Synopsis
Detect evolving inhalational airway injury and occult carbon monoxide or cyanide toxicity, give immediate oxygen and secure specialist toxicology and airway care.
- Smoke injury can combine upper-airway thermal damage, lower-airway chemical injury, carbon monoxide poisoning, cyanide toxicity, bronchospasm, trauma and cutaneous burns.
- An enclosed fire, loss of consciousness, neurological symptoms or several co-exposed household members should raise concern even when the patient looks pink and pulse oximetry seems normal.
- Standard pulse oximetry cannot distinguish oxyhaemoglobin from carboxyhaemoglobin reliably, while PaO2 measures dissolved oxygen and may remain normal in serious carbon monoxide poisoning.
Key red flags
Voice change, stridor, dysphagia, drooling, tongue or oropharyngeal swelling, facial or neck burns and increasing work of breathing predict a narrowing airway. Absence of external burns does not guarantee safety.
Investigation priorities
Define likely toxicants, dose and risk to others.
Management branches
Hoarseness, stridor, oral burns, swelling, respiratory fatigue or a high-risk enclosed fire.
- Move to a monitored resuscitation area, give high-concentration oxygen, remove contaminated clothing when relevant and call senior anaesthesia, critical care and the burns service early.
- Assess mouth, voice, neck, breathing effort and associated facial trauma repeatedly; do not rely on one normal laryngoscopic view or chest radiograph.
The airway is stable and immediate resuscitation is complete.
Key medicines
High-concentration oxygenGive 100% inspired oxygen by a tight-fitting reservoir mask or secured airway, then follow toxicology advice for duration and weaning.
HydroxocobalaminFor known or suspected cyanide poisoning, give an adult 5 g intravenously over 15 minutes. Depending on poisoning severity and clinical response, a second 5 g may be given over 15 minutes to 2 hours; the maximum total dose is 10 g. Give with decontamination and supportive care and follow live TOXBASE or NPIS advice.