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Smoke is generated as a result of thermal degradation of a material; it is a complex mixture of heated air, suspended solid and liquid particles (aerosols), gases, fumes, and vapors. Particulates and aerosols typically make these thermal degradation products visible to the naked eye, resulting in the black, acrid substance so often thought of as "smoke;" however, thermal decomposition also results in generation of gaseous substances that are invisible to the naked eye. The ever-growing variety of materials used in our environment contributes to the broad spectrum of products present in typical smoke.30 The chemical composition of the parent materials, oxygen availability, and temperature at the time of decomposition determine the combustion products found in smoke (Table 128–1).11,29,30,44,54,66,112,122,132,133,156 As a result of these variabilities, specific thermal degradation products resulting from a fire are difficult to predict; in fact, even the composition of smoke is quite variable within the same fire environment.11,38,122

Table 128–1. Common Materials and Their Thermal Degradation Xenobiotics

Smoke inhalation is a complex medical syndrome involving diverse toxicologic injuries, making care of smoke-injured patients very challenging. Victims of smoke inhalation exhibit a spectrum of illness induced by tissue hypoxia. Importantly, smoke inhalation, not burns, is the leading cause of death from fires. However, cutaneous burns found concurrently with smoke inhalation complicate airway management and fluid resuscitation and increase infection risk. Consequently, burn victims with smoke inhalation injury have higher morbidity and mortality than those with burns alone.41,148,154,158,171 Treatment of smoke inhalation should be aimed at correcting tissue hypoxia by maximizing oxygen delivery while avoiding unnecessary therapies that delay or hinder oxygenation.

Disastrous fires are frequent reminders of the role of inhalation injuries in fire deaths.38,86 Throughout the United States, a fire department responds to a fire every 20 seconds.79 In 2007, the National Fire Protection Agency reported 1,557,500 fire incidents in the United States, with 3430 fire deaths and 17,675 fire injuries.79 A civilian fire death occurred every 153 minutes on average in 2007.79 Compared with other countries, the United States has one of the highest fire death ...

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