Burn Emergencies (English)

7/27/2019 Burn Emergencies (English)

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BURN EMERGENCIES

One of the most painful injuries that one can ever experience is a burn injury. When a burn

occurs to the skin, nerve endings are damaged causing intense feelings of pain. Every year,

millions of people in the United States are burned in one ay or another. Of those,

thousands die as a result of their burns. !any re"uire long#term hospitali$ation. %urns are a

leading cause of unintentional death in the United States, exceeded in numbers only by

automobile crashes and falls.

Serious burns are complex injuries. &n addition to the burn injury itself, a number of other

functions may be affected. %urn injuries can affect muscles, bones, nerves, and blood

vessels. 'he respiratory system can be damaged, ith possible airay obstruction,

respiratory failure and respiratory arrest. Since burns injure the skin, they impair the body(s

normal fluid)electrolyte balance, body temperature, body thermal regulation, joint function,

manual dexterity, and physical appearance. &n addition to the physical damage

caused by burns, patients also may suffer emotional and psychological problems that begin

at the emergency scene and could last a long time.

*lassifying burns

%urns are classified in to ays+ !ethod and degree of burn.

!ethods are+

'hermal # including flame, radiation, or excessive heat from fire, steam, and hot li"uids

and hot objects.

*hemical # including various acids, bases, and caustics.

Electrical # including electrical current and lightning.

ight # burns caused by intense light sources or ultraviolet light, hich includes

sunlight.

-adiation # such as from nuclear sources. Ultraviolet light is also a source of radiation

burns.

ever assume the source of a burn. /ather information and be sure.

0egrees are+


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1irst degree burns are superficial injuries that involve only the epidermis or outer layer

of skin. 'hey are the most common and the most minor of all burns. 'he skin is reddened

and extremely painful. 'he burn ill heal on its on ithout scarring ithin to to five

days. 'here may be peeling of the skin and some temporary discoloration.

Second degree burns occur hen the first layer of skin is burned through and the second

layer, the dermal layer, is damaged but the burn does not pass through to underlying

tissues. 'he skin appears moist and there ill be deep intense pain, reddening, blisters and

a mottled appearance to the skin. Second degree burns are considered minor if they involve

less than 23 percent of the body surface in adults and less than 24 percent in children.

When treated ith reasonable care, second degree burns ill heal themselves and produce

very little scarring. 5ealing is usually complete ithin three eeks.'hird degree burns involve all the layers of the skin. 'hey are referred to as full

thickness burns and are the most serious of all burns. 'hese are usually charred black and

include areas that are dry and hite. While a third#degree burn may be very painful, some

patients feel little or no pain because the nerve endings have been destroyed. 'his type of

burn may re"uire skin grafting. 6s third degree burns heal, dense scars form.

0etermining the severity of burns

Source of the burn # a minor burn caused by nuclear radiation is more severe than a burn

caused by thermal sources. *hemical burns are dangerous because the chemical may still

be on the skin.

%ody regions burned # burns to the face are more severe because they could affect

airay management or the eyes. %urns to hands and feet are also of special concern

because they could impede movement of fingers and toes.

0egree of the burn # the degree of the burn is important because it could cause infection

of exposed tissues and permit invasion of the circulatory system.

Extent of burned surface areas # &t is important to kno the percentage of the amount of

the skin surface involved in the burn.

'he adult body is divided into regions, each of hich represents nine percent of the total

body surface. 'hese regions are the head and neck, each upper limb, the chest, the

abdomen, the upper back, the loer back and buttocks, the front of each loer limb, and

the back of each loer limb. 'his makes up 77 percent of the human body. 'he remaining

one percent is the genital area. With an infant or small child, more emphasis is placed on

the head and trunk.

6ge of the patient # 'his is important because small children and senior citi$ens usually

have more severe reactions to burns and different healing processes.


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8re#existing physical or mental conditions # 8atients ith respiratory illnesses, heart

disorders, diabetes or kidney disease are in greater jeopardy than normally healthy people.

'reatment of burns

*ool a burn ith ater. 0o hat you must to get cool ater on the burn as soon as you

can. /o to the nearest ater faucet and turn on the cold spigot and get cool ater on the

burn. 8ut cool, ater#soaked cloths on the burn. &f possible, avoid icy cold ater and ice

cubes. Such measures could cause further damage to burned skin.

ever apply ointment, grease or butter to the burned area. 6pplying such products, actuallyconfine the heat of the burn to the skin and do not allo the damaged area to cool. &n

essence, the skin continues to 9simmer.9 6fter the initial trauma of the burn and after it has

had sufficient time to cool, it ould then be appropriate to put an ointment on the burn.

Ointments help prevent infection.

'he one exception to the 9*ool a %urn9 method is hen the burn is caused by lime poder.

&n that case, carefully brush the lime off the skin completely and then flush the area ith

ater. &n the event of any serious burns, call 7#2#2.

Burns, Chemical

'-O0U*'&O

%ackground+ 6cids are defined as proton donors :5;< and bases as proton acceptor :O5#


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5ydrofluoric acid is somehat different than other acids in that it produces a li"uifaction

necrosis.

'he severity of the burn is related to a number of factors, including the p5 of the agent, the

concentration of the agent, the length of the contact time, the volume of the offending

agent and the physical form of the agent. Solid pellets of alkaline substances result in a

prolonged contact time in the stomach and more severe burns. &n addition, concentrated

forms of some acids and bases generate significant heat hen diluted, resulting in both

thermal as ell as caustic injury.

