Burns, , and Electrical Injuries Harish Kinni 10/3/2013

Burns Direct or indirect contact with heat, electrical, radiation, or chemical agents Regeneration of damaged epidermis occurs from basal layer of cells and dermal appendage skin cells Inhalation Injury: airway edema, particular debris, mucosal damage, CO and CN toxicity o Low threshold for intubation (fiber optic scope) o NIPPV, Nebs (no steroids), suctioning, alveolar lavage, aerosolized NAC ± heparin o Higher fluid requirements

Determine Total Surface area burns using rules of 9 (must be at least 2nd degree partial or full thickness o Children have different proportions (larger heads) Fluid Resuscitation o Parkland formula for fluid resuscitation (4 mL/kg/ % burn of LR) o Children: Galveston formula: LR 5000 mL/m2 TBSA burned + 2000 mL/m2 (maintenance) o First half over 8 hours and rest of next 16 hours o Infants should get D5 due to inadequate reserve Monitor fluid status (HR, BP, UO): overload increase risk of , ARDS, and death Care o Appropriate pain control o Irrigation with soap and water o Immunization or tetanus immunoglobulin if needed o Debride burn if open o DRY dressing only o Escharotomy, GI prophylaxis Transfer to Burn Center with major Burns: >20% burns, 10% full thickness, involving face, hands, feet or cosmetic or function issues, and inhalation injury Frostbite Tends to occur when environment is not accounted for 15°C is maximal vasoconstriction but below causes hunter response (intermittent vasodialation to prevent limb ischemia) Risk Factors: EtOH, aerosol sprays, ice packs, smoking, previous cold injuries, poor insulation and excessive sweating Cellular damage causing edema and thrombus formation and ischemia Non freezing injury o Frostnip: superficial cold insult that is transient o Chilbain (pernio): cold injury after repetitive exposure o Trench foot: prolonged exposure to cold and wet over days Burns, Frostbite, and Electrical Injuries Harish Kinni 10/3/2013

Diagnosis: H&P, PE, X ray, isotope scan for long term viability, MRI/MRA Management o PREVENT partial thaw o ABCs, protect part, rehydrate patient, immerse in circulating water (37-39 degree) to thaw, pain control. o Post thaw: dry and elevate part, debride broken vesicles (leave hemorrhagic ones intact), tetanus and step prophylaxis, consider thrombolytic if within 24 hours, admission with surgery consult (plastics) via direct effect of current conversion to thermal and blunt injury Heat produced is related to current, resistance (tissue type), and time Internal injury may not be contiguous o Electrothermal: seen with high voltage causes partial to deep burns o Arc burns: indirect, high voltage, thermal burns o Radiate Burns: partial thickness burns o Vascular injury: most to media (delayed bleeding and thrombosis) . Intimal injury can cause immediate thrombosis o Trauma from being thrown Cardiovascular injury: asystole or V fib can be seen as well as other arrhythmia and EKD abnormalities o Paralysis of respiratory muscles could also lead to induced V fib o Vascular electrical can lead to immediate coagulation necrosis, thrombosis . Lightening can causes temporary spasm Skin injuries tend to be worst at source and ground o Lightening can cause linear (water to steam burns), punctate (small cigarette like burns), feathering (pathognomonic for lightening, temporary), thermal (clothing and jewelry catching fire) Injury to extremities can lead to compartment syndrome, affecting joints more over long bones, as well as joint dislocations due to tetanic spasm o Rhabdomyolysis CNS can be affected by causing temporary, confusion, anterograde amnesia o Electrical injuries can have weakness lower> upper and even ascending paralysis o Lightening has keraunoparalysis . Temporary paralysis . Lower and sometimes upper extremities that are blue, mottled, cold, and pulseless. . Vascular spasm and sympathetic nervous system instability Management o Ensure scene safety o ABCs . Main concern is cardiovascular and trauma injuries . Rhabdo, Burn wound care, protect extremity with splint in functional position, and possible surgery consult o Disposition . Discharge: normal EKG and no myoglobinuria: d/c home Electrical weapon: asymptomatic and normal exam . Admission: EKG change to telemetry, significant burns to burn center, pregnancy if past 1st trimester for fetal monitoring