Patient
Sourcing
Built directly from JRCALC G0630 (Burns and Scalds, v10.26), D0270 (Oxygen, v47.34) and the JRCALC CBRN chapter (section 4.2, Cyanide). There is no standalone JRCALC "smoke inhalation" guideline — content is drawn from these three chapters. Hydroxocobalamin is not a paramedic-scope drug under JRCALC; it is carried only by specialist teams (HART).
Signs / Increased Risk of Airway Burns Table 4.12
Tap all that apply. Likelihood of airway injury increases with number of risk factors present.
Time-Critical Features
Any one of these → correct A/B, TIME-CRITICAL transfer to nearest appropriate hospital, alert/information call.
Hot Air / Gas Inhalation — Warning
These patients may initially appear well but can deteriorate very rapidly and need complex airway intervention. Do not be reassured by a normal-looking patient with a history of enclosed-space exposure.
<C>ABCDE
- Airway — patency; early intervention may be required for inhalational burns. If intubation is impossible, needle cricothyroidotomy is the management of choice.
- Waveform capnography should be used whenever intubation is performed.
- Breathing — rate, depth, any breathing difficulty.
- Evidence of trauma — consider neck/back trauma pathways separately.
- Co-existing or precipitating medical conditions.
Burn Size Estimate
Rule of Nines / Lund and Browder preferred. For small or large burns (<15% or >85%) the patient's palmar surface including fingers ≈ 1% TBSA can be used. Do not attempt to grade depth (superficial/partial/full thickness) in the initial hours — impractical and unnecessary at this stage.
Consider risk of underestimating TBSA in patients with large breasts or who are obese — standardised charts can be affected.
Documentation prompts
- How the patient was burned / exposed
- Time of burn/exposure onset and duration of exposure
- Temperature of the source
- Whether first aid was undertaken before arrival
Oxygen
Major trauma / burns and scalds: 15 L/min via high concentration oxygen mask (target saturation 94–98% once vital signs normal, but continue high flow while abnormal in the prehospital phase).
Base the decision to treat on history (enclosed-space fire, smoke exposure) and clinical signs (headache, nausea, confusion, altered consciousness, or any neurological symptom) — not on the monitor.
If the history/symptoms fit: give high-concentration O₂ at maximum dose and keep it there until the patient has fully recovered — do not wean early to chase a 94–98% target. This is empirical/supportive management, not a monitored or confirmed diagnosis. Confirmation (COHb level) requires a hospital blood gas — a genuine diagnostic ceiling at this level of care. HART carry CO-measuring equipment; NWAS frontline crews do not.
Stop the Burning Process
Cool / Irrigate
- Irrigate with copious water as soon as practicable — effective up to 3 hours post-injury.
- Max 20 minutes irrigation, except chemical burns (acid/alkali/corrosive) — continue up to 1 hour; alkali burns require prolonged irrigation, continue until definitive care.
- Do NOT use ice or ice water — worsens burn injury and risks hypothermia.
- Saline if no other irrigant available.
Dress the Burn
Small sheets of clingfilm layered (do not wrap around limbs). Clean cotton sheet if no clingfilm. Elevate affected area if possible. Do NOT apply creams, ointments, wet gauze or non-adherent dressings — interferes with assessment.
Fluid Resuscitation
Caution in elderly patients or heart failure — use fluids judiciously, observe for circulatory overload. Do not delay transfer for cannulation — continue en-route.
Wheeze
If wheezing as a result of smoke inhalation: nebulised salbutamol, 6–8 litres O₂/min driving gas.
Cyanide — Recognition CBRN 4.2
Cyanide-containing gases can be formed from burning plastics and are often present in house fires. Acts at a cellular level inhibiting oxygen metabolism — cellular hypoxia can occur despite adequate inspired O₂ and normal SpO₂.
- Onset often very rapid — within 20–30 seconds of toxic exposure.
- Death can occur within 5–8 minutes of significant exposure.
- If the patient remains asymptomatic after 15 minutes, significant poisoning is unlikely unless exposure is ongoing.
Other CBRN Differentials Present in Fire Scenarios
Not exhaustive — consider if presentation is atypical for simple smoke exposure.
- Nerve agent / organophosphate pattern: excessive secretions, wheeze, confusion, convulsions, bradycardia. DuoDote® is the countermeasure of choice where administered per local protocol — not routine for house-fire smoke inhalation.
- Opioid pattern (illicit drug lab context): respiratory depression, decreased consciousness, pin-point pupils.
Escalation Decision
Most house fires are NOT CBRN incidents. Consider escalation only if the picture is atypical — e.g. multiple casualties with a common unexplained toxidrome, chemical/industrial premises, suspected deliberate release, or unusual smells/liquids/powders out of context for a domestic fire.
Transfer to Further Care
Convey to nearest ED if any of the following (list from JRCALC G0630, not exhaustive for CBRN):
- Any full-thickness burns
- Deep dermal burns >5% TBSA (adult) — all deep dermal burns in children
- All chemical and electrical burns (including lightning)
- Any high-pressure steam injury
- Suspected non-accidental injury, regardless of complexity
- Burns to face, hands, feet, genitalia, perineum, or flexural surfaces (neck/axilla/elbow/knee)
- Circumferential deep dermal burns
- Burns associated with suspected inhalation injury
- Burns with significant co-morbidities, other injuries, or sepsis
- Social circumstances or inadequate pain control at scene