'he long#term effect of caustic burns is scarring. 0epending on the site of the burn, thiscan be significant. Ocular burns can result in opacification of the cornea ith complete loss

of vision. Esophageal and gastric burns can result in significant stricture formation.

1re"uency+

&n the U.S.+ 'here are over 244,444 exposures to acid)base type products every year.

'he majority of those involve household cleaning products. Exposures are nearly e"ual

beteen adults and children.

!ortality)!orbidity+ 'here ere @@ reported fatalities in 2773 and 27 in 277A resulting

from exposures to acid and base products.

Of approximately @3,344 exposures to acid and base chemicals, there ere 2@B cases of

major toxicity and seven deaths in 277A. Of 3@,?34 exposure to bleaches, there ere >C

cases of major toxicity and no deaths. 0rain cleaners produced 37 cases of major toxicity

and seven deaths in 3,244 exposures.

*&&*6

5istory+

*linical signs and symptoms vary depending on the route of exposure and the particular

substances involved. 0ue to the variety of presentations, the emergency physician must be

prepared to handle all possibilities. Some exposures, such as hydrofluoric acid, may

present ithout immediate pain and should be considered in the patient ith complaints of

slo#onset, deep pain after exposure to an appropriate product.

8atient history should include+


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Offending agent, concentration, physical form, p5

-oute of exposure

'ime of exposure

Dolume of exposure

8ossibility of coexisting injury

8hysical+

&f the exposure as an ingestion, the main immediate concern is the patients ability to

protect her)his airay. &f there is evidence of airay compromise :oropharyngeal edema,stridor, use of accessory muscles


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ater. &t also generates significant heat hen diluted. 'hese attributes make it a good drain

cleaner.

itric 6cid+

*ommon uses include engraverFs acid, metal refining, electroplating and fertili$er

manufacture.

5ydrofluoric 6cid+

*ommon uses include rust removers, tire cleaners, tile cleaners, glass etching, dentalork, tanning, semiconductors, refrigerant manufacture, fertili$er manufacture and

petroleum refining. 'his is actually a eak acid that in dilute form ill not cause

immediate burning and pain on contact.

5ydrochloric 6cid+

*ommon uses include toilet bol cleaners, metal cleaners, soldering fluxes, dye

manufacture, metal refining, plumbing applications and laboratory chemicals.

*oncentrations range from 3#>>.

8hosphoric 6cid+

*ommon uses include metal cleaners, rustproofing, disinfectants, detergents and

fertili$er manufacture.

6cetic acid

*ommon uses include printing, dyes, rayon and hat manufacture, disinfectants and

hair ave neutrali$ers. Dinegar is dilute acetic acid.

1ormic 6cid+

*ommon uses include airplane glue, tanning and cellulose manufacture.

*hloroacetic 6cids+

!onochloroacetic acid is used in the production of carboxymethylcellulose,

phenoxyacetates, pigments and some drugs. &t has significant systemic toxicity by ay of

entering and blocking the tricarboxylic acid cycle and inhibiting cellular respiration. &t is

highly corrosive.


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'richloroacetic acid is used in laboratories and in chemical manufacture. &t is highly

corrosive and 9fixes9 tissues it comes into contact ith. &t does not inhibit cellular

respiration.

0ichloroacetic acid is used in chemical manufacture. &t is a eaker acid than

trichloroacetic acid and does not inhibit cellular respiration.

%ases+

Sodium 5ydroxide and 8otassium 5ydroxide+

Used in drain cleaners, oven cleaners, *linitestG tablets and denture cleaners. 'heyare extremely corrosive. *linitestG tablets contain >3#34 aO5 or HO5. Solid or

concentrated aO5 or HO5 is more dense than ater and generates significant heat hen

diluted. %oth the heat generated and the alkalinity contribute to burns.

*alcium 5ydroxide+

*alcium hydroxide is also knon as slaked lime. &t is used in mortar, plaster and

cement, but is not as caustic as potassium and sodium hydroxide or calcium oxide.

Sodium and *alcium 5ypochlorite+

'his is the common ingredient in household bleach and pool chlorinating solution.

8ool chlorinators also contain sodium hydroxide and have a p5 around 2C.3, thus they are

very caustic. 5ousehold bleach has a p5 around 22 and is much less corrosive.

*alcium Oxide+

*alcium oxide is also called lime and is the caustic ingredient in cement. &t generates

heat hen diluted ith ater and can produce a thermal and caustic burn.

6mmonia+

6mmonia is used in cleaners and detergents. 'he dilute form is not highly corrosive.

/aseous anhydrous ammonia is used in a number of industrial applications, particularly in

fertili$er manufacturing. &t is very hygroscopic # has a high affinity for ater. &t produces

injury by desiccation and heat of dilution in addition to a chemical burn. &t can cause

severe skin burns as ell as pulmonary injury.

8hosphates+


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8hosphates are commonly used in many types of household detergents and cleaners.

Substances include tribasic potassium phosphate, trisodium phosphate and sodium

tripolyphosphates.

Silicates+

'hese include sodium silicate and sodium metasilicate. 'hey are used to replace

phosphates in detergents. 0ishashing detergents are alkaline, primarily to builders such

as silicates and carbonates. 'hey are moderately corrosive.

