Initial assessment (ABCDE) (ABCDE; concurrent burn **TBSA**; enclosed-space fire, duration of exposure, loss of consciousness; soot in nares/oropharynx, singed nasal hairs, carbonaceous sputum; stridor, hoarseness, dysphagia, facial burns = airway risk; obtain **COHb** (ABA, AAP, ERC, WHO))
Carbon monoxide recognition (Headache, nausea, confusion, syncope — **cherry-red skin unreliable in children**; COHb: mild **<10–15%**, moderate **15–25%**, severe **>25%** or neurologic symptoms; pulse oximetry **unreliable** for CO — use COHb (ABA, AAP, ERC))
First-line therapy
Oxygen • inhaled
Duration: Until COHb normalizes · 100% O₂ via **non-rebreather** at 10–15 L/min — first-line for all suspected CO exposure; continue until COHb normal and symptoms resolved; wean only when serial COHb acceptable (ABA, AAP, ERC)
• **ABCDE + exposure history:** enclosed-space fire, duration, LOC; assess concurrent burns (TBSA) — see **Burns** card for fluid resuscitation and burn-centre referral (ABA, AAP, WHO).
• **Physical signs:** soot in nares/oropharynx, singed nasal hairs, carbonaceous sputum; stridor, hoarseness, dysphagia, facial/oral burns — even mild symptoms warrant admission and airway vigilance (ABA, ERC).
• **COHb interpretation:** mild <10–15% · moderate 15–25% · severe >25% or any neurologic symptoms; treat all symptomatic patients with **100% O₂** regardless of level (ABA, AAP, ERC).
• **Pulse oximetry limitation:** standard SpO₂ does **not** detect carboxyhemoglobin — falsely reassuring; obtain **venous or arterial COHb**; repeat until normalized (ABA, AAP).
• **Bronchodilators:** salbutamol if bronchospasm/wheeze — does not replace O₂ or CO monitoring (AAP asthma principles, ERC).
Duration: As indicated · Consider **HBO** for severe CO poisoning; admit any symptomatic inhalation, abnormal COHb, facial/oral burns, hoarseness, or concurrent significant burns (ABA, AAP, ERC, WHO)
• **HBO indications:** severe neurologic symptoms, COHb **>25%**, loss of consciousness, cardiac ischemia, or high risk of neurologic sequelae — consult toxicology/HBO center; transfer when stable; balance with burn/inhalation airway stability (ABA, AAP, ERC).
• **Hospital admission:** any symptomatic smoke inhalation, abnormal COHb, facial/oral burns, hoarseness, stridor (observe even if not intubated), concurrent significant burns, or cyanide treatment given (ABA, AAP, WHO).
• **Cyanide suspicion (mild pathway):** enclosed-space fire + altered mental status, lactic acidosis, normal SpO₂ with disproportionate illness, or shock — escalate to severe pathway; consult poison center; do not delay hydroxocobalamin if high suspicion (ABA, AAP).
• **C-spine:** immobilize only if jump/fall mechanism with trauma concern — not routine for all fire victims (ABA, ERC trauma principles).
• ABCDE + exposure: enclosed-space fire, duration, LOC; soot/singed hairs/carbonaceous sputum; facial burns, hoarseness, stridor = airway risk — do not wait for florid edema (ABA, AAP, ERC).
• 100% O₂ via non-rebreather reduces CO half-life; continue until COHb normalizes; pulse oximetry unreliable for CO — obtain serial COHb (ABA, AAP).
• COHb: mild <10–15% · moderate 15–25% · severe >25% or neuro symptoms — consider HBO consult for severe poisoning; transfer to HBO-capable center when indicated (ABA, ERC).
• Hospital admission: symptomatic inhalation, abnormal COHb, airway signs, facial/oral burns, concurrent burns, or cyanide treatment — see **Burns** for concurrent thermal injury (ABA, AAP, WHO).
• Bronchoscopy not routine for all — reserve for severe inhalation, persistent pulmonary failure, atelectasis, or unclear airway (ABA, AAP).
• ABA — Inhalation injury and airway management in burn patients (2024)
