Clinical Recognition A history of exposure in a closed space should heighten concern for smoke inhalation Need for CPR at the site implies significant carbon monoxide poisoning and/or hypoxia secondary to decreased ambient oxygen concentration or severe respiratory disease The physician should also consider the types of material involved to determine the risk of poisoning from carbon monoxide or other toxins Important elements from the patient’s history include the mechanism of inhalation injury, duration of exposure, location, and pre-existing comorbidities Physical examination that reveals facial burns, singed nasal hairs, pharyngeal soot, or carbonaceous sputum justifies a presumption of smoke inhalation Any sign of neurologic dysfunction, including irritability or depression, should be presumed related to tissue hypoxia until proven otherwise Signs of respiratory dysfunction, including tachypnea, cough, hoarseness, stridor, decreased breath sounds, wheezing, rhonchi, or rales may be detected on presentation or may be delayed for 12 to 24 hours, depending on the severity of the insult Auscultatory findings often precede chest radiograph abnormalities by 12 to 24 hours Radiographic changes may include diffuse interstitial infiltration or local areas of atelectasis and edema ( Fig 90.3 ) Acute respiratory failure may occur at any point ABG analysis provides the ultimate assessment of effective respiratory function Fiberoptic bronchoscopy can document the extent and severity of injury by assessing for the presence of hyperemia, edema and soot, and can help remove debris In general, it is respiratory function, not the appearance of surface lesions, that guides supportive care; therefore, most patients can be treated effectively without bronchoscopy FIGURE 90.3 Smoke inhalation in a 9-year-old girl A: There is bilateral central alveolar process consistent with acute smoke inhalation B: A day later, the patient has been extubated and there is marked improvement in the appearance of pulmonary edema (Courtesy of Soroosh Mahboubi, MD, The Children’s Hospital of Philadelphia.) Triage Considerations Initial assessment and resuscitation at the scene should proceed according to the principles outlined in Chapter A General Approach to the Ill or Injured Child Because of the likelihood of carbon monoxide exposure and the difficulty of assessing hypoxemia clinically, all victims should receive the maximum concentration of inspired oxygen possible in transport and in the ED until further evaluation is complete ( Table 90.1 ) Clinical Assessment In the ED, assessment of airway and respiratory functions must proceed simultaneously with cardiovascular stabilization Supplemental oxygen at the maximum concentration should be provided, and if there is concern for cyanide toxicity (from burning plastic, vinyl, wool, or silk) then hydroxocobalamin IV (Cyanokit) should be administered at a dose of 70 mg/kg (maximum g) Thermal injury to the nose, mouth, or face, or compromise of the upper airway (stridor, hoarseness, barking cough, retractions, delayed inspiration, or difficulty handling secretions) indicates the need for direct laryngoscopy The presence of significant pharyngeal, supraglottic, or glottic edema is an indication for immediate elective endotracheal intubation because worsening edema may lead to respiratory arrest and a difficult emergency intubation through a distorted airway Elective tracheostomy may be considered if placing or securing the endotracheal tube will further traumatize an edematous airway or severe facial burns TABLE 90.1 MANAGEMENT OF SMOKE INHALATION ... endotracheal intubation because worsening edema may lead to respiratory arrest and a difficult emergency intubation through a distorted airway Elective tracheostomy may be considered if placing