Sodium *arbonate+

Sodium carbonate is used in detergents. &t is moderately alkaline, depending on the

concentration.

ithium 5ydride+

ithium hydride is used to absord carbon dioxide in space technology applications. &t

vigorously reacts ith ater to generate hydrogen and lithium hydroxide. &t can produce

thermal and alkaline burns.

0&11E-E'&6S

%urns, Ocular

%urns, 'hermal

*austic &ngestions

5a$mat

WO-HU8

ab Studies+

ab studies depend on the burn type and extent of exposure.

Severe %urns+

Electrolytes, creatinine, %U and glucose


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U6, *omplete blood count :*%*h ill provide 2A mg)kg of acetaminophen and

4.@3 mg)kg of

hydrocodone.

*ontraindications

6void use in patients ith documented hypersensitivity to acetaminophen

or hydrocodone

bitartrate and patients ith elevated intracranial pressure.

&nteractions


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8henothia$ines may decrease its analgesic effects. *onversely, the

toxicity of this drug

increases hen administered concurrently ith *S depressants,

ben$odia$epines, or

tricyclic antidepressants.

8regnancy

* # Safety for use during pregnancy has not been established.

8recautions

Withold for drosiness. 5epatic toxicity may occur in overdose. Use

orco or a product that does not contain acetaminophen in patients ith a history of severehepatic disease. &t may

cause constipation and stomach upset.

0rug ame

Oxycodone and acetaminophen :'ylox, 8ercocet< # &s a drug

combination indicated for the relief of moderate to severe pain. &t is the drug of choice for

aspirin hypersensitive patients.

'he folloing formulations of hydrocodone)acetaminophen are

available+

'ylox#3)344 8ercocet#3)C@3

6dult 0ose

6dminister 2#@ tabs or caps po ">#Ah prn pain.

8roducts containing more than 344 mg of acetaminophen per tablet

should only be

prescribed one tablet per dose.

8ediatric 0ose

6dminister 4.43#4.23 mg)kg)dose oxycodone.

0o not exceed 3 mg)dose of oxycodone ">#Ah prn.

*ontraindications


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6void use in patients ith documented hypersensitivity to this drug or

related products.

&nteractions

8henothia$ines may decrease the analgesic effects of this medication.

*onversely, its toxicity increases hen administered concurrently ith either *S

depressants or tricyclic antidepressants.

8regnancy


8recautions 0uration of action may increase in the elderly.

%e aare about the total daily dose of acetaminophen that the patient is

getting. 'he

maximum dose of acetaminophen is >,444 mg)@>hr. 5igher doses may

cause liver toxicity.

0rug *ategory+ onsteroidal 6nti#inflammatory agents :S6&0S< # 6re most commonly

used for the relief of mild to moderate pain. 6lthough the effects of S6&0s in the

treatment of pain tend to be patient specific, ibuprofen is usually the 0O* for the initial

therapy. Other options include flurbiprofen, ketoprofen, and naproxen.

0rug ame

&buprofen :&buprin, 6dvil, !otrin< # &s usually the 0O* for the treatment

of mild to

moderate pain, if there are no contraindications.

&t inhibits inflammatory reactions and pain probably by decreasing the

activity of the en$yme cyclo#oxygenase, hich results in the inhibition of prostaglandin

synthesis.

&t is useful for outpatient oral use here non#sedating drugs are

preferred. &t also has the

advantage of anti#inflammatory effect.

6dult 0ose


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6dminister >44#A44#B44 mg po, roughly 244 mg)h :e.g. >44 mg ">h,

A44 mg "Ah


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Hetoprofen :Oruvail, Orudis, 6ctron< # &s used for the relief of mild to

moderate pain and inflammation.

6dminister small dosages initially to patients ith a small body si$e, the

elderly and those ith renal or liver disease.

When administering this medication, doses higher than ?3 mg do not

increase its

therapeutic effects. 6dminister high doses ith caution and closely

observe the patient for response.

6dult 0ose

6dminister @3 to 34 mg "A#Bh prn.

0o not exceed C44 mg)d.

8ediatric 0ose

*hildren beteen C mo and 2> yrs of age+ 6dminister 4.2J2 mg)kg "A#

Bh.

Older than 2@ years of age+ 6dminister the same regimen as in adults.

*ontraindications


related products.

&nteractions

8robenecid and lithium, may increase the concentrations, and possibly,

the toxicity of

S6&0s. *onversely, the effect of loop diuretics may decrease hen

administered

concurrently ith this drug.

8rothrombin time :8'< may increase hen ketoprofen is administered

concurrently ith

anticoagulants. !onitor 8' closely and instruct patients to atch for

signs and symptoms of bleeding.


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*oncurrent administration ith phenytoin may increase serum

phenytoin levels, resulting in an increase in pharmacologic and toxic effects of phenytoin.

8regnancy

% # Usually safe but benefits must outeigh the risks.

8recautions

6void use in patients diagnosed ith /& disease, cardiovascular disease,

renal or hepatic

impairment, and patients receiving anticoagulants.

0rug ame

1lurbiprofen :6nsaid, Ocufen< # 5as analgesic, antipyretic and anti#

inflammatory effects. &t may inhibit cyclo#oxygenase en$yme, causing the inhibition of

prostaglandin biosynthesis

that may in turn result in analgesic and anti#inflammatory activities.

6dult 0ose

6dminister @44#C44 mg)d po divided bid#"id.

8ediatric 0ose

Safety and efficacy in children have not been established.

