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Smoke Inhalation & Hydrogen Cyanide Poisoning

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Smoke Inhalation & Hydrogen Cyanide Poisoning SMOKE INHALATION & HYDROGEN CYANIDE POISONING The Danger Posed to Firefighters & Victims in Structure Fires CONTENTS 5 Hydrogen Cyanide Fire smoke’s silent killer BY KEN RIDDLE, DEPUTY CHIEF FIRE MARSHAL Smoke Inhalation & 6 Acute Cyanide Poisoning Hydrogen cyanide poisoning proves increasingly common in smoke-inhalation victims BY RICHARD ALCORTA, MD, FACEP Hydroxocobalamin: 18 Treatment for Smoke Inhalation-Associated Cyanide Poisoning SMOKE INHALATION & HYDROGEN CYANIDE POISONING Meeting the needs of fire victims A Jems Communications Supplement BY JEAN-LUC FORTIN, MD, M. RUTTIMAN, MD, Sponsored by EMD Pharmaceuticals L. DOMANSKI, MD, & J.J. KOWALSKI, MD Publisher/General Manager Jeff Berend Senior Editor Keri Losavio Cyanide as a Chemical Supplement Editor Jennifer Doyle Supplement Art Director Daniel DiPinto 22 Terrorism Weapon Production Manager Tim Francis BY MARC ECKSTEIN, MD, FACEP Smoke Inhalation & Hydrogen Cyanide Poisoning is an edi- torial supplement sponsored by EMD Pharmaceuticals and published by Jems Communications, 525 B Street, Suite 1900, San Diego, CA 92101-4495; 800/266-5367 (fed. ID #13-935377). Copyright 2004 Elsevier Inc. No material may be reproduced or uploaded on computer network services without the expressed permission of the publisher. Subscription infor- mation: To subscribe to a Jems Communications publication, visit www.jems.com. Advertising information: Rates are available on request. Contact Jems Communications Advertising Department at 525 B Street, Suite 1900, San Diego, CA 92101-4495; 800/266-5367. SMOKE INHALATION &HYDROGEN CYANIDE POISONING 3 HYDROGEN CYANIDE Fire Smoke’s Silent Killer TREATMENT FOR SMOKE ommend using, and discusses how INHALATION in the United States important rapid treatment is to improv- has not changed much during the past ing chances for survival. several years: We remove the victim In the second presentation, Jean-Luc from the source, provide high-flow Fortin, MD, chief of medicine for the 100% oxygen and assist with ventila- Third Division of the Paris (France) Fire tion, if needed. Responding EMS per- Brigade, provides data on an alternative sonnel and firefighters are primarily cyanide antidote that is currently avail- concerned with carbon monoxide poi- able in Europe. Hydroxocobalamin is soning and hypoxia in smoke-inhala- routinely used in France to treat tion patients. However, hydrogen smoke-inhalation victims at the scene cyanide poisoning is an increasingly of fires. Dr. Fortin reviews data from a common byproduct of fire smoke in retrospective study of 81 smoke-inhala- structure fires, threatening both fire tion victims treated with hydroxocobal- victims and firefighters. Unfortunately, amin by the Paris Fire Brigade. The it is rarely treated in the United States, results are promising, with a 62.1% sur- and when it is, the current U.S. drug vival rate following hydroxocobalamin therapy for cyanide poisoning carries a administration as part of treatment for risk of actually doing more harm than cyanide poisoning and carbon monox- good. ide exposure. At the International Association of The final presenter, Marc Eckstein, Fire Chiefs EMS Section’s Fire-Rescue MD, medical director for the Los Deputy Chief Ken Riddle Med Conference in April, I served as Angeles Fire Department and an asso- the moderator for a panel of experts ciate professor of emergency medicine has more than 30 years’ experience who addressed the topic of cyanide at the University of Southern with emergency poisoning in smoke inhalation and California School of Medicine, discuss- services in both chemical terrorism. The presentations, es the intentional use of cyanide as an the private and compiled in this special issue, are agent of war and terror. He notes that public sectors. A designed to educate emergency cyanide is plentiful, readily available member of the Las Vegas Department of response professionals on the risks of and does not require special expertise Fire & Rescue for 25 years, Riddle cur- cyanide poisoning, as well as the treat- to use. Dr. Eckstein also indicates that rently serves as the city’s fire marshal. ment options. if hydroxocobalamin becomes avail- As a chief officer for the past 10 years, In the first article, Richard Alcorta, able in the United States, cyanide poi- he has been responsible for the opera- MD, medical director at the Maryland soning may be successfully treated in a tions, administration and medical services Institute for Emergency Medical prehospital setting. divisions. While serving in those positions, he designed and developed several major Services System, notes that smoke Collectively, the presentations programs, including an ambulance inhalation causes 