Smoke Inhalation ConcernAPPROACH

RESPIRATORY · 19 SECTIONS

⚲

589 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Wheezing, Undifferentiated Wheezing In Infants Stridor And Upper Airway Symptoms Dyspnea Aspiration Event Cough Hemoptysis Upper Respiratory Infection Symptoms Suspected Pulmonary Embolism Presentation Smoke Inhalation Concern Smoke Exposure And Inhalational Injury

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx67

Exposure details

›Exposure timeline and setting

›Enclosed space exposure

›Duration of exposure

›Time since last exposure

›Source material

›Structural fire smoke

›Wildfire smoke

›Chemical smoke

›Explosion

›Loss of consciousness

›Estimated proximity to flame

›Rescue details

›Self extricated

›Found down

›Required CPR

›Co exposed individuals

›Other symptomatic contacts

›Pets affected

Presenting symptoms OPQRST

›Symptom characterization

›Primary symptom

›Dyspnea

›Cough

›Chest tightness

›Sore throat

›Hoarseness

›Associated symptoms

›Wheeze

›Stridor

›Sputum

›Carbonaceous sputum

›Headache

›Dizziness

›Nausea

›Confusion

›Syncope

›Seizure

›Chest pain

›O onset

›Sudden onset

›Gradual onset

›Delayed onset after exposure

›P provocation and palliation

›Worse with exertion

›Worse when supine

›Relief with oxygen

›Q quality

›Burning throat

›Tightness

›Irritative cough

›R region and radiation

›Upper airway symptoms

›Lower chest symptoms

›S severity

›Dyspnea at rest

›Dyspnea on exertion

›Speech limitation

›T timing

›Progressive symptoms

›Improving symptoms

›Episodic symptoms

Baseline and prior episodes

›Baseline respiratory and neurologic status

›Baseline exercise tolerance

›Baseline oxygen requirement

›Prior smoke inhalation

›Prior CO exposure

›Prior asthma exacerbations

›Prior COPD exacerbations

02Alarm Features/alarm26

Immediate airway and respiratory threats

›High risk airway features

›Stridor

›Voice change

›Drooling

›Inability to handle secretions

›Progressive facial or neck swelling

›Oropharyngeal blistering

›Extensive facial burns

Shock and end organ threat

›High risk vital sign patterns

›SpO2 below 90 percent on room air

›Respiratory rate 30 or higher

›Systolic BP below 90 mmHg

›Heart rate 130 or higher

›Temperature 38.5 C or higher

›GCS 14 or less

Toxic exposure red flags

›CO and cyanide red flags

›Altered mental status

›Syncope

›Seizure

›Severe metabolic acidosis

›Lactate 10 mmol per L or higher

›Hemodynamic instability despite oxygen

Escalation triggers

›Immediate escalation logic

›If impending airway compromise then early intubation

›If persistent hypoxemia on high flow oxygen then ventilatory support

›If suspected cyanide toxicity with shock or lactate 10 mmol per L or higher then antidote per protocol

