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Smoke inhalation commonly occurs in fire victims and is associated with high morbidity and mortality. In addition to thermal injury, burning organic and inorganic materials can produce a very large number of different toxins, leading to chemical injury to the respiratory tract as well as systemic effects from absorption of poisons through the lungs. “Smoke bombs” do not release true smoke but can be hazardous because of irritant components, particularly zinc chloride.

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  1. Mechanism of toxicity. Smoke is a complex mixture of gases, fumes, and suspended particles. Injury may result from the following:

    1. Thermal damage to the airway and tracheobronchial passages.

    2. Irritant gases, vapors, and fumes that can damage the upper and lower respiratory tract (See Gases, Irritant). Many common irritant substances are produced by thermal breakdown and combustion, including acrolein, hydrogen chloride, phosgene, and nitrogen oxides.

    3. Asphyxia due to consumption of oxygen by the fire and production of carbon dioxide and other gases.

    4. Toxic systemic effects of inhaled carbon monoxide, cyanide, and other systemic poisons. Cyanide is a common product of combustion of plastics, wool, and many other natural and synthetic polymers.

  2. Toxic dose. The toxic dose varies depending on the intensity and duration of the exposure. Inhalation in a confined space with limited egress is typically associated with delivery of a greater toxic dose.

  3. Clinical presentation

    1. Thermal and irritant effects include singed nasal hairs, carbonaceous material in the nose and pharynx, cough, wheezing, and dyspnea. Stridor is an ominous finding that suggests imminent airway compromise due to swelling in and around the larynx. Pulmonary edema, pneumonitis, and adult respiratory distress syndrome (ARDS) may occur. Inhalation of steam is strongly associated with deep thermal injury but is not complicated by systemic toxicity.

    2. Asphyxia and systemic intoxicants may cause dizziness, confusion, syncope, seizures, and coma. In addition, carbon monoxide poisoning (See Carbon monoxide), cyanide poisoning (See Cyanide), and methemoglobinemia (See Methemoglobinemia) have been documented in victims of smoke inhalation.

  4. Diagnosis should be suspected in any patient brought from a fire, especially with facial burns, singed nasal hairs, carbonaceous deposits in the upper airways or in the sputum, or dyspnea.

    1. Specific levels. Carboxyhemoglobin and methemoglobin levels can be measured with co-oximetry. Unfortunately, cyanide levels are not readily available with short turnaround times; thus, the diagnosis is usually based on clinical findings.

    2. Other useful laboratory studies include arterial blood gases or oximetry, chest radiography, spirometry, or peak expiratory flow measurement. Arterial blood gases, pulse oximetry, and chest radiograph may reveal early evidence of chemical pneumonitis or pulmonary edema. However, arterial blood gases and conventional pulse oximetry are not reliable in patients with carbon monoxide poisoning or methemoglobinemia. (A newer pulse CO-oximeter is capable of detecting carboxyhemoglobin and methemoglobin.)

  5. Treatment

    1. Emergency and supportive measures

      1. Immediately assess the airway; hoarseness or stridor suggests laryngeal edema, which may necessitate direct laryngoscopy and endotracheal intubation if sufficient swelling is present (See Perform endotracheal intubation). Assist ventilation if necessary (See Breathing).

      2. Administer high-flow supplemental oxygen by ...

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