5,000–10,000 deaths provide a broad overview of cyanide transport program for the department. and more than 23,000 injuries—includ- poisoning and its treatment, both in Riddle was certified as a paramedic for ing 5,000 firefighters—in the United conjunction with smoke-inhalation several years and also served as a flight States annually. Dr. Alcorta presents exposure and as an agent of chemical medic. An author and frequent speaker data from several studies revealing terrorism. I believe you will find the on fire-based EMS issues, he is the elevated cyanide concentrations in articles extremely informative and immediate-past chair of the International smoke-inhalation victims, highlighting timely. Armed with this knowledge, I Association of Fire Chiefs EMS Section the direct relationship between cyanide am optimistic that we can eventually and the past president of the Southern blood concentrations and probability of reduce the significant number of Nevada Fire Chiefs Association. Riddle death, and indicating that cyanide and smoke-inhalation deaths experienced continues to serve as the conference manager for the EMS Section’s Fire- carbon monoxide enhance the toxic each year in this country, as well as Rescue Med Conference, held annually in effects of one another. He also reviews enhance our level of emergency pre- Las Vegas. the current treatment for smoke inhala- paredness for the potential use of tion, which some authorities do not rec- cyanide in chemical terrorism. SMOKE INHALATION &HYDROGEN CYANIDE POISONING 5 SMOKESMOKE INHALATIONINHALATION && ACUTEACUTE CYANIDECYANIDE POISONINGPOISONING Hydrogen cyanide poisoning proves increasingly common in smoke-inhalation victims BY RICHARD ALCORTA, MD, FACEP The family had gone to bed only two hours before the fire started. A space heater in the living room ignited a sofa cushion, which smoldered for a period of time, emitting toxic gases even before the flames appeared. Within minutes after flames appeared, the fire spread upward from the burning sofa cush- ions and ignited first the draperies, then the ceiling. As the fire gained force, toxic smoke filled the room and entered the hallway. The smoke detector located down the hall finally activated and awakened the family. Meanwhile, a neighbor saw the flames while he was walking his dog and called 9-1-1. The fire’s heat and its dense black smoke prevented the family from exiting via the stairs. When firefighters arrived within four minutes of the 9-1-1 call, they had to rescue the three victims through a second-story window. All were found huddled close to the window, disoriented or unconscious, with soot in their noses and mouths. The mother and four-year- old boy were given oxygen and transported to a hospital where they survived. The father, who had rushed into the hall and into his son’s room in an attempt to rescue him, went into full respiratory arrest. He had only 10% burns on his face and hands, but his condition, which initially appeared to stabilize, rapidly deteriorated en route to the hospital, despite 100% oxygen and supportive care. He died without regaining consciousness. EMERGENCY medical and fire- toxicity that EMS and fire profes- rescue professionals tend to sionals will encounter. equate cyanide poisoning with Smoke inhalation is an impor- The JEMS continuing education program is coordinated by the accidental or intentional inges- tant but often overlooked cause of Center for Emergency Medicine, Pittsburgh, and the University of Pittsburgh, School of Health and Rehabilitation Sciences. tion. However, cyanide toxicity cyanide poisoning. A substantial from smoke inhalation in a struc- body of evidence reveals that tural or an enclosed-space fire is cyanide can be as great a threat as the most likely cause of cyanide carbon monoxide in fire smoke. 6 JEMS COMMUNICATIONS Photo Glen E. Ellman SMOKE INHALATION &HYDROGEN CYANIDE POISONING 7 This article will discuss: Studies completed by the Objectives • Why cyanide poisoning is a National Institute of Standards and growing concern in the fire and Technology in conjunction with the List reasons for the increased • EMS communities; Fire Protection Research Foundation incidence of smoke inhalation- • The role of cyanide in smoke document a significant increase in associated cyanide poisoning. inhalation-associated morbidi- toxic gases in smoke immediately • Determine the role of cyanide ty and mortality as evidenced before flashover occurs, as well as 2 in smoke inhalation-associated by two prospective studies— after flashover. Conditions of high a 2002 meta-analysis of fire temperature and low oxygen pro- morbidity and mortality. victim studies and animal mote degradation of synthetics, • Describe the management of research on cyanide-related which release hydrogen cyanide and smoke inhalation-associated incapacitation; and other
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