03Medications/meds29

Current medications and interactions

›Medication reconciliation relevance

›Inhaled bronchodilators

›Inhaled corticosteroids

›Systemic steroids

›Beta blockers

›Sedatives

›Opioids

›Anticoagulants

›Antiplatelets

High risk medication considerations

›Medication related risks

›Chronic opioid use

›Hypoventilation risk

›Higher aspiration risk

›Benzodiazepines

›Delirium risk

›Respiratory depression risk

›Warfarin or DOAC

›Airway bleeding risk with instrumentation

›Trauma related bleeding risk

Treatment medication contraindication screen

›Contraindications to common therapies

›Nebulized beta agonist caution

›Significant tachyarrhythmia

›Severe ischemic chest pain

›Systemic steroid caution

›Active uncontrolled infection concern

›Poorly controlled diabetes

›Hyperbaric contraindication prompts

›Untreated pneumothorax

›Inability to equalize pressure

04Diet/diet10

Intake and hydration

›Recent intake status

›Poor oral intake

›Vomiting

›Dehydration risk

›Aspiration risk

Inhalational exposure modifiers

›Recent exposures

›Alcohol use around exposure

›Smoking or vaping baseline

›Recent inhaled drug use

›Occupational smoke or fumes exposure

05Review of Systems/ros24

Respiratory and ENT

›Airway and breathing symptoms

›Dyspnea

›Wheeze

›Stridor

›Cough

›Hemoptysis

›Sore throat

›Hoarseness

›Dysphagia

Neurologic and systemic

›Neuro and constitutional symptoms

›Headache

›Dizziness

›Confusion

›Syncope

›Seizure

›Weakness

›Fever

›Chills

Cardiovascular and GI

›Cardiac and GI symptoms

›Chest pain

›Palpitations

›Nausea

›Vomiting

›Abdominal pain

06Collateral History and Family History/chafh10

Collateral and scene information

›Collateral reliability

›EMS report

›Fire service report

›Bystander report

›Family report

Family history relevant to risk

›Family history

›Premature coronary artery disease

›Sudden cardiac death

›Inherited anemia or hemoglobinopathy

›Malignant hyperthermia history

07Risk Factors/rf30

Patient factors increasing severity

›High risk patient groups

›Age 65 years or older

›Pregnancy

›Chronic lung disease

›Asthma

›COPD

›Interstitial lung disease

›Coronary artery disease

›Heart failure

›Anemia

›Chronic kidney disease

›Immunocompromised state

Exposure and environmental risks

›Exposure features increasing toxicity

›Enclosed space fire

›Prolonged exposure time

›Found down

›Synthetic material combustion

›Industrial chemical exposure

Airway edema and delayed deterioration risks

›Predictors of airway compromise

›Facial burns

›Neck burns

›Oropharyngeal burns

›Soot in mouth or nose

›Hoarseness

›Stridor

›Need for large volume resuscitation

Thrombosis and bleeding risks

›Co morbid risks

›Active anticoagulation

›Recent surgery or trauma

›Prior VTE history

08Differential Diagnosis/ddx55

Life threatening

›Life threatening causes

›Upper airway thermal injury with obstruction

›Rapidly progressive stridor

›Oropharyngeal burns

›Carbon monoxide poisoning (T58)

›Headache with exposure

›Altered mental status

›Ischemic ECG changes

›Cyanide poisoning (T65.0)

›Shock

›Severe lactic acidosis

›Acute respiratory failure (J96.00)

›Persistent hypoxemia

›Hypercapnia

›ARDS (J80)

›Bilateral infiltrates

›High oxygen requirement

›Inhalation associated bronchospasm with impending fatigue

›Rising CO2

›Exhaustion

›Burn associated inhalation injury with systemic toxicity (T27)

›Enclosed space fire

›Carbonaceous sputum

›Pneumothorax related to blast or barotrauma (J93.9)

›Unilateral decreased breath sounds

›Pleuritic chest pain

Common

›Common causes

›Smoke induced bronchitis

›Cough

›Normal imaging early

›Asthma exacerbation (J45.901)

›Wheeze

›Triggered by irritant smoke

›COPD exacerbation (J44.1)

›Increased dyspnea

›Increased sputum

›Chemical irritant exposure without burns

›Burning eyes

›Throat irritation

›Anxiety or panic reaction (F41.0)

›Paresthesias

›Normal oxygenation

Less common

›Less common and mimics

›Aspiration pneumonitis (J69.0)

›Vomiting

›New focal infiltrate

›Pneumonia (J18.9)

›Fever

›Focal consolidation

›Acute coronary syndrome (I21.9)

›Chest pain

›Troponin elevation

›Toxic inhalation pneumonitis from specific chemicals (T59)

›Delayed pulmonary edema

›Exposure specific odor history

09Past Medical History/pmh27

Respiratory and cardiac history

›Relevant chronic disease history

›Asthma

›Prior ICU admission

›Prior intubation

›COPD

›Baseline home oxygen

›Baseline hypercapnia history

›Obstructive sleep apnea

›Home CPAP use

›Opioid sensitivity history

›Coronary artery disease

›Prior MI

›Prior PCI or CABG

›Heart failure

›Baseline EF

›Baseline diuretic use

Other relevant history

›Other comorbidities and procedures

›Diabetes mellitus (E11.9)

›Chronic kidney disease (N18.9)

›Seizure disorder (G40.909)

