Smoke Inhalation Injury

Aka: Smoke Inhalation Injury, Smoke Inhalation, Inhalation Injury, Airway Management in Burn Injury

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II. Epidemiology

  1. Incidence: 5% of hospitalized burn patients have Inhalation Injury
  2. Leading cause of death from Burn Injury (responsible for 50-80% of burn-related deaths)
  3. Inhalation Injury increases mortality in burn patients by 3 fold

III. Pathophysiology

  1. Upper airway is typically affected by Heat Injury
    1. Air Temperatures in fires are typically hundreds of degrees higher at head level than at floor
    2. Steam inhalation and chemicals, in contrast, cause sub-glottic, more distal injury
  2. Inhalation injuries are mediated by chemical lung injury (not typically heat)
    1. Results in large volume fluid influx into the lungs

IV. Risk Factors

  1. Entrapment within burning structure
  2. Burns to head, face, neck or chest

V. Signs: Findings suggestive of Smoke Inhalation

  1. Altered Mental Status
    1. Burn Injury alone should not alter mentation
  2. Full thickness facial burns
  3. Singed facial hair (e.g. nasal hair)
  4. Oral and nasal mucosal Burn Injury
  5. Burn Injury occuring in a confined space
  6. Sputum with soot (carbonaceous Sputum)
  7. Hoarseness or Stridor
  8. Bullae in oropharynx or Larynx
  9. Productive Cough

VI. Signs: Respiratory distress (late findings)

  1. Dyspnea
  2. Tachypnea
  3. Wheezing
  4. Rhonchi
  5. Hypoxia
  6. Nasal flaring
  7. Accessory Muscle use (e.g. intercostal retractions)

VII. Labs

  1. Arterial Blood Gas
  2. Serum Lactic Acid
    1. Increased with cyanide Poisoning
    2. No specific Cyanide lab testing in most clinical settings
  3. Carboxyhemoglobin level
    1. Increased with Carbon Monoxide Poisoning
    2. Continuous finger probe Carboxyhemoglobin monitoring is commercially available
  4. Complete Blood Count
  5. Consider serum Troponin
    1. Indicated for Chest Pain, EKG changes or increased Cardiovascular Risk

VIII. Imaging

  1. Chest XRay
    1. Typically normal early in course of Inhalation Injury

IX. Diagnostics

  1. Electrocardiogram
    1. Observe for Myocardial Ischemia
  2. Pulmonary Function Tests
  3. Nasolaryngoscopy
  4. Flexible Bronchoscopy
    1. Evaluate the extent of upper airway and Bronchial injury

X. Complications

  1. Carbon Monoxide Poisoning
  2. Cyanide Poisoning
    1. Results from inhalation of burning materials (e.g. wool, silk, polyurethane, plastics and vinyl)
    2. Consider in residential and industrial fires, especially if concurrent Carbon Monoxide Poisoning
    3. Hypotension may be the only initial finding
    4. Late findings include decreased mental status, Bradycardia, respiratory depression and cardiovascular collapse
  3. Methemoglobinemia
  4. Respiratory injury
    1. Particulate matter and sulfur and nitrogen compounds result in direct lung injury and VQ Mismatch
    2. Causes Hypoxia, airway edema, airway obstruction and ARDS

XI. Evaluation

  1. Altered Mental Status
    1. Burn Injury alone is typically associated with alert, Agitated Patient in pain
    2. Decreased level of conciousness suggests other cause
      1. Carbon Monoxide Poisoning
        1. May be associated with Headache, Nausea, Vomiting, Dizziness, myalgias
      2. Cyanide Poisoning
      3. Head Trauma

XII. Precautions

  1. Children under age 8 years (esp. under age 2 years) are more susceptible to airway edema
    1. See Advanced Airway in Children
    2. Children have narrow airways at baseline (e.g. 4 mm)
      1. Even 1 mm of circumferential airway edema may drop airway diameter by 50% (increased resistance 16 fold)
    3. Children have a shorter, narrower airway that is unable to cool hot air as it is inspired
      1. Extensive injury to distal Bronchioles and alveoli may occur more easily in children

