wound care and pain management to minimize disability and improve cosmetic and functional outcomes Clinical Considerations In the appropriate clinical circumstances (fire, usually in an enclosed space) it is important to consider carbon monoxide and cyanide poisoning For carbon monoxide, one should administer 100% O2 and send a carboxyhemoglobin level Indications for potential hyperbaric treatment include loss of consciousness at the scene, persistent neurologic symptoms including seizure, evidence of cardiac injury, or significant elevation of carboxyhemoglobin levels (>25% to 40%) The decision to pursue hyperbaric treatment should be made in conjunction with a toxicologist, poison control center, or hyperbaric physician Cyanide poisoning must be treated before the quantitative level is available Indications to consider hydroxycobalamin treatment for cyanide toxicity include history of cardiopulmonary resuscitation (CPR), abnormal vital signs, intubation, evidence of hypoxic injury, and severe metabolic acidosis Clinical Recognition Recognition of the severely injured burn patient is based on a combination of the severity of burn and TBSA involved Burn shock occurs in adults with burns over 30% of BSA but may occur in children with burns over only 20% of BSA Circumferential burns and full-thickness burns are of the highest concern Triage Considerations Please see triage guidelines in Table 104.1 Major burns should be triaged to rapid physician assessment and care Clinical Assessment As part of the primary trauma survey, the clinician must be vigilant in carefully evaluating all patients for evidence of inhalational injury Patients with a history of fire exposure in an enclosed space, soot in the nose or mouth, or facial or airway burns may require intubation for airway protection These patients may also require treatment for carbon monoxide and cyanide exposure In the secondary survey, it is of the greatest