›Prior airway surgery

›Prior tracheostomy

›Psychiatric disease with self harm risk

Baseline functional status

›Functional baseline

›Baseline ADL independence

›Baseline mobility

›Caregiver support reliability

10Physical Exam/exam48

General and vital signs interpretation

›General assessment

›Work of breathing

›Ability to speak full sentences

›Mental status

›Signs of distress

›Vital sign patterns

›Hypoxemia on room air

›Tachypnea

›Fever

›Hypotension

›Tachycardia

Airway and ENT

›Upper airway exam

›Facial burns

›Singed nasal hairs

›Soot in nares

›Soot in oropharynx

›Oral burns

›Uvular edema

›Tongue swelling

›Hoarseness

›Stridor

Pulmonary and chest

›Lung exam

›Wheeze

›Crackles

›Diminished breath sounds

›Prolonged expiratory phase

›Accessory muscle use

›Chest wall and burn survey

›Circumferential chest burns

›Restrictive chest excursion

›Associated trauma signs

Cardiovascular and perfusion

›Perfusion and hemodynamics

›Capillary refill delay

›Cool extremities

›New murmur

›Dysrhythmia

Neurologic

›Neurologic status

›GCS

›Focal deficits

›Ataxia

›Agitation

›Seizure activity

Skin

›Burn and exposure findings

›Total body surface area estimate prompt

›Burn depth prompt

›Cyanosis

›Cherry red skin prompt

›Urticaria or angioedema signs

11Lab Studies/labs29

Core labs for inhalation toxicity

›Initial laboratory evaluation

›Venous blood gas or arterial blood gas

›pH trend for acidosis

›PaCO2 for ventilatory failure

›PaO2 for hypoxemia

›Co oximetry

›Carboxyhemoglobin level

›Methemoglobin level

›Lactate

›Cyanide toxicity support if markedly elevated

›Trend with resuscitation

›CBC

›Leukocytosis for infection or stress

›Hemoglobin for anemia risk

›CMP

›Creatinine for renal dosing

›AST ALT for hypoxic injury

›Troponin

›Myocardial ischemia from CO exposure

›Serial testing if symptoms or ECG changes

Point of care testing and pitfalls

›Diagnostic limitations

›Pulse oximetry limitation with CO exposure

›Normal PaO2 does not exclude CO poisoning

›Early imaging may be normal despite inhalation injury

Infection and aspiration evaluation

›When fever or focal findings

›Blood cultures

›Sputum culture

›Procalcitonin local protocol dependent

›Viral testing local protocol dependent

12Imaging/img46

Scoring Systems

›Severity tools and structured assessment

›CO poisoning severity markers

›Neurologic symptoms

›Cardiac ischemia

›Pregnancy

›High carboxyhemoglobin

›Cyanide toxicity markers

›Lactate 10 mmol per L or higher in enclosed space fire

›Shock not responding to oxygen

›Burn inhalation injury structured approach

›Enclosed space exposure

›Soot in airway

›Facial burns

MRI

›MRI considerations

›Indications

›Delayed neurologic deficits after CO exposure

›Persistent altered mental status with unclear etiology

›Contraindications

›MRI incompatible implanted device

›Hemodynamic instability

›Interpretation pearls

›Basal ganglia injury pattern in CO exposure

›Alternative diagnoses if atypical pattern

›CT considerations

›CT chest indications

›Suspected inhalation pneumonitis with severe hypoxemia

›Concern for occult trauma

›CT neck indications

›Concern for deep neck space injury

›Concern for airway structural injury

›Contrast cautions

›Kidney injury risk

›Contrast allergy history

›Interpretation pearls

›Airway edema

›Ground glass changes for inhalation injury

Ultrasound

›POCUS applications

›Lung ultrasound

›B lines for pulmonary edema

›Pneumothorax evaluation

›Cardiac ultrasound

›LV function assessment

›RV strain assessment if alternative diagnosis concern

›IVC assessment

›Volume status support

›Integration with overall shock assessment

13Special Tests/spec17

Airway evaluation adjuncts

›Airway focused tests

›Flexible nasolaryngoscopy

›Supraglottic edema assessment

›Soot and thermal injury assessment

›Bronchoscopy

›Lower airway soot burden assessment

›Airway edema and sloughing assessment

Gas exchange and monitoring adjuncts

›Additional physiologic testing

›Serial blood gases

›Rising PaCO2 for fatigue

›Worsening acidosis trend

›Serial lactate

›Response to resuscitation

›Persistent elevation suggesting ongoing toxicity

›Continuous end tidal CO2

›Ventilation adequacy

›Early hypoventilation detection

14ECG/ecg16

Indications and high risk patterns

›ECG use cases

›Any suspected CO poisoning

›Chest pain

›Syncope

›Palpitations

›Older age or cardiac risk factors

›High risk ECG findings

›ST elevation

›ST depression

›T wave inversion in ischemic pattern

›Ventricular arrhythmia

›High grade AV block

Serial ECG logic

›Repeat ECG triggers

›Persistent symptoms

›Rising troponin

›Hemodynamic instability

15Assessment/ax26

Problem representation and severity

›Working problem list

›Suspected smoke inhalation injury (T27)

›Upper airway risk features present

›Lower airway symptoms present

›Oxygen requirement trend

›Suspected carbon monoxide poisoning (T58)

›Exposure context supportive

›Neurologic symptoms supportive

›Carboxyhemoglobin level supportive

›Suspected cyanide toxicity (T65.0)

