• Maintain high index of suspicion as airway edema can develop rapidly and unpredictably 4
• Monitor continuously for deterioration during transport 3

Scene Safety and Decontamination

• Remove patient from contaminated environment immediately 3
• Remove all contaminated clothing and gear to stop ongoing chemical contact 3
• If eye exposure occurred, flush eyes with copious tepid water for at least 15 minutes 3

Assessment for Specific Toxicities

Carbon Monoxide Poisoning

• All patients with suspected CO poisoning should receive 100% oxygen immediately 1
• Consider hyperbaric oxygen therapy (HBOT) if the patient develops loss of consciousness, neurological deficits, cardiac changes, or significant metabolic acidosis 3
• The European Committee of Hyperbaric Medicine recommends HBOT for patients with altered consciousness, neurological symptoms, or respiratory/cardiac symptoms regardless of carboxyhemoglobin level 1

Cyanide Poisoning

• Measure plasma lactate if available; levels >8 mmol/L suggest cyanide poisoning 3
• Administer hydroxocobalamin 5 g IV if severe cyanide poisoning suspected with cardiac arrest, shock, or coma 3

Transport and Disposition

Immediate Transfer Required

• Direct admission to a burn center is strongly preferred over staged transfer as it reduces time to definitive treatment and improves outcomes 4
• Use ambulance transport with continuous monitoring 3
• Avoid delaying transfer for bronchoscopy, which should NOT be performed in the field or emergency department 3, 4

Hospital-Level Evaluation

Once at the hospital, the patient will require: 3, 4

• Arterial blood gas to assess oxygenation, ventilation, and acid-base status 3
• Continuous pulse oximetry and cardiac monitoring 3
• Flexible bronchoscopy (only if intubated) as the gold standard for diagnosing severity of inhalation injury 4
• Chest X-ray and blood gases are NOT diagnostic for smoke inhalation but help assess complications 2

Critical Pitfall to Avoid

Nearly one-third of burn patients are unnecessarily intubated in the prehospital setting, which increases complications, hospital stays, and mortality. 2 This firefighter with cough and weakness alone does NOT meet criteria for immediate intubation unless signs of airway obstruction, severe respiratory distress, or altered mental status develop. However, close continuous monitoring is essential as deterioration can occur rapidly. 2, 4

Ongoing Monitoring During Transport

• Reassess airway patency frequently 3
• Monitor for development of stridor, increased work of breathing, or declining mental status 4
• Be prepared for difficult intubation if airway edema develops 3
• Pulmonary edema can be delayed, requiring vigilant reassessment 3