Too Hot, Too Cold, Just Fried.

Burns, Frostbite, Electrical & Lightning Injuries

Jennifer W. Hsieh PGY-2 Henry Ford Hospital Department of Emergency Medicine

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 Second Degree Burn

http://media.merchantcircle.com/9619455/second-degree-burn-2_full.jpeg Third Degree Burn

http://www.wix.com/integumentary/integumentary First Degree Burn

http://www.nosunblock.com/photos/most-viewed?start=8 Fourth Degree Burn

http://eso-cdn.bestpractice.bmj.com/best-practice/images/bp/en-gb/412-7_default.jpg 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 2-5% FULL >5% FULL THICKNESS THICKNESS, HIGH THICKNESS, VOLTAGE, HIGH VOLTAGE, INHALATION, INVOLVEMENT CIRCUMFERENTIAL, FACE, EYES COMORBIDITIES 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 ischemia Zone of hyperemia 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

Deep Injury Superficial 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 .

} 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?