Emergency Briefcase · Airway & Critical Care

Smoke & Fire Inhalation

A time-critical approach to airway injury, carbon monoxide exposure, cyanide toxicity, and burn resuscitation—without waiting for the classic findings.

Airway can worsen rapidlySpO₂ can misleadTreat before confirmation
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Commit Before You Reveal

Work the case in sequence. Each reveal adds information and forces the next decision.

Arrival

A 42-year-old is pulled from an enclosed-space house fire. Facial soot, hoarse voice, cough, and headache are present. SpO₂ is 99% on room air.

Best action: Give 100% oxygen immediately. Standard pulse oximetry cannot distinguish oxyhemoglobin from carboxyhemoglobin and may appear falsely reassuring.

Airway evolves

Progressive dysphonia, stridor, carbonaceous sputum, and increasing work of breathing develop.

Best action: Secure the threatened airway before edema makes laryngoscopy and ventilation more difficult. Optimize the first attempt and name the rescue plan.

Shock physiology

Lactate is 11 mmol/L with hypotension and altered mental status after the enclosed-space fire.

Best action: The exposure and physiology support presumptive cyanide toxicity. Do not delay antidote, airway, oxygenation, perfusion, seizure care, or evaluation for coexisting CO toxicity while waiting for an assay.
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Four Injuries, One Scene

Upper airwaySoot, facial burns, edema, hoarseness, dysphonia, stridor.
Lower airwayWheeze, cough, bronchorrhea, casts; bronchoscopy may define injury.
Carbon monoxideHeadache, confusion, syncope, ischemia; obtain co-oximetry.
CyanideEnclosed fire, shock, coma, seizure, severe lactate elevation.

Do not miss

Deterioration may reflect thermal airway edema, chemical lower-airway injury, CO, cyanide, cutaneous burns, and trauma simultaneously. Treat the syndrome—not a single number.

CO essentials

  • Start 100% oxygen before confirmation.
  • Use venous or arterial co-oximetry.
  • COHb level may not track clinical severity or exposure timing.
  • Consider hyperbaric consultation for severe neurologic, cardiac, metabolic, pregnancy, or high-level exposure features under local criteria.

Airway clues

  • Progressive hoarseness or stridor
  • Deep facial or oropharyngeal burns
  • Edema or secretion difficulty
  • Increasing work of breathing
  • Declining mental status or ventilation
  • Anticipated swelling or long transport
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First-Hour Actions

Remove from exposure; give 100% oxygenUse a tight-fitting nonrebreather or a secured airway with high inspired oxygen.
Secure a threatened airway earlyUse the most experienced operator, optimized first-pass strategy, smaller tube availability, and explicit rescue planning.
Test without delaying treatmentObtain ABG/VBG with co-oximetry, lactate, ECG, and troponin when indicated; assess trauma and burns.
Treat suspected cyanide toxicityWhen exposure and severe physiology are compelling, give hydroxocobalamin empirically while continuing full resuscitation.
Manage the whole burn patientTreat bronchospasm, trauma, hypothermia, pain, and burns; estimate TBSA, start indicated fluids, and consult a burn center.

Airway threat screen

Check all present findings. Multiple or progressive findings lower the threshold for a controlled early airway.

Select findings to build the airway-risk picture.

Critical action checklist

0 of 5 critical actions marked.
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Debrief and Knowledge Check

Normal SpO₂Standard pulse oximetry may look reassuring in CO poisoning.
No soot, no injuryImportant toxic exposure can occur without dramatic external burns.
Single-toxin thinkingCO and cyanide may coexist with thermal and chemical injury.
Waiting for testsTime-sensitive oxygen, airway, and antidotal treatment may precede confirmation.

1. Best immediate oxygen strategy?

Correct: Start 100% oxygen immediately when CO exposure is suspected.

2. A normal SpO₂ excludes CO poisoning.

False. Conventional pulse oximetry is inaccurate when carboxyhemoglobin is present.

3. Best airway timing with progressive stridor?

Correct: Anticipate worsening edema and avoid a crash airway.
0/3Complete the three questions to generate your result.

Bottom line

A normal saturation is not reassurance. Oxygen first, secure a threatened airway before edema wins, and treat suspected cyanide toxicity when the scene and physiology fit.

Emergency Briefcase · Smoke & Fire Inhalation