What is the emergency management for a patient with acute toxic inhalation (e.g., smoke, carbon monoxide, cyanide, organophosphate)?

Emergency Management of Acute Toxic Inhalation

Immediately remove the patient from the toxic environment, administer 100% high-flow oxygen via non-rebreather mask (10-15 L/min) without delay, establish IV access, and prepare specific antidotes based on the suspected toxin while providing aggressive airway and cardiovascular support. 1, 2, 3

Initial Stabilization (All Toxic Inhalations)

Immediate Actions

• Remove all contaminated clothing and decontaminate exposed skin with copious water irrigation for at least 15 minutes to prevent continued absorption and secondary contamination of healthcare staff 4
• Administer 100% oxygen immediately via non-rebreather mask at 10-15 L/min—do not delay oxygen therapy while awaiting diagnostic confirmation 2, 3
• Secure airway early if patient shows signs of upper airway compromise (soot around mouth/nose, hoarseness, stridor, or altered mental status) 5
• Establish cardiac monitoring with 12-lead ECG to detect ischemia or dysrhythmias 2

Respiratory Support Algorithm

• If patient requires >6 L/min oxygen or shows persistent respiratory distress despite conventional oxygen, escalate to high-flow nasal cannula (HFNC) as first-line noninvasive support 6, 7
• HFNC is superior to conventional oxygen for preventing intubation in patients with PaO2/FiO2 ≤200 mmHg and respiratory rate >25 breaths/minute 6
• Consider early intubation if patient has depressed mental status, inability to protect airway, or refractory hypoxemia despite HFNC 1

Carbon Monoxide Poisoning

Diagnostic Approach

• Obtain carboxyhemoglobin (COHb) level immediately via co-oximetry—standard pulse oximetry is falsely reassuring, showing SpO2 >90% even with COHb levels as high as 25% 2
• Suspect CO poisoning in any enclosed-space fire victim with altered mental status, soot around mouth/nose, or plasma lactate ≥10 mmol/L 8
• Normal PaO2 does not rule out CO poisoning, as CO causes "anemic hypoxia" with normal dissolved oxygen 2

Treatment Protocol

• Continue 100% normobaric oxygen until COHb normalizes (<3% in nonsmokers, <10% in smokers) and symptoms resolve, typically 6 hours 3
• Consider hyperbaric oxygen (HBO2) at 3.0 atmospheres for: 1, 3
  • Loss of consciousness during or after exposure
  • Neurological deficits or seizures
  • Ischemic cardiac changes on ECG
  • COHb >25%
  • Pregnancy with any symptoms of CO poisoning
  • Severe metabolic acidosis
• Administer up to three HBO2 treatments if symptoms persist 3

Cyanide Poisoning

Recognition

• Suspect cyanide in fire victims with severe metabolic acidosis (lactate ≥8 mmol/L), altered mental status, seizures, or cardiovascular collapse despite oxygen therapy 1, 8
• Cyanide and CO poisoning frequently coexist in structure fires—assess for both 5, 9, 10

Antidote Administration

• First-line: Hydroxocobalamin 5 grams IV over 15 minutes (preferred because it does not cause hypotension or worsen oxygen-carrying capacity) 1
• Alternative: Sodium nitrite 300 mg (10 mL of 3% solution) IV at 2.5-5 mL/minute, followed immediately by sodium thiosulfate 12.5 grams (50 mL of 25% solution) IV over 10-30 minutes 1, 8
• Use sodium nitrite only when hydroxocobalamin is unavailable, as it can cause methemoglobinemia and hypotension 1
• Sodium thiosulfate enhances cyanide elimination and is reasonable to add to either hydroxocobalamin or sodium nitrite 1, 8
• Monitor blood pressure continuously during antidote infusion and slow rate if hypotension develops 8

Organophosphate/Nerve Agent Poisoning

Clinical Recognition

• Cholinergic crisis presentation: excessive secretions (salivation, lacrimation, bronchorrhea), miosis, muscle fasciculations, bradycardia, bronchospasm, and altered mental status 1, 11
• Severe cases progress to seizures, respiratory failure, and cardiovascular collapse 1

Antidote Protocol

• Atropine 2-4 mg IV every 5-10 minutes until secretions are controlled—do not give atropine if patient is significantly hypoxemic due to risk of ventricular fibrillation 11
• Maintain atropinization for at least 48 hours until cholinesterase activity recovers 11
• Pralidoxime (2-PAM) 1000-2000 mg IV over 15-30 minutes, followed by repeat doses every 10-12 hours if muscle weakness persists 11
• Pralidoxime is most effective if given within 36 hours of exposure but should be administered as soon as organophosphate poisoning is suspected 11

Airway Management Considerations

• Avoid succinylcholine for intubation as it is contraindicated with anticholinesterase activity 11
• Patients require full awakening and clearance of secretions before extubation, as delayed muscle weakness can occur up to 4 days post-exposure 1
• Monitor for rhabdomyolysis (check creatine kinase and potassium) and treat with aggressive hydration and urine alkalinization if myoglobinuria develops 1

Chlorine Gas Inhalation

Decontamination

• Strip all clothing outside the medical facility and irrigate skin/eyes with copious water for 15 minutes to prevent secondary contamination 4
• Healthcare personnel must wear organic vapor cartridge respirators or powered air-purifying respirators—surgical masks are inadequate 4

Supportive Care

• Administer humidified oxygen and bronchodilators for bronchospasm 4
• No specific antidote exists—treatment is entirely supportive with aggressive airway management 4

Critical Pitfalls to Avoid

• Never delay oxygen administration while awaiting laboratory confirmation of CO or cyanide poisoning 2, 3
• Never rely on pulse oximetry or PaO2 to rule out CO poisoning—these are falsely normal 2
• Never discharge patients without identifying and eliminating the toxin source to prevent re-exposure 3
• Never use morphine, theophylline, aminophylline, or phenothiazines in organophosphate poisoning as they worsen toxicity 11
• Never give atropine to hypoxemic patients before correcting oxygenation due to arrhythmia risk 11
• Never assume a single toxin exposure—fire victims commonly have combined CO and cyanide poisoning requiring treatment for both 5, 9, 10

Follow-Up Requirements

• All CO poisoning patients require clinical follow-up at 1-2 months to assess for delayed neurological sequelae (memory disturbance, depression, anxiety, sleep disorders) 3
• Patients with cardiac involvement need cardiology follow-up 3
• Organophosphate victims require monitoring for at least 48-72 hours due to risk of delayed toxicity from continued GI absorption 11

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