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Burns, Frostbite, Electrical & Lightning Injuries
Jennifer W. Hsieh PGY-2 Henry Ford Hospital Department of Emergency Medicine
Too Hot, Too Cold, Just Fried.
http://www.brombear.com/story_goldilocks.htm
Thermal Burn Injuries
Thermal Burns- Overview
} Classification } TBSA } Burn center criteria } ABCs } Wound care
Classification
} 1st degree: Epidermis } 2nd degree: Epidermis + partial dermis
} 3rd degree: Epidermis + entire dermis
} 4th degree: Epidermis + entire dermis +muscle/bone
Classification
} 1st degree: painful and erythematous } 2nd degree: painful with blisters
} Superficial } Papillary dermis (erythematous with clear blisters,
moist and blanchable) } Deep
} Reticular dermis (white with some erythema, hemorrhagic blisters, less moist and blanchable)
} 3rd degree: painless, white, stiff, dry, not blanchable } 4th degree: painless, charred, stiff, thrombosed
vessels
http://media.merchantcircle.com/9619455/second-degree-burn-2_full.jpeg
Second Degree Burn
http://www.wix.com/integumentary/integumentary
Third Degree Burn
http://www.nosunblock.com/photos/most-viewed?start=8
First Degree Burn
http://eso-cdn.bestpractice.bmj.com/best-practice/images/bp/en-gb/412-7_default.jpg
Fourth Degree Burn
TBSA
} Exclude 1st degree burns } Rule of 9’s } Lund-Browder chart
Rule of Nines
http://www.bmj.com/content/329/7457/101.full
Lund-Browder Chart
Rosen’s (pg. 790)
Transfer to Burn Center If…
} 2nd degree > 10% TBSA, all 3rd degree } Face, hands, feet, genitalia, perineum, major
joints } Electrical & chemical burns } Inhalation injury } Patients with significant comorbidities } Concomitant trauma } Children in hospital without qualified peds care } Patients requiring special social intervention
http://www.ameriburn.org/BurnCenterReferralCriteria.pdf
Burn Severity AGE MINOR MODERATE MAJOR
10-50 YRS < 10% TBSA 10-20% TBSA >20%
<10 OR >50 YRS < 5% TBSA 5-10% TBSA >10%
ALL PATIENTS < 2% FULL THICKNESS
2-5% FULL THICKNESS, HIGH VOLTAGE, INHALATION, CIRCUMFERENTIAL, COMORBIDITIES
>5% FULL THICKNESS, HIGH VOLTAGE, INVOLVEMENT FACE, EYES EARS, GENITALS, JOINTS
Outpatient Resource
} DRH Ambulatory Burn Clinic } Open Mon-Fri 8:00 am-4:30 pm } Physician Clinic Tues & Thurs by appointment } (313) 745-3449 } Dressing changes; wound checks; long-term care for
chronic wounds, frostbite, compartment syndrome } Have patient call first regarding insurance
} Accepts Molina, Great Lakes, Omnicare } Needs referral if uninsured, Total Health, Procare,
Midwest
A B C ’s!
} Inhalational Injury: } Early obstruction usually from chemical irritation
(CO, CN levels!) } Clinical signs: facial burns, singed nasal hair,
carbonaceous sputum } Laryngoscopy: soot, charring, mucosal inflammation,
edema, necrosis of airway } Succinylcholine? } V/Q scans to detect parenchymal injury } Consider bronchodilators, heparin and NAC nebs } ARDS
Fluids?
} Parkland formula } 4 mL x Wt (in kg) x TBSA (in %) of LR over
first 24h } half over first 8h, other half over
remaining16h } End point of resuscitation is organ
perfusion!
Fluids?