›Enclosed space fire supportive

›Lactate markedly elevated supportive

›Shock supportive

Complications to rule out

›Immediate complications

›Airway obstruction progression

›Acute respiratory failure

›Aspiration

›ARDS

›Myocardial ischemia

›Dysrhythmia

Diagnostic uncertainty and alternatives

›Alternative diagnoses if discordant data

›Asthma exacerbation

›COPD exacerbation

›Pneumonia

›Pulmonary embolism

›ACS

16Plan/plan66

First 5 minutes

›Immediate stabilization workflow

›Resuscitation bay triggers

›Stridor

›Altered mental status

›SpO2 below 90 percent on oxygen

›Hypotension

›Monitoring

›Continuous pulse oximetry

›Continuous cardiac monitoring

›End tidal CO2 when available

›Access

›Two large bore IV if moderate to severe symptoms

›IO if unable to obtain IV in unstable patient

›Oxygen

›Non rebreather 15 L per minute for suspected CO exposure

›Escalate to HFNC or NIV for persistent hypoxemia

›Airway

›Early intubation if high risk airway features

›Prepare difficult airway and backup plan

Diagnostics and sequencing

›Initial diagnostic bundle

›Co oximetry and lactate early

›Blood gas early if respiratory distress

›ECG within 10 minutes if chest pain or CO concern

›Chest radiograph for moderate to severe symptoms

›Reassessment loop

›Recheck vitals every 15 minutes until stable

›Repeat airway exam for evolving edema

›Repeat blood gas if rising work of breathing

›Repeat lactate if suspected cyanide toxicity

Therapeutics

›Respiratory support and symptom control

›Bronchodilator for bronchospasm

›Salbutamol 5 mg nebulized

›Repeat every 20 minutes times 3 then reassess

›Ipratropium for moderate to severe bronchospasm

›0.5 mg nebulized

›Repeat every 20 minutes times 3 then reassess

›Systemic steroid for asthma or COPD trigger local protocol dependent

›Prednisone 50 mg PO once

›Methylprednisolone 125 mg IV once if unable to take PO

›Humidified oxygen

›Comfort

›Secretion clearance

›Carbon monoxide poisoning treatment

›High flow oxygen until asymptomatic and levels improving

›Hyperbaric consult triggers local protocol dependent

›Pregnancy

›Loss of consciousness

›Persistent neurologic symptoms

›Myocardial ischemia

›Severe metabolic acidosis

›Suspected cyanide toxicity treatment

›Hydroxocobalamin IV local protocol dependent

›Adult dose 5 g IV over 15 minutes

›Repeat 5 g IV if severe or persistent instability

›Supportive shock care

›Balanced crystalloid bolus 500 mL

›Repeat based on perfusion and ultrasound findings

›Norepinephrine infusion if persistent hypotension

›Analgesia and sedation

›Avoid respiratory depression when possible

›Titrate to effect with close monitoring

Consultation

›Specialty involvement

›Burn center consult for suspected inhalation injury with burns

›Toxicology or poison center consult for CO or cyanide concern

›Hyperbaric service consult when criteria met

›ICU consult for ventilatory support or significant toxicity

17Disposition/dispo30

ICU and admission criteria

›ICU level care criteria

›Intubation or impending airway compromise

›Persistent hypoxemia requiring HFNC NIV or mechanical ventilation

›Hemodynamic instability

›Severe acidosis

›Significant neurologic impairment

›Significant cardiac ischemia or dysrhythmia

›Inpatient admission criteria

›Oxygen requirement beyond initial ED period

›Abnormal chest imaging with symptoms

›Persistent bronchospasm after ED therapy

›Elevated carboxyhemoglobin with symptoms

›Lactate elevation requiring serial monitoring

Observation pathway criteria

›Observation appropriate when

›Mild to moderate symptoms improving

›Stable vitals on minimal oxygen

›No high risk airway features

›Reliable reassessment capability

Discharge criteria and follow up

›Discharge criteria

›Normal mentation

›No stridor

›No hoarseness progression

›SpO2 94 percent or higher on room air or baseline requirement

›Tolerating oral intake

›No concerning ECG changes

›Reliable supervision and return access

›Follow up timing

›Primary care within 48 to 72 hours

›Burn clinic follow up if burns present

›Pulmonary follow up if persistent symptoms

18Discharge Instructions/di26

Copy discharge instructions

›Summary

›You were evaluated after breathing in smoke

›Your breathing and oxygen levels were stable at discharge

›Medications

›Use your inhaler as prescribed if you have asthma or COPD

›If a new inhaler was prescribed take it exactly as directed

›Avoid sedating medicines unless prescribed

›Activity

›Rest for 24 hours

›Avoid smoke exposure and strong fumes

›Avoid heavy exercise for 24 to 48 hours if symptoms return with exertion

›Follow up

›See your clinician within 2 to 3 days

›Return sooner if symptoms are not improving

›Return to the ED immediately for

›Trouble breathing at rest

›Noisy breathing

›New hoarse voice

›Trouble swallowing

›Chest pain

›Fainting

›Confusion

›Severe headache

›Vomiting that prevents drinking fluids

›Fever

›Worsening cough or coughing blood

19References/r7

Guidelines and key sources

›Evidence based sources

›Advanced Trauma Life Support ATLS 10th edition American College of Surgeons 2018

›American Burn Association guidelines for burn care and burn center referral most recent update local protocol dependent

›CDC clinical guidance for carbon monoxide poisoning most recent update local protocol dependent

›Undersea and Hyperbaric Medical Society UHMS indications for hyperbaric oxygen therapy most recent update local protocol dependent

›European Resuscitation Council guidance on toxic exposures and resuscitation relevant sections most recent update local protocol dependent

›Goldfrank Toxicologic Emergencies cyanide and carbon monoxide chapters most recent edition

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.

