This is the protocol for Smoke Inhalation:Smoke Inhalation
Let’s break it down!
Smoke inhalation is no stranger to soldiers. Whether it’s from a vehicle fire, a residential fire, or an explosive. Smoke inhalation is the primary cause of death for victims of fire, accounting for about 50-80% of deaths. Hot smoke injures or kills by a combination of thermal damage, poisoning, and pulmonary irritation and swelling, caused by carbon monoxide, cyanide, and other combustion products. For a more in-depth review, check out this video:
Carbon monoxide poisoning is also a common complication of smoke inhalation. The reason why carbon monoxide is harmful to the human body is because it has a higher affinity to hemoglobin than oxygen does. In other words, it essentially “boots” out the oxygen molecules from red blood cells and replaces it with something useless to the body. Since pulse oximeters only measure hemoglobin “saturation”, it’ll often show that the patient has a 100% SpO2. However, this is misleading. What the patient will ultimately need is hyperbaric oxygen therapy, which involves sending the patient to a facility with a special chamber designed for these specific types of injuries. There’s a good chance you won’t have one nearby, but it always helps to find out!
Any time someone has been close to a fire, particularly in an enclosed space, that should signal you to check for an inhalation injury. Sometimes the patient will only have subtle symptoms like a bad cough. Other times, they’ll clearly have burns around their face and be covered in soot. The video below shows a real patient with an inhalation injury:
Nearly one-third of all hospitalized burn patients with inhalation injury develop major upper airway obstruction. There’s a good chance that you’ll end up having to perform an advanced airway maneuver for these patients. If you don’t know when you need to pull the trigger to intubate or cric, here are few good indications:
- Lack of spontaneous breathing
- Severe facial burns
- Loss of consciousness
If you can’t remember how to intubate or do a cricothyroidotomy, check out these links:
This should be your immediate go-to if available. Patients with smoke inhalation or almost always hypoxic to some degree. High flow O2 via non-rebreather mask is preferred.
Albuterol is a beta 2 agonist, which means it acts as a bronchodilator. An inhaled agent that’ll expand the bronchi will help improve oxygenation. You use a meter dosed inhaler or you can use a nebulizer. This is how you do both if you don’t remember:
Dexamethasone is a steroid that functions to help prevent inflammation of the airway. Although this seemingly makes good sense, the use of dexamethasone is controversial and is generally accepted to have no role for routine use. Only use for the most severe cases.
For obvious reasons, we don’t want the patient to move around too much and exacerbate the inflammation in their airway. You should treat this in the same way you treat epiglottitis…very very carefully!
Most inhalation injuries do not result in any long-term functional impairments, but the initial response to inhalation burns and carbon monoxide poisoning is what poses the greatest threat to life. Regardless of how the patient seems at first, a Priority evacuation must be initiated. If there is an immediate threat to the airway, an Urgent evacuation will be necessary to provide definitive airway management.
Good luck out there!
- EMRAP Corependium: Thermal Burns
- UpToDate: Inhalation injury from heat, smoke, or chemical irritants
- Mlcak RP, Suman OE, Herndon DN. Respiratory management of inhalation injury. Burns. 2007;33(1):2–13. doi:10.1016/j.burns.2006.07.007
- Advanced Tactical Paramedic Protocols Handbook. 10th ed., Breakaway Media LLC, 2016.