*ontraindications


related products.

&nteractions

8robenecid and lithium, may increase the concentrations, and possibly,

the toxicity of

S6&0s. *onversely, the effect of loop diuretics may decrease hen

administered

concurrently ith this drug.

*oadministration ith anticoagulants may prolong prothrombin time.

!onitor 8' and


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patients closely, and instruct them to atch for signs and symptoms of

bleeding.

ephrotoxicity of both cyclosporine and flurbiprofen may be increased.

*oncurrent administration ith phenytoin may increase serum

phenytoin levels, resulting in

an increase in pharmacologic and toxic effects of phenytoin.

8regnancy

* # Safety for use during pregnancy has not been established.8recautions

Severe /& tract ulceration and bleeding can occur. !onitor patients

closely hen

administering prolonged treatments.

S6&0s can inhibit platelet aggregation, but at a loer degree than that

seen ith aspirin.

Exercise caution in patients that have anticoagulation defects or are

receiving anticoagulant

therapy.

o hite blood cell counts can occur but usually return to normal as

therapy continues.

-e#evaluate the therapy if persistent leukopenia, granulocytopenia or

thrombocytopenia

occur.

0rug ame

aproxen :6naprox, aprelan, aprosyn< # &s used for the relief of mild

to moderate pain. &t

inhibits inflammatory reactions and pain by decreasing the activity of the

en$yme

cyclo#oxygenase hich results in a decrease of prostaglandin synthesis.


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6dult 0ose

6dminister 344 mg, folloed by @34 mg "A#Bh.

0o not exceed a 2.@3 g)d.

8ediatric 0ose

Older than @ yrs of age+ 6dminister @.3 mg)kg)dose.

0o not exceed 24 mg)kg)d.

Kounger than @ yrs of age+ Safety and efficacy have not been established.

*ontraindications


related products.

0o not administer to patients diagnosed ith peptic ulcer disease, recent

/& bleeding or

perforation, renal insufficiency, and those at high risk of bleeding.

&nteractions

8robenecid and lithium, may increase the concentrations, and possibly, the

toxicity of S6&0s.

*onversely, the effect of loop diuretics may decrease hen administered

concurrently ith this

drug.

8rothrombin time :8'< may increase hen naproxen is administered

concurrently ith

anticoagulants. !onitor 8' closely and instruct patients to atch for signs

and symptoms of

bleeding.

*oncurrent administration ith phenytoin may increase serum phenytoin

levels, resulting in an

increase in pharmacologic and toxic effects of phenytoin.


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8regnancy

% # Usually safe but benefits must outeigh the risks.

8recautions

6cute renal insufficiency, hyperkalemia, hyponatremia, interstitial

nephritis, and renal papillary

necrosis may occur. &t increases the risk of acute renal failure in patients

ith preexisting renal

disease or compromised renal perfusion.

o hite blood cell counts occur rarely, and usually return to normal inongoing therapy.

0iscontinuation of the therapy may be necessary if there is persistent

leukopenia,

granulocytopenia, or thrombocytopenia.

8erform ophthalmological studies in patients ho develop eye complaints

during therapy and

therapy discontinued if changes are noted. *hanges may include blurred

or diminished vision,

corneal deposits and retinal disturbances, scotomata, changes in color

vision, and macula

degeneration.

1OOW#U8

1urther &npatient *are+

6dmission is recommended for significant dermal burns or eye injuries.

6dmission folloing caustic ingestions depend on symptoms and endoscopic findings.

1urther Outpatient *are+

0ermal burns treated on an outpatient basis should be rechecked every @#C days.

6ny ocular burns treated as on an outpatient basis should be rechecked in @> hours.

Endoscopic examination of all transmucosal or transmural esophageal burns should be

repeated in @#C eeks.


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&n)Out 8atient !eds+

Significant dermal burns re"uire ade"uate &D fluid resuscitation and analgesics

:morphine sulphate


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arger dermal burns can produce significant scarring. Extensive esophageal lesions can

result in future stricture formation.

5ydrofluoric acid burns can cause progressive tissue injury and even result in loss of

digits.

Even moderate corneal burns can result in scarring and loss of vision. Sometimes this

can be remedied by corneal

transplantation.

8atient Education+

1or occupational exposures, the patient should be educated on the proper safetyprecautions hen orking ith ha$ardous materials. 6ll industries are re"uired to inform

employees of any dangerous materials they may come into contact ith in the orkplace

and must provide them ith ade"uate training and protective e"uipment hen orking

ith these.

When children suffer chemical burns, the parents must be counseled on ho to keep

medications and chemicals out of the reach of children. 8arents may not think that

something like automatic dishashing detergent may be a danger to children.

'hey need to be educated on the various substances in the home that are potentially

dangerous.

!&S*E6EOUS

!edical)egal 8itfalls+

1ailure to evaluation a patient ith a caustic ingestion because no oropharyngeal lesions

are seen

1ailure to evaluate and treat a burn and not obtaining psychiatric evaluation in a suicide

attempt

'reatment of a hydrofluoric acid burn as a general acid burn

'ES' LUES'&OS

*!E Luestion 2+ 6 >4 year old construction orker presents complaining of bilateral foot

pain. 5e had been pouring cement all day.


