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Smoke is generated as the result of thermal degradation of a material; it is a complex mixture of heated air containing suspended solid and liquid particles (aerosols), gases, 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 of common materials also results in the generation of gaseous substances that are invisible to the naked eye. The complex and ever-growing variety of materials used in our environment contributes to the broad spectrum of products present in typical smoke.32,159 The chemical composition of the parent materials, oxygen availability, and temperature at the time of decomposition all help determine the combustion products found in smoke (Table 120–1).118,127 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.127

TABLE 120–1Toxic Thermal Degradation Products

Smoke inhalation is a complex medical syndrome involving diverse toxicologic injuries, making care of smoke-injured patients very challenging. These injuries occur both locally within the respiratory tract and systemically. It is, in fact, smoke inhalation—not thermal burns—that is the leading cause of death from fires. Cutaneous burns, however, 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 rates than those with burns alone.47,157,159

Compared with other industrialized countries, the United States has one of the highest rates of fire-related deaths in the world.159,168 Throughout the United States, a fire department responds to a fire every 23 seconds.71 In 2015, the National Fire Protection Agency reported 1,345,500 fire incidents in the United States, and approximately 501,500 of these events were structural fires. There were 3,280 fire-related deaths and 15,700 fire-related injuries reported in 2015.71 On average, a civilian fire death occurs every 160 minutes, and a civilian injury from a structural fire occurs every 34 minutes.71 Seventy-eight percent of civilian fire deaths occur in home structural fires.71 An estimated 50% to 80% of fire-related deaths result from smoke inhalation rather than dermal burns or trauma, and deaths related to smoke inhalation occur much more prevalently in an enclosed-space environment.23,70,118,180 Studies indicate that from 10% to ...

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