Smoke Inhalation ConcernAPPROACH

RESPIRATORY · 19 SECTIONS

⚲

589 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx67

Exposure details

›Exposure timeline and setting

›Enclosed space exposure

›Duration of exposure

›Time since last exposure

›Source material

›Structural fire smoke

›Wildfire smoke

›Chemical smoke

›Explosion

›Loss of consciousness

›Estimated proximity to flame

›Rescue details

›Self extricated

›Found down

›Required CPR

›Co exposed individuals

›Other symptomatic contacts

›Pets affected

Presenting symptoms OPQRST

›Symptom characterization

›Primary symptom

›Dyspnea

›Cough

›Chest tightness

›Sore throat

›Hoarseness

›Associated symptoms

›Wheeze

›Stridor

›Sputum

›Carbonaceous sputum

›Headache

›Dizziness

›Nausea

›Confusion

›Syncope

›Seizure

›Chest pain

›O onset

›Sudden onset

›Gradual onset

›Delayed onset after exposure

›P provocation and palliation

›Worse with exertion

›Worse when supine

›Relief with oxygen

›Q quality

›Burning throat

›Tightness

›Irritative cough

›R region and radiation

›Upper airway symptoms

›Lower chest symptoms

›S severity

›Dyspnea at rest

›Dyspnea on exertion

›Speech limitation

›T timing

›Progressive symptoms

›Improving symptoms

›Episodic symptoms

Baseline and prior episodes

›Baseline respiratory and neurologic status

›Baseline exercise tolerance

›Baseline oxygen requirement

›Prior smoke inhalation

›Prior CO exposure

›Prior asthma exacerbations

›Prior COPD exacerbations

02Alarm Features/alarm26

Immediate airway and respiratory threats

›High risk airway features

›Stridor

›Voice change

›Drooling

›Inability to handle secretions

›Progressive facial or neck swelling

›Oropharyngeal blistering

›Extensive facial burns

Shock and end organ threat

›High risk vital sign patterns

›SpO2 below 90 percent on room air

›Respiratory rate 30 or higher

›Systolic BP below 90 mmHg

›Heart rate 130 or higher

›Temperature 38.5 C or higher

›GCS 14 or less

Toxic exposure red flags

›CO and cyanide red flags

›Altered mental status

›Syncope

›Seizure

›Severe metabolic acidosis

›Lactate 10 mmol per L or higher

›Hemodynamic instability despite oxygen

Escalation triggers

›Immediate escalation logic

›If impending airway compromise then early intubation

›If persistent hypoxemia on high flow oxygen then ventilatory support

›If suspected cyanide toxicity with shock or lactate 10 mmol per L or higher then antidote per protocol