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6fter ashing, his feet are irritated and erythematous appearing. Which of the folloing is

the most likely causeM

6+ *ontact dermatitis

%+ 6llergic dermatitis

*+ 1ungal infection

0+ *austic burn

E+ 6cid burn

Kour *hoice+

*!E Luestion @+ 6 mother brings in her @ year old child after finding her playing ith the

automatic dishashing crystals. 'he child is coughing and drooling. o burns are noticed

in the mouth. 'his child is likely suffering from hich of the folloingM

6+ -espiratory tract irritation from the detergents and en$ymes used in the dishashing

formulation

%+ 6n allergic reaction from the detergents and en$ymes used in the dishashing

formulation

*+ 6 caustic burn secondary to the phosphates, carbonates and silicates used in the

dishashing formulation

0+ 6n upper respiratory infection

E+ Epiglottitis

Kour *hoice+

8earl Luestion 2+ What is the typical burn mechanism associated ith alkali :basic< burnsM

8earl Luestion @+ What is the typical burn mechanism associated ith most acid burnsM

8earl Luestion C+ What type of acid burn acts by a different mechanism than that of other

acidsM

8earl Luestion >+ When ingested, concentrated acids and bases :or granular forms< produce

damage to the intestinal mucosa by an additional mechanism, other than the direct acid or

base damage. What is the mechanismM

Electric Injuries

'-O0U*'&O


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%ackground+ Electrical injuries are infre"uent but ill be eventually encountered by most

practitioners of emergency medicine. 'hese injuries run a gamut of both diagnostic and

treatment modalities. /enerally, they may be classified as lightning, lo voltage and high

voltage.

8athophysiology+ Electrons floing abnormally through the body of a person produce

injury and)or death by depolari$ing muscles and nerves, by initiating abnormal electrical

rhythms in the heart and brain, and by producing electrical burns by both heating and by

poration of the cellular membranes.

*urrent passing through the brain, in both lo and high voltage circuits, producesunconsciousness instantly and directly due to the depolari$ation of the brain(s neurons.

6lternating current may produces ventricular fibrillation if the path of the current involves

passage through the chest, arm to arm, arm to leg, head to arm, etc.

*ircuits through a person hich last for a protracted periods :minutes< produce ischemic

brain damage if respiratory movement is interfered ith.

6ll circuits may produce myonecrosis, myoglobinemia and myoglobinuria and their

attendant complications.

*ircuits may produce electrical burns ith relatively massive amounts of tissue destruction

by heating of the tissues due to the physical property of friction from the passage of

electrons :Noule heating< and by destruction of cell membranes by producing holes in the

membranes :poration


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ightning+

Overall, the survival from lightning strike is over 34. &f cardiac)respiratory arrest has

occurred, prolonged *8- may effect recovery. Unfortunately, prolonged arrest comes ith

an increasing probability of permanent brain injury, persistent vegetative states and brain

death.

o Doltage Electrical &njury+

Without cardiac)respiratory 6rrest

'his situation is encountered fre"uently in children ho bite extension cords. 'he burns

of the mouth are often severe and re"uire extensive plastic revision. 5oever, systemic

problems are infre"uent.

With *ardiac)respiratory 6rrest

'hese patients often are not transported to the E0, as they are pronounced dead at the

scene. &f they are transported and, if the *8- has been prompt and effective, complete and

total recovery, usually ith no apparent injury may occur. Unfortunately, as ith lightning,

protracted periods ithout brain perfusion result in permanent brain damage.

5igh Doltage+

/enerally, patients ho have been in high voltage circuits do not arrest but have

extensive injuries from burns and have risk of acute and chronic problems from

myoglobinuria. Electrical burns from high voltage circuits generally are much orse than

they appear in the E0.

-ace+ 'here appears to be no racial variation in electrical injury susceptibility. 5istorically,

tradespersons in the United States have been predominately *aucasian, thus, the numbers

of injuries has shon a hite predominance.

Sex+ 6ccording to one researcher :0al$iel


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6ge+ Electrical injuries are most fre"uent in young adult males beteen the ages of @4#>4.

'his probably reflects exposure opportunities more than differences in susceptibility.

*&&*6

5istory+ 0ue to multiple causes in electrical injury cases, the history can be either very

obvious or extremely subtle.

ightning+

8atients ho come to the E0 are generally observed to have been struck by lightningith the characteristic flash and boom.

Usually they are rendered unconscious or arrest and history must be obtained from

bystanders.

o Doltage 6lternating *urrent+

o voltage is A44 volts or less, the sort of voltage encountered in domestic and

industrial iring. &njury from o Doltage

6* can be subcatergi$ed into those ith and those ithout cardiac)respiratory arrest

and)or loss of consciousness.

o Doltage Without oss of *onsciousness and)or 6rrest+

'ypically these patients are infants and young children ho bite into appliances

cords. 'he circuit is generally restricted to the mouth. 'he adult ill almost alays be able

to relate that the child as found ith the cord in his or her mouth.

Older children and adults may be injured this ay hile orking on electrical

appliances or home electrical circuits,

hen the circuit does not involve the heart or brain.

o Doltage With oss of *onsciousness and)or 6rrest+

'he presentation may be so subtle, that the correct diagnosis may be missed. 6lays

be alert to the possibility that a sudden arrest might be the result of an electric circuit.

-escue orkers, co#orkers, family and friends should be "ueried about this possibility.

5igh Doltage 6lternating *urrent+

'hese cases involve voltages higher than A44. /enerally, the injuries are so

characteristic that history taking is less important than in lo voltage injuries. 5oever,

there are to possibilities.

