Smoke Inhalation Injuries

With many wildfires in the Western U.S. and Canada out of control and more reported daily, it’s clear that this is a very active fire season. Tens of thousands have been forced to evacuate their homes, and more than 1,000 structures have been destroyed. Although deaths have been few so far, air quality is poor in the fire areas and even far downwind. Smoke inhalation injuries are a possibility in some places.

You might be surprised to know that the greatest immediate threat in wildfires is rarely the flames themselves. More people die from smoke inhalation than from burns. For the family medic, therefore, knowing how to identify and treat this injury is essential.

Many believe that the ambulance is always just around the corner and the rescue helicopter is no more than a few minutes away. In natural disasters like wildfires and floods, however, medical personnel may be unable to reach those in need. In these situations, rapid recognition and intervention by those at the scene can mean the difference between life and death.

SMOKE COMPONENTS

Smoke is a complex mixture of gases, particulate matter, and chemical toxins produced by “incomplete combustion.” Incomplete combustion occurs when a fuel burns in a limited supply of oxygen. This leads to the production of harmful byproducts.

Common components include carbon monoxide, hydrogen cyanide, nitrogen oxides, and a host of toxic particles. The exact composition varies, depending on exactly what’s burning; plastics, treated wood, synthetic fabrics, and petroleum products are especially dangerous. In a long-term survival setting, a poorly ventilated wood stove or a brush fire can pose the same health hazards.

HOW SMOKE INHALATION KILLS

The damage occurs through three main mechanisms:

• Heat and toxic gases injure the upper airway, causing swelling that can rapidly obstruct breathing.

• Carbon monoxide binds to red blood cells far easier than oxygen, reducing the blood’s ability to carry oxygen to vital organs.

• Fine particles and chemical irritants penetrate deep into the lungs, triggering inflammation, fluid accumulation, and, later, infection.

Serious exposure can produce respiratory failure hours after the victim appears to have safely escaped the fire.

SYMPTOMS OF SMOKE INHALATION

Symptoms often begin with coughing, watery eyes, and a sore throat. Victims may report signs of early carbon monoxide poisoning, such as headache, dizziness, nausea, or confusion. Hoarseness, stridor (a high-pitched sound on inhalation), or facial burns around the mouth and nose are seen if there is an airway injury. Soot in the nostrils or mouth is another red flag. In severe cases, the patient becomes cyanotic (turns blue), restless, or loses consciousness.

Symptoms can worsen over the next 24-48 hours as swelling and inflammation progresses. A person who seems only mildly affected at the scene may later develop life-threatening respiratory distress.

TREATMENT OF SMOKE INHALATION

bag valve (AMBU) bag

In an austere environment, the medic must transport the victim from the smoke-filled area and into fresh air. If the patient is unconscious and not breathing, open the airway and begin rescue breathing or bag-valve-mask ventilation if available. High-flow oxygen is the mainstay of treatment but, off the grid, pure oxygen may not be an option. It’s important to know that even room air is better than continued exposure to smoke.

Assess the victim’s airway carefully. Look for singed nasal hairs, soot, facial burns, or worsening hoarseness. These findings indicate a high risk of obstruction. In a modern ER, a breathing tube would be placed early; If not available, keep the patient calm, elevate the head of the bed or litter, and prepare for the possibility of performing a tracheotomy if a complete obstruction develops. The procedure is described here.

The family medic should support breathing by encouraging coughing to clear secretions. If the patient can drink, small sips of water may help keep the airway moist. Monitor closely for increasing breathing rate, use of accessory (neck) muscles, or declining mental status.

Antibiotics are not needed for smoke inhalation alone, but secondary pneumonia may develop over the following days. Watch for fever and increased amounts of phlegm.

CARBON MONOXIDE

Carbon monoxide poisoning deserves special mention. In the absence of laboratory testing, assume significant exposure if the patient was in a closed space with a lot of smoke or if mental status is altered. Off the grid, fresh air and rest are the only practical treatments available. Avoid any activity that increases oxygen demand until the patient improves. This may take at least a few weeks.

AVOIDING SMOKE INHALATION INJURY

Prevention remains the most effective strategy. In a homestead or retreat, install and maintain working smoke detectors if power or batteries allow. Keep fire extinguishers charged and accessible. Design wood stoves and heating systems with proper ventilation.

In normal times, when the air quality is poor, you can protect yourself by:

• Staying indoors with the windows closed (turn the air conditioner on: Most central air conditioning systems do not pull air from the outside; they cool and recirculate the air already inside your home).

• Using a HEPA (high-efficiency particulate air) filter in your home.

During wildfire season, prepare for rapid evacuation and have N95 or better masks available for short-term use in smoky air. Teach family members the stop-drop-and-roll technique and the importance of staying low under smoke. The concentration of smoke is less the lower you go. If venturing into a smoke-dense environment, be sure to wear personal protection gear. A rescuer who becomes a second casualty helps no one.

For the group medic, smoke inhalation is a reminder that environmental injuries often outnumber classic trauma. Stocking simple airway supplies, knowing how to recognize progressive obstruction, and practicing basic respiratory support will serve the group well. In long-term disaster settings, knowledge and preparation remain the most reliable tools in the medical woodshed.

Joe Alton MD

Dr. Alton