{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,16]],"date-time":"2026-07-16T14:16:03Z","timestamp":1784211363816,"version":"3.55.0"},"reference-count":13,"publisher":"Springer Science and Business Media LLC","issue":"1","license":[{"start":{"date-parts":[[2026,7,16]],"date-time":"2026-07-16T00:00:00Z","timestamp":1784160000000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"},{"start":{"date-parts":[[2026,7,16]],"date-time":"2026-07-16T00:00:00Z","timestamp":1784160000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"funder":[{"DOI":"10.13039\/501100006254","name":"Ruhr-Universit\u00e4t Bochum","doi-asserted-by":"crossref","id":[{"id":"10.13039\/501100006254","id-type":"DOI","asserted-by":"crossref"}]}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["Int J Emerg Med"],"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Ammonia inhalation can cause rapid airway compromise and noncardiogenic pulmonary oedema. Although hospital management has been described, prehospital strategies in severe cases remain largely undocumented.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Case presentation<\/jats:title>\n                    <jats:p>A 44-year-old obese male (160\u00a0kg) was exposed to an ammonia cloud at a decommissioned power plant. He presented with mucosal burns, severe dyspnoea, and hypoxemia despite high-flow oxygen. Prehospital providers initiated nebulized adrenaline, performed ocular irrigation, and prepared for surgical airway backup. Rapid sequence intubation was conducted under video laryngoscopy. Immediately post-intubation, copious foamy secretions confirmed fulminant pulmonary oedema. Despite FiO\u2082 1.0 and a PEEP of 12 cmH\u2082O, oxygenation remained marginal at 89\u201390%. Intravenous corticosteroids were administered, burns were covered, and the patient was transported by helicopter to a burn and critical care centre. On-scene decontamination was deferred due to instability; the EMS team underwent full decontamination after patient handover. Ground transport to the nearest regional centre would have required approximately 60\u00a0min; HEMS transport directly to the tertiary burn centre (MHH Hannover) took approximately 35\u00a0min. Beyond transport time, HEMS use involved inherent aeromedical risks: residual ammonia off gassing in the confined cockpit and cabin posed a risk of mucosal irritation or pilot incapacitation, and inadvertent chemical contamination of sensitive avionics or airframe components posed a corrosion risk. These were weighed against clinical urgency and the absence of adequate regional ICU or burn capacity. No formal risk-based framework currently exists to guide HEMS transport of CBRN-exposed patients; this case underscores the need for one.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>This case demonstrates the unique prehospital challenges of ammonia inhalation: the need for early definitive airway management, refractory hypoxemia beyond the capacity of prehospital ventilators, and operational dilemmas such as delayed decontamination, patient weight, and limited local ICU resources. It highlights the urgent need for structured EMS protocols for caustic inhalation events. Beyond the clinical case, this report addresses the complexity of transport decision-making in critically ill patients with incomplete decontamination, including civil aviation safety considerations and the absence of a risk-based framework for CBRN aeromedical transport.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1186\/s12245-026-01308-9","type":"journal-article","created":{"date-parts":[[2026,7,16]],"date-time":"2026-07-16T06:45:38Z","timestamp":1784184338000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Prehospital airway and operational management of severe ammonia intoxication: a case report"],"prefix":"10.1186","volume":"19","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-2247-5395","authenticated-orcid":false,"given":"Lydia Johnson","family":"Kolaparambil Varghese","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Regina","family":"Schulz","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Raphael","family":"Abels","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3636-8136","authenticated-orcid":false,"given":"Gerrit","family":"Jansen","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2026,7,16]]},"reference":[{"issue":"3","key":"1308_CR1","doi-asserted-by":"publisher","first-page":"180","DOI":"10.4103\/ijccm.IJCCM_460_17","volume":"22","author":"K Gupta","year":"2018","unstructured":"Gupta K, Mehrotra M, Kumar P, Gogia AR, Prasad A, Fisher JA. Smoke Inhalation Injury: Etiopathogenesis, Diagnosis, and Management. Indian J Crit Care Med M\u00e4rz. 2018;22(3):180\u20138.","journal-title":"Indian J Crit Care Med M\u00e4rz"},{"key":"1308_CR2","unstructured":"Shubert J, Sharma S. Inhalation injury. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 [zitiert 25. September 2025]. Verf\u00fcgbar unter: http:\/\/www.ncbi.nlm.nih.gov\/books\/NBK513261\/."