XIII. Management

  1. See Burn Injury
  2. Monitoring
    1. Intravenous Access
    2. Oxygen Saturation monitoring
    3. Telemetry monitoring
  3. Interventions: Airway
    1. Supplemental Oxygen 100% Non-Rebreathing Mask
      1. Continue until Carboxyhemoglobin <5% (at least <10% in smokers)
      2. Carbon Monoxide decreases 50% in 60 minutes on Non-Rebreather Mask
      3. Carbon Monoxide decreases 50% in 30 minutes on 100% oxygen while intubated
      4. Cyanide exposure is also common in enclosed structure fires
        1. Hydrogen cyanide forms from burning wool, silk, polyurethane and nylon
    2. Consider hyperbaric oxygen (see indications below)
    3. Consider Advanced Airway and Mechanical Ventilations
      1. Monitor upper airway closely and prophylactically intubate early if airway compromise is suspected
      2. Airway edema peaks at 12 hours after Inhalation Injury
      3. Mechanical Ventilation settings (lung protective strategy)
        1. Keep Tidal Volumes at 3-5 ml/kg
        2. Keep plateau pressures <30 cm H2O
        3. Administer PEEP
      4. Rapid Sequence Intubation precautions
        1. Succinylcholine is typically safe in acute Burn Injury
        2. Hyperkalemia risk starts at 5 days post-injury (protocols recommend avoiding 48 hours after burn)
      5. Endotracheal Tube precautions
        1. Place at least a 7.5 Endotracheal Tube (otherwise more difficult suctioning, bronchoscopy)
        2. Have a back-up smaller Endotracheal Tube, in case unable to pass the larger ET Tube (airway edema)
        3. Use lower ET Tube cuff pressure to prevent trachea-esophageal fistula
        4. Secure and monitor the Endotracheal Tube well
          1. Accidental Endotracheal Intubation may be very difficult to replace due to edema
    4. Endotracheal Intubation indications
      1. Includes all standard intubation indications
        1. See Advanced Airway
        2. Respiratory Failure
        3. Altered Mental Status
        4. Unprotected airway or inability to handle own secretions
      2. Expectation of further tracheal edema within next 24 hours
      3. Hoarseness or increasing Stridor (upper airway obstruction)
      4. Supraglottic edema and inflammation on bronchoscopy or Nasolaryngoscopy
      5. Severe Third Degree Burns to face or oropharynx
      6. Extensive burns >20% BSA
      7. Circumferential neck burn
      8. Prolonged transport and tenuous airway status
      9. Respiratory Muscle Fatigue
      10. Hypoventilation (PCO2>50 mmHg and pH <7.20)
      11. Hypoxemia despite maximal Supplemental Oxygen
        1. Carbon Monoxide >20% may require intubation due to Hypoxemia
  4. Other interventions
    1. Intravenous crystalloid
      1. See Burn Management (includes Parkland Formula)
      2. Maintain urinary output of 0.5 to 1 mL/kg/hour
    2. Opioid Analgesics
    3. Airway adjuncts to consider
      1. Bronchodilators (e.g. Nebulized Albuterol) for Wheezing, or Asthma Exacerbation
      2. Humidified oxygen (decreases thickness of secretions)
      3. Nebulized Epinephrine
        1. Consider for temporary stabilization of upper airway symptoms until definitive management
      4. Inhaled Mucolytics (may help clear Fibrin, mucus and debris from airway)
        1. Inhaled N-Acetylcysteine
        2. Inhaled Heparin
      5. Systemic Corticosteroids may be indicated in certain inhalations
        1. However, not routinely recommended aside from specific indications
        2. Examples: Nitrogen oxide, Zinc Oxide, sulfur trioxide, titanium tetrachloride
        3. Discuss with poison control, pulmonology or burn center
    4. Cyanokit (IV Hydroxycobalamin)
      1. Empiric therapy for suspected cyanide Poisoning
      2. Indications (Paris Fire Brigade Protocol)
        1. Known Smoke Inhalation in an enclosed space AND
        2. One of the following criteria
          1. Altered Mental Status
          2. Soot in nares or mouth
          3. Full cardiopulmonary arrest (without full body burns incompatible with life)
      3. Dosing
        1. Hydroxycobalamin (Vitamin B12a) 70 mg/kg up to 5 grams IV over 15 minutes
        2. May give a second dose up to 5 grams
      4. Efficacy
        1. Resulted in 50% ROSC rate in full arrest Smoke Inhalation patients
        2. Much safer empiric therapy than the Lily Kit (Methemoglobinemia, Hypotension)
        3. Hydroxycobalamin neutralizes Cyanide without affecting cellular oxygen use
      5. Adverse Effects
        1. Skin Flushing
        2. Red pigmented urine
      6. References
        1. Fortin (2006) Clin Toxicol 44 (suppl 1):37-44 +PMID:16990192 [PubMed]
        2. Borron (2007) Ann Emerg Med 49(6): 794-801 +PMID:17481777 [PubMed]

