Smoke Inhalation—Part 2

Assessing the scene and your patient at the scene of fire


   Smoke inhalation is a caustic event that can be lethal. In the United States, there are between 5,000 and 10,000 deaths from smoke inhalation each year. In the May issue we reviewed assessing the scene and your patient. This month we review patient management.

Management

   Treatment should always start with securing the patient's airway, breathing and circulation, as well as management of any life-threatening injuries. Administer supplemental oxygen in cases of smoke inhalation. Depending on the source consulted, humidified oxygen may be used. Oxygen administration is important when trying to reverse or prevent hypoxia, as well as assisting with displacement of carbon monoxide from hemoglobin. The half-life (which can be broadly defined as the amount of time it takes for half of the active elements to be either broken down or eliminated from the body) of carbon monoxide at room temperature is approximately 3 to 4 hours; 100% oxygen reduces the half-life to a range of 30-90 minutes. Hyperbaric oxygen can reduce the half-life of CO to 15-30 minutes.1-3

   Aggressive airway management may be required in cases of smoke inhalation. Heat exchange in the upper airway is normally efficient. Because of this, distal airway involvement may be spared, while the upper airway remains at increased risk for injury and edema. Airway injury is possible due to the direct effects of the products of combustion on the mucosa and alveoli. This can present a challenge in the field, as airway edema can develop quickly despite seemingly benign initial presentations.4-6

Airway & Breathing

   The following factors should be assessed in any patient who has been the victim of smoke inhalation: Is the patient's airway patent or at risk for becoming occluded? Is the patient able to speak in complete sentences, or is he speaking in partial sentences while using accessory muscles to breathe? Are there signs of potential smoke inhalation, such as soot in the nares and oropharynx?4-6

   Different techniques can be used to address the patient's airway. The head-tilt chin-lift is often used in atraumatic situations. A traumatic situation may require a chin-thrust or modified jaw-thrust. If the airway is closed or is at risk for closing, and depending on the patient's condition, consider using a variety of airway management techniques. Oropharyngeal or nasopharyngeal airways are useful to assist in preventing the tongue from occluding the patient's airway.4-9

   Advanced airway management may be needed in patients who show signs of possible respiratory tract injury, such as singed nasal hairs, facial burns, oral burns, sooty sputum, and/or respiratory difficulty with stridor or wheezes. There is extensive information available in the scientific literature regarding optimal airways in the field. Providers are encouraged to become familiar with the various techniques available. Examples include the use of rapid sequence intubation, blind nasotracheal intubation and surgical airways.4-6, 7

   Your decision to provide airway intervention must take numerous factors into consideration. The patient's overall condition, provider's experience level, provider's comfort level, location of the closest emergency department, local protocols and medical direction guidance are only a few of the variables that need to be considered. Each situation will be unique, and you should consult with your local protocols regarding the use of any advanced airway techniques.4-6, 7

Intravenous Fluids

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