},{"key":"1308_CR3","doi-asserted-by":"publisher","first-page":"2050313X2513276","DOI":"10.1177\/2050313X251327670","volume":"13","author":"PJ Fletcher","year":"2025","unstructured":"Fletcher PJ, Kidd B, Zorn JT, Costello J. Management of inhalational injury secondary to prolonged anhydrous ammonia exposure with venovenous ECMO: A case report. SAGE Open Med Case Rep 17 M\u00e4rz. 2025;13:2050313X251327670.","journal-title":"SAGE Open Med Case Rep 17 M\u00e4rz"},{"issue":"5","key":"1308_CR4","doi-asserted-by":"publisher","first-page":"444","DOI":"10.1097\/00005373-198505000-00014","volume":"25","author":"R Arwood","year":"1985","unstructured":"Arwood R, Hammond J, Ward GG. Ammonia inhalation. J Trauma Mai. 1985;25(5):444\u20137.","journal-title":"J Trauma Mai"},{"key":"1308_CR5","doi-asserted-by":"crossref","unstructured":"Pangeni RP, Timilsina B, Oli PR, Khadka S, Regmi PR. A multidisciplinary approach to accidental inhalational ammonia injury: a case report. Ann Med Surg (Lond). September 2022;82:26. 104741.","DOI":"10.1016\/j.amsu.2022.104741"},{"issue":"8","key":"1308_CR6","first-page":"523","volume":"90","author":"BA Tobe","year":"1964","unstructured":"Tobe BA. The Metabolism of the Volatile Amines. Can Med Assoc J 22 Februar. 1964;90(8):523\u201330.","journal-title":"Can Med Assoc J 22 Februar"},{"issue":"3","key":"1308_CR7","doi-asserted-by":"publisher","first-page":"439","DOI":"10.1016\/j.suc.2023.01.006","volume":"103","author":"E Bittner","year":"2023","unstructured":"Bittner E, Sheridan R. Acute Respiratory Distress Syndrome, Mechanical Ventilation, and Inhalation Injury in Burn Patients. Surg Clin North Am Juni. 2023;103(3):439\u201351.","journal-title":"Surg Clin North Am Juni"},{"issue":"2","key":"1308_CR8","doi-asserted-by":"publisher","first-page":"126","DOI":"10.1097\/ACO.0000000000001228","volume":"36","author":"J Dilday","year":"2023","unstructured":"Dilday J, Leon D, Kuza CM. A review of the utility of high-frequency oscillatory ventilation in burn and trauma ICU patients. Curr Opin Anaesthesiol 1 April. 2023;36(2):126\u201331.","journal-title":"Curr Opin Anaesthesiol 1 April"},{"issue":"10","key":"1308_CR9","first-page":"1214","volume":"131","author":"T Zhou","year":"2018","unstructured":"Zhou T, Song WF, Shang Y, Yao SL, Matalon S. Halogen Inhalation-Induced Lung Injury and Acute Respiratory Distress Syndrome. Chin Med J (Engl) 20 Mai. 2018;131(10):1214\u20139.","journal-title":"Chin Med J (Engl) 20 Mai"},{"issue":"4","key":"1308_CR10","doi-asserted-by":"publisher","first-page":"891","DOI":"10.1097\/CCM.0b013e318211f8e0","volume":"39","author":"BA Latenser","year":"2011","unstructured":"Latenser BA. The significance of reduced airway hyperemia and enhanced oxygenation after epinephrine nebulization in a preclinical evaluation. Crit Care Med April. 2011;39(4):891\u20133.","journal-title":"Crit Care Med April"},{"issue":"6","key":"1308_CR11","doi-asserted-by":"publisher","first-page":"396","DOI":"10.1097\/BCR.0000000000000575","volume":"38","author":"G Foncerrada","year":"2017","unstructured":"Foncerrada G, Lima F, Clayton RP, Mlcak RP, Enkhbaatar P, Herndon DN. u. a. Safety of Nebulized Epinephrine in Smoke Inhalation Injury. J Burn Care Res. 2017;38(6):396\u2013402.","journal-title":"J Burn Care Res"},{"issue":"2","key":"1308_CR12","doi-asserted-by":"publisher","first-page":"61","DOI":"10.3109\/15563650.2011.553196","volume":"49","author":"DW de Lange","year":"2011","unstructured":"de Lange DW, Meulenbelt J. Do corticosteroids have a role in preventing or reducing acute toxic lung injury caused by inhalation of chemical agents? Clin Toxicol (Phila) Februar. 2011;49(2):61\u201371.","journal-title":"Clin Toxicol (Phila) Februar"},{"issue":"19","key":"1308_CR13","doi-asserted-by":"publisher","first-page":"4765","DOI":"10.3390\/ijms20194765","volume":"20","author":"D Mokra","year":"2019","unstructured":"Mokra D, Mikolka P, Kosutova P, Mokry J. Corticosteroids in Acute Lung Injury: The Dilemma Continues. Int J Mol Sci 25 September. 2019;20(19):4765.","journal-title":"Int J Mol Sci 25 September"}],"container-title":["International Journal of Emergency Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/link.springer.com\/article\/10.1186\/s12245-026-01308-9","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s12245-026-01308-9.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s12245-026-01308-9.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,7,16]],"date-time":"2026-07-16T13:53:41Z","timestamp":1784210021000},"score":1,"resource":{"primary":{"URL":"https:\/\/link.springer.com\/10.1186\/s12245-026-01308-9"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,7,16]]},"references-count":13,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2026,12]]}},"alternative-id":["1308"],"URL":"https:\/\/doi.org\/10.1186\/s12245-026-01308-9","relation":{},"ISSN":["1865-1380"],"issn-type":[{"value":"1865-1380","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,7,16]]},"assertion":[{"value":"3 December 2025","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"4 July 2026","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"16 July 2026","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"Not applicable.","order":1,"name":"Ethics","label":"Ethics approval and consent to participate","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"Written informed consent for publication was obtained from the patient [or the patient\u2019s next of kin].","order":2,"name":"Ethics","label":"Consent for publication","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"The authors declare no competing interests.","order":3,"name":"Ethics","label":"Competing interests","group":{"name":"EthicsHeading","label":"Declarations"}}],"article-number":"185"}}