How should I assess and manage a patient after fire or smoke inhalation, including airway protection, high‑flow oxygen, carbon monoxide level evaluation, indications for hyperbaric oxygen therapy, bronchoscopy, and burn resuscitation?

Assessment and Management of Fire and Smoke Inhalation Injury

Immediate Assessment and Airway Protection

All patients with suspected smoke inhalation should receive 100% high-flow oxygen immediately without delay, regardless of initial oxygen saturation or arterial blood gas results. 1, 2

Clinical Indicators Requiring Immediate Evaluation

Suspect inhalation injury based on:

• Fire in an enclosed space (highest risk factor) 3, 2
• Carbonaceous sputum (most indicative finding of actual inhalation injury) 3
• Soot on face, around nose/mouth, or in airway 3, 2
• Singed nasal or facial hairs 3, 2
• Dysphonia, dyspnea, wheezing, or stridor 2, 4
• Facial or neck burns with vapor/smoke exposure 2

Critical pitfall: Normal oxygen saturation (>90%), normal chest X-ray, normal arterial blood gases, and normal FEV1/FVC ratio do NOT exclude inhalation injury and should not provide false reassurance. 3, 2

Immediate Intubation Indications

Intubate immediately without delay if ANY of the following are present: 2

• Severe respiratory distress
• Severe hypoxia or hypercapnia
• Altered mental status or coma
• Symptoms of airway obstruction (stridor)
• Deep circular neck burns
• Whole face involvement with extensive burns (TBSA ≥40%)

Do not wait for diagnostic testing if these criteria are met—progressive glottic edema can develop rapidly and unpredictably. 2

Diagnostic Evaluation

Bronchoscopy

Flexible bronchoscopy is the gold standard for diagnosing smoke inhalation injury. 3, 2 However, several important caveats apply:

• Bronchoscopy should only be performed in patients who are already intubated due to risk of airway compromise during the procedure 2
• Normal bronchoscopy findings do NOT exclude inhalation injury, as it only assesses the proximal airway 3
• Severity of bronchoscopic lesions correlates with morbidity, ICU length of stay, duration of mechanical ventilation, and severity of hypoxemia 3, 2
• Consider rigid bronchoscopy after airway fires to look for tracheal tube fragments and assess injury 1

Monitoring Strategy for Non-Intubated Patients

For patients with face/neck burns or suspected inhalation who do not meet immediate intubation criteria: 2

• Close continuous monitoring in high-dependency area
• Head-up positioning
• Nil-by-mouth status
• Regular reassessment for progressive airway edema
• Early specialist consultation from burn center

Transfer to a burn center should NOT be delayed for extensive diagnostic testing. 3

Carbon Monoxide Poisoning Management

Oxygen Therapy

All patients with suspected or confirmed CO poisoning should receive 100% oxygen via high-concentration mask for 6-12 hours (or 100% FiO2 if mechanically ventilated). 1

• Start oxygen therapy immediately at first aid stage, even before carboxyhemoglobin levels are available 1
• This applies to all age groups, including children 1

Hyperbaric Oxygen Therapy (HBOT) Indications

The indication for HBOT should be evaluated on a case-by-case basis, considering both benefits and contraindications. 1

HBOT is strongly recommended (Grade B evidence) for: 1

• Patients with altered consciousness and/or neurological symptoms
• Respiratory symptoms
• Cardiac symptoms
• Psychological symptoms
• All pregnant women with CO poisoning, regardless of clinical presentation
• All children with CO poisoning who exhibit impaired consciousness and/or neurological, cardiac, respiratory, or psychological symptoms

Important contraindications and limitations: 1

• HBOT is often contraindicated in severe burn patients due to hemodynamic or respiratory instability in the acute phase
• Technical difficulties with HBOT carry significant risks
• Must have specialized team present to ensure safety conditions
• HBOT equipment must be available within acceptable time frame

HBOT is NOT indicated for burn wound healing. 1

Burn Resuscitation and Supportive Care

Initial Wound Management

• Cool thermal burns with clean running water for 5-20 minutes 2
• Remove all jewelry before swelling occurs to prevent vascular ischemia 2
• Monitor children for hypothermia during cooling 2

Pain Management

Use multimodal analgesia with titration based on validated comfort and analgesia assessment scales. 1

• Titrated intravenous ketamine can be combined with other analgesics for severe burn-induced pain 1
• Over-the-counter analgesics for initial pain control 2
• Non-pharmacological techniques should be combined with analgesic drugs for dressings when patient is stable 1

Transfer Criteria to Burn Center

Direct admission to a burn center is strongly preferred over staged transfer, as it reduces time to definitive treatment and improves morbidity and mortality. 2

Burn center treatment is recommended for: 2

• Second- or third-degree burns involving face, hands, feet, genitals, perineum, or flexure lines
• Burns >10% body surface area (>5% in children)
• Any smoke inhalation injury (increases pediatric mortality three-fold even with TBSA <10%)

Mechanical Ventilation Strategy

For intubated patients with inhalation injury: 5

• Use lung-protective ventilation strategies
• No sound evidence supports ventilation modes different from those used in non-burn patients
• High-frequency percussive ventilation may be considered but lacks definitive evidence 5
• Maintain bronchial hygiene with therapeutic coughing, chest physiotherapy, deep breathing exercises, and early ambulation 4

Cyanide Poisoning

In all burn patients exposed to enclosed fire, cyanide poisoning should be suspected along with carbon monoxide poisoning. 5

• Treat cyanide poisoning with hydroxocobalamin 5