03Medications/meds29

Current medications and interactions

›Medication reconciliation relevance

›Inhaled bronchodilators

›Inhaled corticosteroids

›Systemic steroids

›Beta blockers

›Sedatives

›Opioids

›Anticoagulants

›Antiplatelets

High risk medication considerations

›Medication related risks

›Chronic opioid use

›Hypoventilation risk

›Higher aspiration risk

›Benzodiazepines

›Delirium risk

›Respiratory depression risk

›Warfarin or DOAC

›Airway bleeding risk with instrumentation

›Trauma related bleeding risk

Treatment medication contraindication screen

›Contraindications to common therapies

›Nebulized beta agonist caution

›Significant tachyarrhythmia

›Severe ischemic chest pain

›Systemic steroid caution

›Active uncontrolled infection concern

›Poorly controlled diabetes

›Hyperbaric contraindication prompts

›Untreated pneumothorax

›Inability to equalize pressure

04Diet/diet10

Intake and hydration

›Recent intake status

›Poor oral intake

›Vomiting

›Dehydration risk

›Aspiration risk

Inhalational exposure modifiers

›Recent exposures

›Alcohol use around exposure

›Smoking or vaping baseline

›Recent inhaled drug use

›Occupational smoke or fumes exposure

05Review of Systems/ros24

Respiratory and ENT

›Airway and breathing symptoms

›Dyspnea

›Wheeze

›Stridor

›Cough

›Hemoptysis

›Sore throat

›Hoarseness

›Dysphagia

Neurologic and systemic

›Neuro and constitutional symptoms

›Headache

›Dizziness

›Confusion

›Syncope

›Seizure

›Weakness

›Fever

›Chills

Cardiovascular and GI

›Cardiac and GI symptoms

›Chest pain

›Palpitations

›Nausea

›Vomiting

›Abdominal pain

06Collateral History and Family History/chafh10

Collateral and scene information

›Collateral reliability

›EMS report

›Fire service report

›Bystander report

›Family report

Family history relevant to risk

›Family history

›Premature coronary artery disease

›Sudden cardiac death

›Inherited anemia or hemoglobinopathy

›Malignant hyperthermia history

07Risk Factors/rf30

Patient factors increasing severity

›High risk patient groups

›Age 65 years or older

›Pregnancy

›Chronic lung disease

›Asthma

›COPD

›Interstitial lung disease

›Coronary artery disease

›Heart failure

›Anemia

›Chronic kidney disease

›Immunocompromised state

Exposure and environmental risks

›Exposure features increasing toxicity

›Enclosed space fire

›Prolonged exposure time

›Found down

›Synthetic material combustion

›Industrial chemical exposure

Airway edema and delayed deterioration risks

›Predictors of airway compromise

›Facial burns

›Neck burns

›Oropharyngeal burns

›Soot in mouth or nose

›Hoarseness

›Stridor

›Need for large volume resuscitation

Thrombosis and bleeding risks

›Co morbid risks

›Active anticoagulation

›Recent surgery or trauma

›Prior VTE history

08Differential Diagnosis/ddx55

Life threatening

›Life threatening causes

›Upper airway thermal injury with obstruction

›Rapidly progressive stridor

›Oropharyngeal burns

›Carbon monoxide poisoning (T58)

›Headache with exposure

›Altered mental status

›Ischemic ECG changes

›Cyanide poisoning (T65.0)

›Shock

›Severe lactic acidosis

›Acute respiratory failure (J96.00)

›Persistent hypoxemia

›Hypercapnia

›ARDS (J80)

›Bilateral infiltrates

›High oxygen requirement

›Inhalation associated bronchospasm with impending fatigue

›Rising CO2

›Exhaustion

›Burn associated inhalation injury with systemic toxicity (T27)

›Enclosed space fire

›Carbonaceous sputum

›Pneumothorax related to blast or barotrauma (J93.9)

›Unilateral decreased breath sounds

›Pleuritic chest pain

Common

›Common causes

›Smoke induced bronchitis

›Cough

›Normal imaging early

›Asthma exacerbation (J45.901)

›Wheeze

›Triggered by irritant smoke

›COPD exacerbation (J44.1)

›Increased dyspnea

›Increased sputum

›Chemical irritant exposure without burns

›Burning eyes

›Throat irritation

›Anxiety or panic reaction (F41.0)

›Paresthesias

›Normal oxygenation

Less common

›Less common and mimics

›Aspiration pneumonitis (J69.0)

›Vomiting

›New focal infiltrate

›Pneumonia (J18.9)

›Fever

›Focal consolidation

›Acute coronary syndrome (I21.9)

›Chest pain

›Troponin elevation

›Toxic inhalation pneumonitis from specific chemicals (T59)

›Delayed pulmonary edema

›Exposure specific odor history

09Past Medical History/pmh27

Respiratory and cardiac history

›Relevant chronic disease history

›Asthma

›Prior ICU admission

›Prior intubation

›COPD

›Baseline home oxygen

›Baseline hypercapnia history

›Obstructive sleep apnea

›Home CPAP use

›Opioid sensitivity history

›Coronary artery disease

›Prior MI

›Prior PCI or CABG

›Heart failure

›Baseline EF

›Baseline diuretic use

Other relevant history

›Other comorbidities and procedures

›Diabetes mellitus (E11.9)

›Chronic kidney disease (N18.9)

›Seizure disorder (G40.909)