5igh Doltage Without oss of *onsciousness and)or 6rrest+

'his is the characteristic situation ith an electrical injury from high voltage. Unless

there is a very high resistance pathay in the circuit, voltages of more than A44 usually do


31/44

not cause cardiac)respiratory arrest. 'hus, the history obtained from the patient should tell

you ho the injury occurred. 0etails of the voltages can be obtained from the poer

company.

5igh Doltage ith 6rrest and)or oss of *onsciousness+

'his is the more unusual presentation from high voltage circuit injuries presenting to

the E0. &f the circuit traverses the head, there ill be loss of consciousness and amnesia for

the events immediately prior to the injury. 'hus, history taking should be directed to rescue

personnel, co#orkers, family or friends ho have knoledge of the circumstances. 0etails

of the voltages can be obtained from the poer company.

0irect *urrent+

0irect current electrical injuries are generally seen in electrical train circuits. 'hese

often involve risk taking behavior by young males. 6rrest and coma are rarely, if ever,

seen. 'he history can be obtained from the patient.

8hysical+ 'he physical examinations should include a careful documentation of injuries.

'here is a bit of difference depending upon the voltage.

5igh Doltage :and, Occasionally, o Doltage With 1lash %urns


32/44

several centimeters. -ecognition of these injuries is important in assessing the extent of

internal damage.

*ontact %urns+

*ontact electrical burns generally have a pattern from the contacted item and are

more limited in si$e than flash burns, although their appearance otherise is nearly

identical to a flash burn. One means of distinguishing is that in skin ith hair, a contact

burn of apparent full thickness ill have unburned hair, hereas a flash burn ill alays

have the hair singed and generally gone.

0ocumenting the 'ypes of %urns+

6rc and contact burns are associated ith internal electrical injury= flash burns are

not. Entrance and exit burns in alternating electrical injuries are not possible, as alternating

current has no such ounds. 5oever, there are arcing and contact burns. 'hese are

markers to here the circuit traversed the body.

o Doltage+

&n lo voltage injuries, there may be flash burns from various sources that ill behave

exactly as ordinary thermal burns and should be documented as such. 5oever, there are

electrical burns that should be documented.

6rcing %urns+

'hese are not seen in lo voltage. 'hermal burns from arcs, here the arc as from

an energi$ed conductor to a grounded conductor are seen. 'hese are the flash type.

0irect *ontact %urns+

'hese ill be seen only if the circuit through the person as prolonged for more than

a fe seconds. &n lo voltage there is insufficient heat to produce skin burns "uickly. 'hus,

the areas here there as electrical contact ill often not be distinguishable on physical

examination or ill only sho focal erythema.

ightning+


33/44

'here is ide variability of findings in a lightning strike victim. %urns are generally not

significant, but should be documented.

'hey ill generally be of the flash type. Singeing of the hair, ithout burning is

characteristic. 'here are a fe things to look for hich are out of the routine+

Scrotal and 8enile %urns+

&n males, there is occasional burning on the undersurface of the scrotum. 'his injury

needs to be identified for early treatment. 'he postictal state that the usual lightning patient

presents ith often makes early identification of these lesions from complaints of painunlikely.

Ear esions+

'he presence of perforation of the eardrum is an occasional feature of a lightning

struck patient. 5emorrhage behind the intact drum is probably more common. 'he

examinations of the lightning struck patient should include an otoscopic exam.

*auses+ Electrical injuries are caused hen a person becomes part of an electrical circuit or

is affected by the thermal effects of a nearby electrical arc. 'he most common

classifications of these injuries are lightning, and high and lo voltage alternating current

:6*< and direct current :0*


34/44

sailboat mast or crane and a person is on the ground at the time the conductor becomes

energi$ed, that person ill be injured. -arely, patients ill get into electrical sitching

e"uipment and directly touch energi$ed components.

o Doltage 6*+

/enerally, there are @ types+ the child ho bites into the cord producing severe lip, face

and tongue injuries and the child or adult ho becomes grounded hile touching an

appliance or other object that is energi$ed.

'he latter type is declining in fre"uency in orth 6merica due to the use of ground faultcircuit interrupters :/1*&s< in any circuits hich supply kitchens, bathrooms or the

outside, as these are places here persons may become easily grounded.

/1*&s stop current flo if there is a leakage current :ground fault< or more than 4.443

amps :4.A atts at 2@4 volts


35/44

&n addition to the more common tests, an assessment of muscle damage should be done

by ordering+

*8H, total and fractionated, if elevated

Urine myoglobin, if urine gives positive hemoglobin test

Serum myoglobin if the urine is positive for myoglobin

'hese tests measure the extent of muscle damage in a very effective ay. 5igh levels of

*8H, identified as muscle ith often some elevation in the myocardial component, are

seen in any significant exposure to lo and high voltage circuits. ightning rarely ill

cause an elevation. &f there is extensive muscle damage, there ill be myoglobinemia and myoglobinuria.

&n any cases here there is arrest or loss of consciousness, arterial blood gas analysis

and a complete drug screen test should strongly be considered.

&maging Studies+

*hest I#-ay: *I-


36/44

1asciotomies of burned extremities may be re"uired in high voltage injuries.

*onsultation ith surgeons ith experience in electrical burn injury should be obtained

early in the high voltage burned patient, as appropriate early fasciotomy may save a limb.

