Burning plastics, wool and other materials in house fires release hydrogen cyanide, which blocks the cells from using oxygen. Smoke inhalation victims with altered consciousness, low blood pressure or high lactate should be treated for both cyanide and carbon monoxide.
Key symptoms
- Headache, confusion and agitation
- Shortness of breath
- Seizures or collapse
- Soot around the nose and mouth
What you find on exam
- Scene safety and removal from smoke
- Level of consciousness
- Low blood pressure, slow or fast heart rate, arrhythmia
- Airway burns: soot, stridor, hoarse voice
Tests
- Lactate: very high levels suggest cyanide
- Blood gas with carboxyhemoglobin
- ECG and cardiac monitoring
- Cyanide level is slow and does not guide early care
Treatment basics
- Remove from smoke and give 100 percent oxygen
- Airway control if there are signs of airway burn
- IV hydroxocobalamin 5 g for suspected cyanide toxicity
- Treat seizures and low blood pressure
- Consider hyperbaric oxygen for carbon monoxide
Red flags
- Altered mental status after smoke exposure
- Hypotension or cardiac arrest
- Lactate of 8 mmol/L or higher
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Related guides
Sources: NASEMSO National Model EMS Clinical Guidelines; National EMS Education Standards (2021). Written by Making Synapses. Making Synapses is not affiliated with these organizations.