NOTE: Refer to the JTS Inhalation Injury and Toxic Industrial Chemical Exposure CPG-25 for additional information. 4
1. Inhalation injury occurs secondary to smoke exposure and is exacerbated by retained carbonaceous particles (soot) and chemicals. Clinical signs include progressive voice changes, soot about the mouth and nares, hypoxia, and shortness of breath (See Initial Burn Survey for airway management recommendations). If available, use bronchoscopic lavage to remove debris. Be judicious, as excessive irrigation may transport irritants to uninjured lung. Serial bronchoscopy may be required to remove large debris or casts. Patients diagnosed with inhalation injury should receive aerosolized unfractionated heparin 5000 units per ETT every 4 hours; mix heparin with albuterol, as heparin can induce bronchospasm.
2. Populations at risk for carbon monoxide (CO) toxicity include those exposed in enclosed spaces to fires, engines, and cooking stoves. Symptoms of CO toxicity include confusion, stupor, coma, seizures, and cardiac ischemia. Administer 100% oxygen and measure CO-hemoglobin levels via co-oximetry if available. Hyperbaric oxygen therapy may further reduce the CO-hemoglobin half-life but this therapy is cumbersome and not available while deployed.
3. Cyanide is encountered in fires and industrial processes. Early effects include dizziness, headache, nausea, and anxiety. High dose exposure causes rapid onset of coma, seizure, respiratory depression, hypotension, and tachycardia. Lactic acidosis > 8 mmol/L is common. Administer 100% oxygen via mechanical ventilation. Hydroxocobalamin is the preferred antidote; infuse 5 grams IV over 7 minutes. It may be infused over 2-5 minutes in cases of cardiac arrest or severe hypotension, and may be repeated if no clinical improvement.4 CyanokitTM should be available at every Role 3 hospital and Role 2 hospitals as well if there is a high risk of managing burn casualties.
4. Hydrogen fluoride (HF) is a byproduct of standard fire suppression systems. Exposure to HF may result in rapidly progressive or fatal respiratory failure despite minimal external evidence of injury. Symptoms include shortness of breath, cough, or hypoxia; there must be a high level of suspicion for HF inhalation.9 Treatment is supportive. If hypocalcemia is present, administer nebulized calcium gluconate (1.5 ml of 10% calcium gluconate in 4.5 ml water) q4hr until normalization of serum calcium levels. In the absence of significant burns, consider steroids if symptoms do not improve. Bronchopneumonia can develop within a week.