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Smoke is generated as the 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.26 The chemical composition of the parent materials, oxygen availability, and temperature at the time of decomposition determines the combustion products found in smoke (Table 128–1).99,112 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.112

TABLE 128–1.Common Materials and Their Thermal Degradation Products

Smoke inhalation is a complex medical syndrome involving diverse toxicologic injuries, making care of smoke-injured patients very challenging. In fact, 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 the risk of infection. Consequently, burn victims with smoke inhalation injury have higher morbidity and mortality than those with burns alone.36,138

Disastrous fires are a frequent reminder of the role of inhalation injury in fire deaths. Throughout the United States, a fire department responds to a fire every 23 seconds.67 In 2011, the National Fire Protection Agency reported 1,389,500 fire incidents in the United States, with 3005 fire deaths and 17,500 fire injuries.67 On average, a civilian fire death occurred every 208 minutes and a civilian injury from a structural fire occurs every 30 minutes.

Compared with other industrialized countries, the United States has one of the highest rates of fire-related deaths in the world.4 An estimated 50% to 80% of these deaths result from smoke inhalation rather than dermal burns or trauma....

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