Fundamentals in the clinical management of intoxication due to smoke inhalation

Dueñas-Laita A, Burillo Putze G, Alonso JR, Bajo Bajo A, Climent García B, Corrales Magin E, Felices F, Ferrer Dufol A, Hernández Frutos MP, Nogué S, Puiguriguer Ferrando J

Intoxication due to smoke inhalation is the main cause of morbidity and mortality from

fires. Smoke is a mixture of carbon particles suspended in hot air containing toxic gases.

Carbon monoxide (CO) and cyanuric acid are the gases that are mainly responsible for

tissue anoxia. The clinical signs of intoxication due to smoke inhalation vary. They may

include eye irritation, sore throat, laryngeal stridor, dysphagia, soot in sputum, cough,

breathlessness, laryngeal spasm, bronchospasm, coronary syndrome, coma, hypoxemia,

lactic acidosis, cyanosis, and death. A finding of soot in the nostrils, mouth or sputum

suggests severe intoxication. Lactate dehydrogenase levels over 10 mmol/L are indicative

of cyanuric acid levels over 40 mmol/L. Pulse oximetry has represented an important

advance for diagnosis, examination, and follow-up in this setting. The possible need for

early intubation must be assessed and oxygen administration (at 100%) is essential. The

treatment of choice for cyanuric acid poisoning is hydroxocobalamin. This antidote must

be administered promptly whenever a patient has inhaled smoke (soot in mouth, throat

or sputum), shows neurologic signs (confusion, coma, agitation, convulsions), or has any

of the following signs: bradypnea, respiratory arrest, cardiac arrest, shock, hypotension,

lactate dehydrogenase over 8 mmol/L, or lactic acidosis. Thereafter, management will be

dictated by symptoms or complications.

Alonso JR, Bajo Bajo A, Burillo-Putze G, Climent García B, Corrales Magin E, Dueñas Laita A, Felices F, Ferrer Dufol A, Hernández Frutos MP, Nogué S, Puiguriguer Ferrando J