EMT Standing Orders:

• Routine Patient Care. Remove the patient from the toxic environment.
• Oxygen 100% via a non-rebreather mask or BVM.
• Decontamination concurrent with initial resuscitation.
• If a CO oximeter is available, consider obtaining carbon monoxide levels.
• Acquire and transmit 12-lead ECG if available.
• If wheezing, consider albuterol 2.5 mg via nebulizer. May repeat every 5 minutes for continued symptoms.
• If altered mental status, check finger stick glucose by glucometer.
• See Burn/Electrocution/Lightning Protocol
• Call for AEMT/Paramedic intercept & assist them in patient care.

AEMT / PARAMEDIC STANDING ORDERS

• Establish IV access
• Consider CPAP for respiratory distress if available
• Consider early advanced airway control in patients with suspected upper or lower airway burns or severe smoke inhalation. See Airway Management Protocol (1 Airway Management).
• Consider epinephrine 3 mg (3 mL) 1:10000 in 3 mL 0.9% NaCl via nebulizer for symptomatic patients, especially if unable to obtain advanced airway.
• If you have a patient with a history of smoke exposure and an altered level of consciousness and/or hemodynamic or respiratory compromise, establish IV access and administer, if available
  • Hydroxocobalamin via use of Cyanokit:
  • Reconstitute: Place the vial of hydroxocobalamin in an upright position; add 0.9% NaCl to the vial (200 mL for 5 grams vial or 100 mL for 2.5 grams vial) using the transfer spike. Fill in the line.
  • Rock vial for at least 60 seconds (do not shake)
  • Using vented intravenous tubing, administer IV over 15 minutes.
  • Depending on clinical response, a second dose may be required.

Note

• Oxygen saturation may be inaccurate in patients exposed to carbon monoxide or cyanide.
• CO oximeter devices may yield inaccurate low/normal results for patients with CO poisoning. All patients with probable or suspected CO poisoning should be transported to the nearest appropriate hospital, based on their presenting signs and symptoms.
• Do not administer other drugs concurrently in the same IV.

Symptoms: headache, confusion, dyspnea, chest tightness, nausea.

Signs: soot in the nose or mouth, change in level of consciousness, seizure, dilated pupils, coughing, tachypnea and hypertension (early), bradypnea and hypotension (late), shock, vomiting.

PEARLS:

Smoke is a combination of many dangerous toxins produced by incomplete combustion. Patients exposed to smoke should be considered for carbon monoxide (CO) and hydrogen cyanide (HCN) poisoning.