New Thinking About Treating Smoke Inhalation Victims

Anybody who has worked in the fire service long enough eventually will treat a victim of smoke inhalation. Sometimes it is a civilian and at other times it may be a firefighter.

Smoke inhalation is more commonly associated with fire deaths than burns. In many cases where a dead burn victim is found, more frequently than not, the person died from smoke inhalation prior to burning. The latest estimate puts the number of smoke inhalation deaths between 5,000 and 10,000 each year. Another 23,000 injuries occur annually from smoke inhalation, including some 5,000 firefighters.

Because of lightweight construction and the increased use of synthetics in buildings and furnishings, today’s fireground environment is likely to reach flashover in a shorter period than before. As a fireground environment reaches flashover much sooner, the levels of toxic gases in the smoke also increase dramatically.

The reduced flashover time also means there is a reduced time for firefighters to intervene before flashover occurs. Conversely, it also means that potential smoke inhalation victims have much less time to escape. All that adds up to increased potential for incapacitation from smoke, thus more severe injuries.

One byproduct of fire is smoke. Smoke contains particulate matter and heated gases, such as hydrochloric acid, sulfur dioxide, ammonia and carbon dioxide, and toxins, including hydrogen sulfide and hydrogen cyanide.

Throughout history, cyanide has been used as a murder weapon, an agent of mass suicide, a war weapon and a terrorist weapon. When cyanide was used as a murder weapon, it was inserted into everyday products ingested by consumers such as Tylenol in 1982 (seven deaths), Sudafed in 1991 (two deaths) and a Coca-Cola product in 2003 (one death). Cyanide was used as an agent of mass suicide in 1978, when 913 followers of the Reverend Jim Jones committed suicide with cyanide-spiked Kool-Aid. Cyanide also was used in genocide when the Nazis in World War II used Zyklon B in concentration camp gas chambers. During World War I, the French used approximately 4,000 tons of cyanide against the Germans, and the Japanese allegedly used cyanide against the Chinese in World War II.

Terrorists also like cyanide. It has been speculated that terrorists placed cyanide in the truck used in the bombing of the World Trade Center in 1993, but it incinerated with the explosion. Cyanide was also used in the 1995 Tokyo subway attack, the 2002 London underground plot, the 2002 Rome water-supply plot and a 2003 incident in Texas.

New research from independent studies about smoke inhalation victims may very well change the treatment modality. More and more evidence suggests that victims of smoke inhalation are also suffering from cyanide poisoning.

Cyanide kills quickly by disabling the blood’s mechanism for carrying oxygen. Cyanide in a fire comes from natural substances such as wool, silk, cotton or paper. Synthetic substances, such as plastics and other polymers, also produce cyanide.

Two studies, one done in Dallas County, TX, and the other in Paris, France, were designed to assess the role of cyanide in fire-related morbidity and mortality. In both studies, blood samples were drawn as close as possible to the times of exposure to smoke.

In the Paris study, conducted in 1988 and 1989, blood was collected by the first-arriving medical squads to residential fires. A total of 109 fire victims were studied – 66 who survived and 43 who died. The data was compared against 114 control individuals – 40 with drug intoxication, 29 with carbon monoxide poisoning and 45 with major trauma.