XIV. Disposition

  1. Monitor in Emergency Department for at least 4-6 hours
    1. Observe with serial exams, Vital Signs and diagnostics
    2. Discharge with close interval follow-up if normal observation without significant airway symptoms
  2. Hospitalization indications
    1. Enclosed space inhalation exposure for >10 minutes
    2. Sputum with soot
    3. pAO2 <60 mmHg
    4. Metabolic Acidosis
      1. Increased Anion Gap and Lactic Acidosis with cyanide Poisoning
    5. Carboxyhemoglobin >15%
    6. A-a Gradient >100 mmHg on 100% Supplemental Oxygen
    7. Significant symptoms or signs (Central facial burns, painful Swallowing or bronchospasm)
  3. Hyperbaric oxygen therapy indications
    1. Base Excess < -2 mmol/L
    2. Carboxyhemoglobin >25% (or >20% in pregnancy, in which fetal Hemoglobin is more CO avid)
    3. Cerebellar symptoms (e.g. Ataxia) or Altered Mental Status
    4. Pulmonary Edema
    5. Cardiac Arrhythmia or Acute Coronary Syndrome
    6. Very young or very old

XV. References

  1. Lafferty in Alcock (2013) Smoke Inhalation Injury, Medscape EMedicine (accessed 12/11/2013)
  2. Latenser in Bope (2011) Burn Treatment Guidelines, Conn's Current Therapy, Elsevier, p. 1151
  3. Schwartz in Cydulka (2011) Tintinalli's Emergency Medicine 7ed, McGraw Hill, New York (accessed 12/11/2013)
    1. http://www.accessmedicine.com/content.aspx?aID=6385384
  4. Tonellato (2022) Crit Dec Emerg Med 33(4): 12
  5. Weir (2020) Crit Dec Emerg Med 34(12): 3-11
  6. Sheridan (2016) N Engl J Med 375(5): 464-9 +PMID: 27518664 [PubMed]

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Related Studies

Ontology: Smoke Inhalation Injury (C0037367)

Definition (MSH) Pulmonary injury following the breathing in of toxic smoke from burning materials such as plastics, synthetics, building materials, etc. This injury is the most frequent cause of death in burn patients.
Concepts Injury or Poisoning (T037)
MSH D015208
ICD10 T59.81 , J70.5
SnomedCT 426936004, 212861004, 35844001, 212863001, 366957009, 367182000
English Inhalation Injuries, Smoke, Inhalation Injury, Smoke, Injuries, Smoke Inhalation, Injury, Smoke Inhalation, Smoke Inhalation Injuries, Smoke inhalation, INHAL INJ SMOKE, SMOKE INHAL INJ, INJ SMOKE INHAL, Smoke inhalation injury (disorder), Smoke inhalation injury, Smoke Inhalation Injury, Smoke Inhalation Injury [Disease/Finding], smoke inhalation injury, inhalation smoke, smoke inhalation, smoke inhalation injuries, Smoke inhalation NOS, Smoke Inhalation, Smoke inhalation (event), Smoke inhalation (disorder), Smoke inhalation (finding), Inhalation;smoke
Dutch rookinhalatie, Rookinhalatietrauma, Trauma, rookinhalatie-
French Inhalation de fumée, Lésion par inhalation de fumées, Blessure par inhalation de fumée, Lésion par inhalation de fumée, Lésions d'inhalation de fumée
German Rauchinhalation, Rauchgasverletzung, Vergiftung, Rauchgas-
Italian Inalazione di fumo, Lesione da inalazione da fumo
Portuguese Inalação de fumos, Lesão por Inalação de Fumaça
Spanish Inhalación de humo, lesión por inhalación de humo, lesión por inhalación de humo (trastorno), inhalación de humo, inhalación de humo (trastorno), Lesión por Inhalación de Humo
Japanese 煙の吸引, ｹﾑﾘﾉｷｭｳｲﾝ, 煤煙吸入傷害, 吸入傷害-ばい煙, ばい煙吸入傷害, 有毒ガス吸入障害, 煤煙吸入損傷
Swedish Inhalationsskador, rök
Czech kouř - poranění inhalací, Vdechnutí kouře
Finnish Savuinhalaatiovamma
Russian INGALIATSIIA DYMOM, TRAVMA, DYMA VDYKHANIE, INGALIATSIONNYE TRAVMY, INGALIATSIONNYE TRAVMY DYMOM, DYMA VDYKHANIE, DYKHATEL'NYE RASSTROISTVA, ДЫМА ВДЫХАНИЕ, ДЫХАТЕЛЬНЫЕ РАССТРОЙСТВА, ДЫМА ВДЫХАНИЕ, ИНГАЛЯЦИОННЫЕ ТРАВМЫ, ИНГАЛЯЦИОННЫЕ ТРАВМЫ ДЫМОМ, ИНГАЛЯЦИЯ ДЫМОМ, ТРАВМА
Croatian DIM, OŠTEĆENJE INHALACIJOM
Polish Urazy wziewne, Uszkodzenia wywołane wdychaniem dymu
Hungarian Füst inhalatioja
Norwegian Røykskade, Inhalasjonsbrannskader, røyk
Derived from the NIH UMLS (Unified Medical Language System)

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