} Galveston formula } 5,000 mL x TBSA burned (in m2) + 2,000 mL
x TBSA (in m2) of LR over first 24 h } half over first 8h, other half over
remaining16h } TBSA determined by Mosteller formula: ([Ht
(in cm) x Wt (in kg)]/3600) 1/2
Anatomy of a Burn
Irreversible necrosis
Zone of hyperemia
Zone of ischemia
Wound Care
} Stop the burning! } Cleanse with soap and water } Cool burn (no ice!) } Tetanus shot? } Escharotomy? } Blisters? } Burn dressings
Burn Dressings
} 1st degree: none } 2nd degree: } Open: topical antimicrobials + non-adherent
dressing. Good for deep and/or contaminated burns with exudate
} Closed: occlusive dressings. Good for superficial burns with minimal exudate
} 3rd degree: Just cover it and transfer to burn center (dry dressing or vaseline gauze)
Pain Control
} Cooling } Topical anesthetics, aloe vera, topical
NSAIDs } Acetaminophen/NSAID PO } Morphine IV } Fentanyl IV or IM
Thermal Burns- Summary
} 1st & 2nd degree burns hurt, 3rd & 4th don’t } 2nd degree burns blister } Always document TBSA } When in doubt, transfer to burn center } When in doubt, intubate } Check carbon monoxide and cyanide levels! } Parkland formula, Galveston formula and organ
perfusion to guide IVF } Appropriate wound care and pain control
FROSTBITE INJURIES
Frostbite- Overview
} Pathophysiology } Symptoms } Classification } Management } Long-term issues
Life vs. Limb
} 15o C (59o F): Maximal peripheral vasoconstriction
} 10o C (50o F): Hunting response } 0o C (32o F) or less: Frostbite
3 Stages of Freezing
} Prefreeze } Viscosity of vascular contents increases,
microvasculature constricts, plasma leaks into interstitium
} Freeze-thaw } Extracellular ice forms, water moves extracellularly,
cells shrink and collapse } Vascular stasis and progressive ischemia } Decrease in bloodflow causes microvascular
collapse, ischemia and necrosis
Symptoms
} Feels waxy or hard } Looks pale or blanched; edematous,
blisters } Patient has numbness, tingling, clumsiness
Classification
} Difficult to predict tissue loss initially (tissue demarcation 30-90 days later)
} Superficial vs. deep } Favorable findings: clear blebs, normal
sensation, warmth, color } Ominous findings: hemorrhagic blebs, no
edema, early eschar formation
Superficial Injury Deep Injury
Rosen’s pg. 1865
Roberts and Hedges pg. 1246
Management- Pre-thaw
} Address hypothermia } Prevent thaw and refreeze } Assess pulses
Management-Thaw
} Immersion in warm (35-42 o C) water until tissue is pliable and distal erythema present
} No dry heat, no friction } Analgesia (ibuprofen or toradol- fibrinolysis,
thromboxane inhibition) } Encourage movement
Management- Post-thaw
} Dry, apply non-compressive dressing, elevate } Pledgets between toes } Aspiration vs. debridement of vesicles } Strep and tetanus prophylaxis? } Hydrotherapy TID } Beware compartment syndrome and core
temperature after-drop
Management- Other considerations
} Thrombolysis? (tPA, heparin) } Anti-inflammatory agents? (steroids, NSAIDs) } Dextran? } Phosphodiesterase inhibitors? (pentoxifylline) } CCBs? } Alpha-blockers (phenoxybenzamine)? } Hyperbarics? } Sympathectomy?
