Treatment of Smoke Inhalation Injury
All patients with suspected or confirmed smoke inhalation should immediately receive high-concentration oxygen therapy without delay, via high-concentration mask or 100% FiO2 for 6-12 hours if mechanically ventilated. 1
Immediate Airway Assessment and Management
Perform immediate endotracheal intubation if any of the following are present: 2
- Severe hypoxia or hypercapnia
- Altered mental status or coma
- Signs of airway obstruction (stridor, laryngeal dyspnea, voice modification)
For patients without immediate intubation indications, closely monitor airway status as edema develops progressively over hours. 2 Look for clinical signs including soot on face/in nares, dysphonia, blackish sputum, and wheezing. 2
Common pitfall: Delaying intubation when subtle signs of airway compromise are present—intubate early before edema makes the procedure difficult or impossible. 2
Oxygen Therapy for Carbon Monoxide Poisoning
Administer 100% oxygen immediately to all patients with suspected CO poisoning, regardless of pulse oximetry readings (which can be falsely elevated in CO poisoning). 1, 3 Continue high-concentration oxygen via mask or 100% FiO2 for 6-12 hours if mechanically ventilated. 1
Hyperbaric Oxygen Therapy (HBOT)
HBOT should NOT be routinely administered for smoke inhalation with CO poisoning. 1, 2 The evidence is conflicting: while the European Committee of Hyperbaric Medicine recommends HBOT for patients with altered consciousness or neurological/cardiac/respiratory symptoms (grade B evidence), the American College of Emergency Physicians and International Society for Burn Injuries note that HBOT is often contraindicated in severe burns due to hemodynamic instability and significant risks. 1
Consider HBOT only in select cases: 1
- Pregnant women with any CO exposure
- Patients with altered consciousness AND/OR neurological, respiratory, cardiac, or psychological symptoms
- Children with CO poisoning and impaired consciousness
- Only if patient is hemodynamically stable and HBOT can be initiated within acceptable timeframe
Cyanide Poisoning Management
Do NOT routinely administer hydroxocobalamin after smoke inhalation. 1, 2 There is insufficient evidence that hydroxocobalamin improves survival, and it carries risk of oxalate nephropathy. 1
Restrict hydroxocobalamin to specific high-risk scenarios: 1
Adults - Give hydroxocobalamin ONLY if:
- Severe cyanide poisoning suspected (cardiac/respiratory arrest, shock, coma) AND
- Severe metabolic acidosis with pH <7.20 1 OR plasma lactate ≥8-10 mmol/L 1
- Dosage: 5g (10g for cardiac arrest) 1
Children - Give hydroxocobalamin if moderate or severe signs present:
Moderate signs: GCS ≤13, confusion, stridor, hoarse voice, polypnea, dyspnea, soot in airways 1 Severe signs: GCS ≤8, seizures, coma, mydriasis, severe hemodynamic disorders, respiratory depression 1
Children are more vulnerable to cyanide poisoning due to higher alveolar ventilation per minute and lower body mass index. 1
Respiratory Support and Monitoring
Perform bronchoscopy at a burn center to assess severity of inhalation injury. 2 This is the gold standard for diagnosis but should not delay treatment. 1
Maintain bronchial hygiene through therapeutic coughing, chest physiotherapy, deep breathing exercises, and early ambulation. 4 Consider bronchodilators and nebulization therapy as needed. 2, 4
Specialized Care Referral
Refer to a burn specialist immediately to determine need for burn center admission. 2 If burn center admission is indicated, transfer directly rather than through intermediate facilities. 2
Follow-up Care
All patients treated for acute CO poisoning require clinical follow-up at 1-2 months post-event to assess for delayed neurological sequelae including memory disturbance, depression, anxiety, vestibular problems, and motor dysfunction. 1 These can develop even after apparently successful acute treatment. 1
For intentional CO poisoning, mandatory psychiatric follow-up is required due to extreme risk of subsequent suicide completion. 1