Case 26 – Where there’s smoke…

Case #26: Where there’s smoke…
Author: Michael Gottlieb, MD
Peer Reviewer: Christopher Lim, MD

A 24 year old male is brought in by ambulance after being found unconscious outside of a burning building. On arrival, he begins to wake up, but is still lethargic. He does not remember what happened and denies any past medical history. He has neither external burns nor stigmata of inhalational injury. His exam is significant for tachypnea and bradycardia, but is otherwise non-focal. While being examined, he intermittently complains of a headache.

Vitals: Temp: 99.2, HR: 56, RR: 16, BP: 92/60, O2 Sat: 98% on RA

An ABG with CO-oximetry was performed which showed a lactate of 10.4 and a carboxyhemoglobin concentration (COHb) of 0.6%. Per the paramedics, his field COHb was 0.8%.

What is the most likely etiology of this patient’s presentation?
What other clinical symptoms might you expect to see with this patient?
What is the initial treatment for this patient?
What further work-up is required?


Baud FJ, Barriot P, Toffis V, et al. Elevated blood cyanide concentrations in victims of smoke inhalation. N Engl J Med. 1991 Dec 19;325(25):1761-6.

Baud FJ, Borron SW, Mégarbane B, et al. Value of lactic acidosis in the assessment of the severity of acute cyanide poisoning. Crit Care Med. 2002 Sep;30(9):2044-50.

Borron SW, Baud FJ. Acute cyanide poisoning: clinical spectrum, diagnosis, and treatment. Arh Hig Rada Toksikol. 1996 Sep;47(3):307-22.

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