'-E6'!E'

8rehospital *are+ 'he first thing that must be done is to remove the patient from the circuit.

'hen, patients ho are in arrest re"uire %asic and 6dvanced *ardiac ife Support

regimens. -emember, in electrically induced arrest, there is no underlying disease causing

the arrest. 'herefore, protracted efforts of resuscitation are met ith success more often

than usual. 8atients ho are unconscious

but not in arrest, re"uire careful ventilatory observation and assistance, if indicated.8atients ith burns above the neck need supplemental oxygen because of the high

probability of airay and lung damage.

Secondary blunt trauma is often encountered due to falls caused by involuntary

muscular contraction. &t is dealt ith identically to any other blunt trauma.

Emergency 0epartment *are+ 8atients ith electrical burns should be stabili$ed and

considered for immediate transfer to the nearest burn center. &f such facilities are not

available, physicians ith experience in burns, preferably in electrical burns, should

assume care of the patient.

6ll patients ith burns and no apparent *S abnormality should be hydrated. Using the

ordinary rule of thumb for treating the ordinary burn patient may result in significant

dehydration. &n *S normal patients, administration of physiologic fluids such as -inger(s

actate at a rates of 24 ml)kg)hour are reasonable during the initial resuscitation.

&n patients ith *S abnormality, hydration must be tempered ith the possibility of

orsening cerebral edema. 'here is no easy ay to titrate this clinically difficult area.

8atients ho have elevated *8H(s and)or myoglobinemia should have mannitol or

furosemide added to their regimen to provide diuresis for the toxic myoglobin. 'his can

help to prevent acute tubular necrosis and renal failure secondary to myoglobinuria.

'he lightning strike patient should be treated based on the *S symptoms. &f

consciousness is present on admission or returns in the E0, in#patient therapy may not be

re"uired. &f *S abnormalities persist, hospitali$ation is indicated.


37/44

'he successfully resuscitated patient exposed to lo voltage ithout significant burns

may also be handled primarily on the basis of *S symptoms and *8H results. &f

consciousness returns, the *8H is no more than to times normal ith negative

hemoglobin in the urine and the pulse is regular, hospitali$ation may be only for brief time

periods.

&rregularities of pulse, electrocardiographic changes, myoglobinuria or *S

abnormalities all re"uire hospitali$ation.

*onsultations+ 8atients ith electrical burns re"uire treatment by burn specialists. 8rompttransfer to the care of such an individual is indicated. &n high voltage electrical burns, early

fasciotomy may be indicated to improve circulation. 'hus, guidance, as rapidly as possible,

should be sought concerning hen to initiate this procedure in the emergency department.

'rauma)*ritical *are

/eneral Surgery

8lastic)%urn Surgery

!E0&*6'&O

5ydration is the key to reducing the morbidity of electrical injury. &f muscle damage is

significant, the use of an osmotic diuretic is also indicated.

0rug *ategory+ 1luids # oss of intravascular volume through the damaged epithelium, as

ell as loss into extravascular spaces re"uires fluid resuscitation. 'his is best be acheived

ith actated ringers.

0rug ame

actated ringers # &t is essentially isotonic and has volume restorative

properties.

6dult 0ose

/enerally administer 24 ml)kg)h during initial resuscitation.


38/44

8ediatric 0ose

Use the same regimen as in adults.

*ontraindications

'he major complication of isotonic fluid resuscitation is interstitial edema.

Edema in an

extremity is unsightly, but not a significant complication. Edema in the

brain or lungs is

potentially fatal. 'he major contraindication to isotonic fluid resuscitation

is pulmonary edema in

hich the added fluid promotes more edema.

&nteractions

o significant drug interactions have been reported ith this product.

8regnancy


8recautions

1luid resuscitation ill be expected to exacerbate cerebral edema.

1luids should be stopped hen the desired hemodynamic response is seen

or pulmonary edema

develops.

0rug *ategory+ Osmotic 0iuretics # &f myoglobinemia and myoglobinuria are present,

acute renal failure can be minimi$ed by the addition of mannitol to the regimen of fluid

resuscitation.

0rug ame

!annitol :Osmitrol< # &t is an osmotic diuretic hich is not

significantly metaboli$ed and

hich passes through the glomerulus ithout being reabsorbed by the

kidney.

6dult 0ose


39/44

34#@44 g)@> h &D

6djust the dose to maintain a urinary output of C4#34 m)h

8ediatric 0ose

Under 2@ y+ Safety and efficacy have not been established.

5oever, trial doses of 4.@g)Hg &D folloed by careful monitoring of

urinary output may

be prudent, again ith the goal of producing diuresis in the child ith

myoglobinuria

*ontraindications

Well established anuria due to severe renal disease.

Severe pulmonary edema.

6ctive intracranial bleeding except during craniotomy.

Severe dehydration.

8rogressive renal damage or dysfunction after institution of mannitol

therapy, including

increasing oliguria and a$otemia.

8rogressive heart failure occurring after institution of mannitol therapy

&nteractions

o significant drug interactions have been reported ith the use of this

product.

8regnancy


8recautions

Severe electrolyte imbalance and dehydration can ensue if a careful

monitoring of

electrolyte status is not performed.

1OOW#U8

1urther &npatient *are+


40/44

&npatient care ill be re"uired for burns and for patients ith *S abnormalities. %urns

re"uire case specific treatment done by persons ith experience and training.

