Core EM - Emergency Medicine Podcast

Episode 207: Smoke Inhalation Injury

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We discuss the injuries sustained from smoke inhalation.

Hosts:

Sarah Fetterolf, MD
Brian Gilberti, MD

https://media.blubrry.com/coreem/content.blubrry.com/coreem/Smoke_Inhalation.mp3
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Tags: Environmental, Toxicology
Show Notes
Table of Contents

00:37 – Overview of Smoke Inhalation Injury

00:55 – Three Key Pathophysiologic Processes

01:41 – Physical Exam Findings to Watch For

02:12 – Airway Management and Early Intervention

03:23 – Carbon Monoxide Toxicity

04:24 – Workup and Initial Treatment of CO Poisoning

06:14 – Cyanide Toxicity

07:19 – Treatment Options for Cyanide Poisoning

09:12 – Take-Home Points and Clinical Pearls

Physiological Effects of Smoke Inhalation:
  • Thermal Injury:
    • Direct upper airway damage from heated air or steam.
    • Leads to swelling, inflammation, and possible airway obstruction.
    • Chemical Irritation:
      • Causes bronchospasm, mucus plugging, and inflammation in the lower airways.
      • Increases capillary permeability, potentially causing pulmonary edema.
      • Systemic Toxicity:
        • Primarily involves carbon monoxide and cyanide poisoning.
          • Clinical Signs and Symptoms:
          • Physical Exam:
            • Facial burns, singed nasal hairs
            • Hoarseness, stridor (upper airway swelling)
            • Carbonaceous sputum (lower airway edema)
            • Systemic Symptoms:
              • Headache, dizziness, nausea
              • Syncope, seizures, altered mental status
                • Airway Management Considerations:
                • Not every patient requires immediate intubation.
                • Intubation should be performed early if airway compromise is suspected, as swelling can rapidly progress.
                • Close airway monitoring recommended for all patients.
                  • Carbon Monoxide Poisoning:
                  • Common cause of death post-smoke inhalation (50–75% of fire-related injuries).
                  • Hemoglobin affinity 250 times greater for CO than oxygen, impairing tissue oxygenation.
                  • Diagnosis:
                    • Carboxyhemoglobin level via VBG (ensure proper lab ordering).
                    • Pulse oximetry unreliable; falsely high readings.
                    • Treatment:
                      • Immediate high-flow oxygen administration.
                      • Consider hyperbaric oxygen therapy for severe cases to reduce delayed neurocognitive sequelae.
                        • Cyanide Poisoning:
                        • Blocks cytochrome oxidase in electron transport chain, halting aerobic ATP production.
                        • Patients present critically ill; notable features include:
                          • Elevated lactate levels (>8–10 mmol/L)
                          • Arterialization of venous blood
                          • Treatment:
                            • First-line therapy: hydroxocobalamin (Cyanokit) binds cyanide forming vitamin B12 for renal excretion.
                            • Alternative: Cyanide antidote kit (amyl nitrite, sodium nitrite, sodium thiosulfate); induces methemoglobinemia and requires monitoring.
                            • Important note: hydroxocobalamin turns blood and urine bright red; draw labs beforehand.
                              • Key Takeaways:
                              • Assess for airway compromise and signs of inhalation injury early.
                              • Maintain a high index of suspicion for CO and cyanide poisoning in smoke inhalation victims.
                              • Immediate, aggressive oxygen therapy and early antidote administration can significantly impact outcomes.

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