Long-term Issues
} Tissue loss } Infection } Pain, paresthesias, hyperhydrosis, cold
hypersensitivity } Avoid reinjury } Scarring, tissue atrophy, arthritis, pediatric
growth abnormalities
Frostbite- Summary
} Microvascular injury plays an important role } Difficult to predict tissue loss but clear blebs, normal
skin and presence of edema are favorable prognosticators
} Use warm water to thaw anytime you suspect frostbite
} AVOID THAW AND REFREEZE } Reperfusion is painful! } Lots of experimental treatments } Patients need long-term follow-up
Electrical and Lightning Injuries
Electrical & Lightning Injuries- Overview
} Physics (briefly) } Low voltage injuries } High voltage/Lightning injuries } Evaluation- systems based } Management } Tasers
Physics 101
} Ohm’s Law: I=V/R } Joule’s Law: P = I2Rt } AC vs. DC
www.amazon.com
Low Voltage Injuries
} Household electrical sources: AC,120 V, 60 Hz } AC more dangerous than DC even at low voltage
due to repetitive muscle stimulation } Let-go threshold at 4-9 mA } Respiratory arrest at 20-40 mA } V-fib at 60-120 mA
} No fatalities with telephone lines } Good prognosis if no immediate symptoms
High Voltage/Lightning Injuries
} Cardiac arrhythmias/arrest } Respiratory arrest } Blunt trauma } Vascular spasms } Neurologic damage/dysfunction } When multiple victims treat those without vital signs first
http://www.youtube.com/watch?v=Ka1Rr6OEZ_E
Evaluation
} Head and Neck } Skull and C-spine } Tympanic membranes } Eye injuries
Evaluation
} Cardiopulmonary } Arrest } EKG changes } HTN } Hemorrhage
Evaluation
} Neurologic } CNS/PNS/ANS } Cerebral edema } Seizures } Confusion, anterograde amnesia } Keraunoparalysis
Evaluation
} Skin } Source and ground contact points } Surface damage often does not
correlate with underlying tissue damage } Burns } Lichtenberg figures
www.wikipedia.org, www.designswan.com
Evaluation
} Mouth burns } Most common electrical injury } Damage to developing dentition } Labial artery } Cosmetic deformity
Evaluation
} Extremities } Compartment syndrome } Fractures } Burns worse at joints } Neurovascular checks } Shoulder dislocations
Management } ABCs } IVF (rhabdomyolysis) } Wound care for burns } Splint injured extremities to prevent contractures } Outpatient vs. Admission } Tele for all high energy injuries (12-24 hrs), cardiac
arrest, abnormal EKG, LOC, cardiac risk factors, corporeal conduction
} Burn unit?
Don’t Tase Me, Bro!
} Brief pulse of direct current } Rare cardiac arrhythmias } Wounds, retained fragments, secondary injuries
Electrical & Lightning Injuries- Summary
} Reverse triage- treat cardiopulmonary arrest FIRST
} Full trauma assessment } Low risk for delayed arrest, especially if low
voltage } Injuries may be worse than they appear } High fluid requirements } Nervous system dysfunction- don’t be too quick
to stop resuscitation or amputate
References } American Burn Association. Burn Center Referral Criteria. 2006. 20 Jan. 2012 <http://www.ameriburn.org/
BurnCenterReferralCriteria.pdf>.
} Danzl DF. Frostbite. In: Marx JA, Hockberger RS, Walls RM, eds. Rosen’s Emergency Medicine. 7th ed. Philadelphia, PA: Mosby Elsevier; 2010:1861-1867.
} Hopson LR, Schwartz RB. Pharmacologic Adjuncts to Intubation. In: Roberts JR, Hedges JR, eds. Roberts and Hedges Clinical Procedures in Emergency Medicine. 5th ed. Philadelphia, PA: Saunders Elsevier; 2010:99-109.
} Mallon B. Major Burns. September 2006. Podcast. EM:RAP.
} Mechem CC, Zafren K. Frostbite. In: UpToDate, Basow DS (Ed), UpToDate, Waltham,MA, 2012.
} Nauss, M. Lightning Injuries. Powerpoint presentation for University of Cincinnati, Department of Emergency Medicine.
} Pinto DS, Clardy PF, Danzl DF, Grayzel J. Environmental Electrical Injuries. In: UpToDate, Basow DS (Ed), UpToDate, Waltham,MA, 2012.
} Prendergast HM, Erickson TB. Procedures Pertaining to Hypothermia and Hyperthermia. In: Roberts JR, Hedges JR, eds. Roberts and Hedges Clinical Procedures in Emergency Medicine. 5th ed. Philadelphia, PA: Saunders Elsevier; 2010:1235-1259.
} Price TG, Cooper M. Electrical and Lightning Injuries. In: Marx JA, Hockberger RS, Walls RM, eds. Rosen’s Emergency Medicine. 7th ed. Philadelphia, PA: Mosby Elsevier; 2010:1893-1902.
} Singer AJ, Taira BR, Lee CC, Soroff HS. Thermal Burns. In: Marx JA, Hockberger RS, Walls RM, eds. Rosen’s Emergency Medicine. 7th ed. Philadelphia, PA: Mosby Elsevier; 2010:758-766.
QUESTIONS?