1urther Outpatient *are+

ightning+

8atients released from the E0 ith good *S function but ith otoscopic abnormalities

should be referred to a person

experienced in treating ear disease and injury. 6ll patients should be referred to an

ophthalmologist for evaluation of possible cataract formation, hich is reported to occurafter lightning strikes.

8atients ithout *S abnormalities, massively elevated *8Hs or ith electrical burns

need no further follo#up. *omplete and full recovery is to be expected.

'ransfer+

6ll patients ith history of exposure to high voltage should be transferred for inpatient

treatment, preferably by a burn center, on this criterion alone. &n addition, mouth burns in a

lo voltage situation should receive speciali$ed treatment generally available only in burn

centers.

'ransfer to an in#patient treatment area should be done if there has not been full return

of *S function, there has been a

greater than three#fold elevation in *8H or the presence of myoglobinemia)uria, or there

is a persistent arrhythmia.

0eterrence)8revention+

8revention of high voltage electrical injuries re"uires on#going public education,

directed particularly to those in construction trades, using cranes and lifts or exposed to the

extreme danger of overhead poerlines. &t is particularly important to educate adolescent

males regarding the serious nature of electrical distribution e"uipment.

ightning+


41/44

When thunderstorms are in the area, never ever be the tallest object. 6void golf courses

and open fields. 0o not stand besides trees. Seek shelter in buildings or cars. &f caught

outdoors, lie on the ground.

o voltage+

ever ever use appliances hich give you a shock, until they are repaired. Encourage

the use of /1*&(s on all outlets here a person may be grounded but alays in bathrooms,

kitchens and outside. &f using e"uipment ith no built in /1*&, use a /1*& extension cord.

*omplications+

ightning+

&f consciousness is regained before arriving, or inside the E0, a full recovery is

expected. 8rolonged unconsciousness leads to a graver prognosis. 1ull recovery is not

expected if unconsciousness persists for @> hours.

o Doltage+

&f there are not significant burns, and if consciousness returns before arriving to or in

the E0, full recovery is usual. -arely, persistent arrhythmias have been recorded.

8ersistence of unconsciousness leads to a graver prognosis. 1ull recovery is not expected if

unconsciousness persists for @> hours.

o Doltage !outh %urns+

With proper treatment, the disfigurement of lo voltage mouth injuries can be

minimi$ed. Scarring ill alays be present but not extremely disfiguring.

5igh Doltage+

Survival ith massive burns is no the exception rather than the rule. 'he incidence of

extremity loss has been reduced ith improved treatment but has not been eliminated.

Severe disfigurement is the rule, even hen extremities are preserved due to the massive

irreparable destruction of nerve and muscle.


42/44

8rognosis+

1or those ithout burns, prognosis is based upon *S function. &f it promptly returns,

prognosis is excellent, even in patients ho arrest.

1or those ith burns, survival continues to improve ith the improvement of burn care.

0isfigurement continues to be a major problem.

8atient Education+

&f the cause of the injury is established, obviously counseling concerning avoiding suchha$ards is important. /enerally, the injury speaks more elo"uently than e do.

!&S*E6EOUS

!edical)egal 8itfalls+

itigation over the injury is to be expected. &t is extremely helpful if you document the

presence and absence of electrical

burns. 0iagramming these injuries is alays indicated. 8hotographing the injured and

uninjured areas of the body is extremely helpful. &t is alays proper to have ritten consent

for photographs.

/enerally in electrical injuries, there is a solvent defendant other than the medical

practitioner. 'hus, suits against practitioners in such cases are rare. 0ocumenting the extent

of the injuries is, hoever, extremely helpful should the practitioner end up being the only

defendant.

8&*'U-ES

*aption+ 6rcing electrical burns, through shoe around rubber sole. 5igh voltage ?,A44v 6*

nominal. ote cratering.

8icture 'ype+ 8hoto


43/44

*aption+ *ontact electrical burn, this as the ground of a 2@4v 6* nominal circuit. ote

vesicle ith surrounding erythema. ote thermal and contact electrical burns cannot be

easily distinguished.

8icture 'ype+

*aption+ *ontact electrical burns 2@4v 6* nominal. 'he right knee as the energi$ed side

and the left as ground. 6gain these are contact and difficult to distinguish from thermal.

ote entrance and exit are not viable concepts in alternating current.

8icture 'ype+

'ES' LUES'&OS

*!E Luestion 2+ aboratory analysis of a person thought to be electrically injured should

include hich of the folloingM

6+ Serum iron

%+ Urine magnesium

*+ 05

0+ 6'

E+ *8H

Kour *hoice+

*!E Luestion @+ Which of the folloing is an important part of the physical examination

in a patient struck by lightning, hich is

often overlookedM

6+ *hest auscultation

%+ 6bdominal palpation

*+ Otoscopic examination

0+ 0igital rectal examination

E+ &ndirect laryngoscopy

Kour *hoice+


44/44

8earl Luestion 2+ What is the most common age and sex for electrically injured patientsM

8earl Luestion @+ 6 @@#year#old male comes in undergoing *8-. 5e as outside orking

ith a drill, as heard to scream and then collapsed. What is on your differential listM

8earl Luestion C+ What does the finding of hemoglobin positive in the urine of a nely

arrived electrical injury patient indicateM

8earl Luestion >+ Why is the diagnosis of myoglobinuria important in an electrically

injured patientM

Documents

Burn Emergencies (English)