›Prior airway surgery

›Prior tracheostomy

›Psychiatric disease with self harm risk

Baseline functional status

›Functional baseline

›Baseline ADL independence

›Baseline mobility

›Caregiver support reliability

10Physical Exam/exam48

General and vital signs interpretation

›General assessment

›Work of breathing

›Ability to speak full sentences

›Mental status

›Signs of distress

›Vital sign patterns

›Hypoxemia on room air

›Tachypnea

›Fever

›Hypotension

›Tachycardia

Airway and ENT

›Upper airway exam

›Facial burns

›Singed nasal hairs

›Soot in nares

›Soot in oropharynx

›Oral burns

›Uvular edema

›Tongue swelling

›Hoarseness

›Stridor

Pulmonary and chest

›Lung exam

›Wheeze

›Crackles

›Diminished breath sounds

›Prolonged expiratory phase

›Accessory muscle use

›Chest wall and burn survey

›Circumferential chest burns

›Restrictive chest excursion

›Associated trauma signs

Cardiovascular and perfusion

›Perfusion and hemodynamics

›Capillary refill delay

›Cool extremities

›New murmur

›Dysrhythmia

Neurologic

›Neurologic status

›GCS

›Focal deficits

›Ataxia

›Agitation

›Seizure activity

Skin

›Burn and exposure findings

›Total body surface area estimate prompt

›Burn depth prompt

›Cyanosis

›Cherry red skin prompt

›Urticaria or angioedema signs

11Lab Studies/labs29

Core labs for inhalation toxicity

›Initial laboratory evaluation

›Venous blood gas or arterial blood gas

›pH trend for acidosis

›PaCO2 for ventilatory failure

›PaO2 for hypoxemia

›Co oximetry

›Carboxyhemoglobin level

›Methemoglobin level

›Lactate

›Cyanide toxicity support if markedly elevated

›Trend with resuscitation

›CBC

›Leukocytosis for infection or stress

›Hemoglobin for anemia risk

›CMP

›Creatinine for renal dosing

›AST ALT for hypoxic injury

›Troponin

›Myocardial ischemia from CO exposure

›Serial testing if symptoms or ECG changes

Point of care testing and pitfalls

›Diagnostic limitations

›Pulse oximetry limitation with CO exposure

›Normal PaO2 does not exclude CO poisoning

›Early imaging may be normal despite inhalation injury

Infection and aspiration evaluation

›When fever or focal findings

›Blood cultures

›Sputum culture

›Procalcitonin local protocol dependent

›Viral testing local protocol dependent

12Imaging/img46

Scoring Systems

›Severity tools and structured assessment

›CO poisoning severity markers

›Neurologic symptoms

›Cardiac ischemia

›Pregnancy

›High carboxyhemoglobin

›Cyanide toxicity markers

›Lactate 10 mmol per L or higher in enclosed space fire

›Shock not responding to oxygen

›Burn inhalation injury structured approach

›Enclosed space exposure

›Soot in airway

›Facial burns

MRI

›MRI considerations

›Indications

›Delayed neurologic deficits after CO exposure

›Persistent altered mental status with unclear etiology

›Contraindications

›MRI incompatible implanted device

›Hemodynamic instability

›Interpretation pearls

›Basal ganglia injury pattern in CO exposure

›Alternative diagnoses if atypical pattern

›CT considerations

›CT chest indications

›Suspected inhalation pneumonitis with severe hypoxemia

›Concern for occult trauma

›CT neck indications

›Concern for deep neck space injury

›Concern for airway structural injury

›Contrast cautions

›Kidney injury risk

›Contrast allergy history

›Interpretation pearls

›Airway edema

›Ground glass changes for inhalation injury

Ultrasound

›POCUS applications

›Lung ultrasound

›B lines for pulmonary edema

›Pneumothorax evaluation

›Cardiac ultrasound

›LV function assessment

›RV strain assessment if alternative diagnosis concern

›IVC assessment

›Volume status support

›Integration with overall shock assessment

13Special Tests/spec17

Airway evaluation adjuncts

›Airway focused tests

›Flexible nasolaryngoscopy

›Supraglottic edema assessment

›Soot and thermal injury assessment

›Bronchoscopy

›Lower airway soot burden assessment

›Airway edema and sloughing assessment

Gas exchange and monitoring adjuncts

›Additional physiologic testing

›Serial blood gases

›Rising PaCO2 for fatigue

›Worsening acidosis trend

›Serial lactate

›Response to resuscitation

›Persistent elevation suggesting ongoing toxicity

›Continuous end tidal CO2

›Ventilation adequacy

›Early hypoventilation detection

14ECG/ecg16

Indications and high risk patterns

›ECG use cases

›Any suspected CO poisoning

›Chest pain

›Syncope

›Palpitations

›Older age or cardiac risk factors

›High risk ECG findings

›ST elevation

›ST depression

›T wave inversion in ischemic pattern

›Ventricular arrhythmia

›High grade AV block

Serial ECG logic

›Repeat ECG triggers

›Persistent symptoms

›Rising troponin

›Hemodynamic instability

15Assessment/ax26

Problem representation and severity

›Working problem list

›Suspected smoke inhalation injury (T27)

›Upper airway risk features present

›Lower airway symptoms present

›Oxygen requirement trend

›Suspected carbon monoxide poisoning (T58)

›Exposure context supportive

›Neurologic symptoms supportive

›Carboxyhemoglobin level supportive

›Suspected cyanide toxicity (T65.0)

›Enclosed space fire supportive

›Lactate markedly elevated supportive

›Shock supportive

Complications to rule out

›Immediate complications

›Airway obstruction progression

›Acute respiratory failure

›Aspiration

›ARDS

›Myocardial ischemia

›Dysrhythmia

Diagnostic uncertainty and alternatives

›Alternative diagnoses if discordant data

›Asthma exacerbation

›COPD exacerbation

›Pneumonia

›Pulmonary embolism

›ACS

16Plan/plan66

First 5 minutes

›Immediate stabilization workflow

›Resuscitation bay triggers

›Stridor

›Altered mental status

›SpO2 below 90 percent on oxygen

›Hypotension

›Monitoring

›Continuous pulse oximetry

›Continuous cardiac monitoring

›End tidal CO2 when available

›Access

›Two large bore IV if moderate to severe symptoms

›IO if unable to obtain IV in unstable patient

›Oxygen

›Non rebreather 15 L per minute for suspected CO exposure

›Escalate to HFNC or NIV for persistent hypoxemia

›Airway

›Early intubation if high risk airway features

›Prepare difficult airway and backup plan

Diagnostics and sequencing

›Initial diagnostic bundle

›Co oximetry and lactate early

›Blood gas early if respiratory distress

›ECG within 10 minutes if chest pain or CO concern

›Chest radiograph for moderate to severe symptoms

›Reassessment loop

›Recheck vitals every 15 minutes until stable

›Repeat airway exam for evolving edema

›Repeat blood gas if rising work of breathing

›Repeat lactate if suspected cyanide toxicity

Therapeutics

›Respiratory support and symptom control

›Bronchodilator for bronchospasm

›Salbutamol 5 mg nebulized

›Repeat every 20 minutes times 3 then reassess

›Ipratropium for moderate to severe bronchospasm

›0.5 mg nebulized

›Repeat every 20 minutes times 3 then reassess

›Systemic steroid for asthma or COPD trigger local protocol dependent

›Prednisone 50 mg PO once

›Methylprednisolone 125 mg IV once if unable to take PO

›Humidified oxygen

›Comfort

›Secretion clearance

›Carbon monoxide poisoning treatment

›High flow oxygen until asymptomatic and levels improving

›Hyperbaric consult triggers local protocol dependent

›Pregnancy

›Loss of consciousness

›Persistent neurologic symptoms

›Myocardial ischemia

›Severe metabolic acidosis

›Suspected cyanide toxicity treatment

›Hydroxocobalamin IV local protocol dependent

›Adult dose 5 g IV over 15 minutes

›Repeat 5 g IV if severe or persistent instability

›Supportive shock care

›Balanced crystalloid bolus 500 mL

›Repeat based on perfusion and ultrasound findings

›Norepinephrine infusion if persistent hypotension

›Analgesia and sedation

›Avoid respiratory depression when possible

›Titrate to effect with close monitoring

Consultation

›Specialty involvement

›Burn center consult for suspected inhalation injury with burns

›Toxicology or poison center consult for CO or cyanide concern

›Hyperbaric service consult when criteria met

›ICU consult for ventilatory support or significant toxicity

17Disposition/dispo30

ICU and admission criteria

›ICU level care criteria

›Intubation or impending airway compromise

›Persistent hypoxemia requiring HFNC NIV or mechanical ventilation

›Hemodynamic instability

›Severe acidosis

›Significant neurologic impairment

›Significant cardiac ischemia or dysrhythmia

›Inpatient admission criteria

›Oxygen requirement beyond initial ED period

›Abnormal chest imaging with symptoms

›Persistent bronchospasm after ED therapy

›Elevated carboxyhemoglobin with symptoms

›Lactate elevation requiring serial monitoring

Observation pathway criteria

›Observation appropriate when

›Mild to moderate symptoms improving

›Stable vitals on minimal oxygen

›No high risk airway features

›Reliable reassessment capability

Discharge criteria and follow up

›Discharge criteria

›Normal mentation

›No stridor

›No hoarseness progression

›SpO2 94 percent or higher on room air or baseline requirement

›Tolerating oral intake

›No concerning ECG changes

›Reliable supervision and return access

›Follow up timing

›Primary care within 48 to 72 hours

›Burn clinic follow up if burns present

›Pulmonary follow up if persistent symptoms

18Discharge Instructions/di26

Copy discharge instructions

›Summary

›You were evaluated after breathing in smoke

›Your breathing and oxygen levels were stable at discharge

›Medications

›Use your inhaler as prescribed if you have asthma or COPD

›If a new inhaler was prescribed take it exactly as directed

›Avoid sedating medicines unless prescribed

›Activity

›Rest for 24 hours

›Avoid smoke exposure and strong fumes

›Avoid heavy exercise for 24 to 48 hours if symptoms return with exertion

›Follow up

›See your clinician within 2 to 3 days

›Return sooner if symptoms are not improving

›Return to the ED immediately for

›Trouble breathing at rest

›Noisy breathing

›New hoarse voice

›Trouble swallowing

›Chest pain

›Fainting

›Confusion

›Severe headache

›Vomiting that prevents drinking fluids

›Fever

›Worsening cough or coughing blood

19References/r7

Guidelines and key sources

›Evidence based sources

›Advanced Trauma Life Support ATLS 10th edition American College of Surgeons 2018

›American Burn Association guidelines for burn care and burn center referral most recent update local protocol dependent

›CDC clinical guidance for carbon monoxide poisoning most recent update local protocol dependent

›Undersea and Hyperbaric Medical Society UHMS indications for hyperbaric oxygen therapy most recent update local protocol dependent

›European Resuscitation Council guidance on toxic exposures and resuscitation relevant sections most recent update local protocol dependent

›Goldfrank Toxicologic Emergencies cyanide and carbon monoxide chapters most recent edition

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.