Right for the Season: Clinical Flowchart for Management of Burns in the Emergency Department November 7, 2019
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Holidays are busy times for everyone, including emergency departments. Maybe it’s the rushing around during preparation or too many people in the kitchen, but inevitably someone gets hurt and burns are among the top injuries seen in the ED during the Thanksgiving holidays.
Thermal burn injuries are a significant cause of morbidity and mortality worldwide. In addition to treatment of the burns, emergency clinicians must assess for inhalation injury, exposure to toxic gases, and related traumatic injuries.
Priorities for emergency resuscitation include stabilization of airway and breathing, intravenous fluid administration, pain control, and local wound care. Special populations, including children and pregnant women, require additional treatment considerations. Referral to specialized burn care for select patients is necessary to improve long-term outcomes.
This pathway outlines evidence-based treatment strategies for treating thermal burn injuries in the ED.
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24-year-old subdued with taser — Brain Teaser. Do you know the answer? November 24, 2018
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Test your knowledge and see how much you know about treating and managing electrical injuries in the ED.
The correct answer: C.
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Human tissues have varying resistance characteristics and susceptibility to damage, so injuries may be thermal, electrical, and/or mechanical, potentially causing burns, thrombosis, tetany, falls, and blast injury. Here are 10 risk management pitfalls to avoid and 4 time- and cost-effective strategies for when you’re managing eletrical Injuries.
10 Risk Management Pitfalls for Electrical Injuries in the Emergency Department
1. “I sent the patient with a low-voltage minor electrical burn home and told her she was fine (she was!). She came back to the ED 2 weeks later and is angry because she developed dizziness and paresthesia in her fingers.”
Electrical injuries have a high incidence of delayed neurological sequelae,41 with studies noting between 25% and 80% of patients reporting neurological complaints after electric shock.39,40 It is important to give specific, detailed discharge instructions, including return precautions for numbness, dizziness, weakness, and mental status changes.
2. “I admitted an electrician with upper extremity and facial burns and airway management who was injured working on a high-voltage line. The orthopedic surgeon called and is angry because he has an open foot fracture. The ED was busy; I can’t take every single patient’s boots off.”
High-voltage injuries have a high incidence of orthopedic injuries, and electrical current at entrance and exit sites can be sufficient to cause open injuries. Remember to completely undress patients so you do not miss injuries on your primary and secondary survey.
3. “The man was found lying in the grass, unconscious. His CT scan and labs were normal. He seemed confused on re-evaluation, so I admitted him for altered mental status, which I thought was probably drug-related. The next day I got a call from the hospitalist; apparently the ENT said he has extensive inner and middle ear damage and is now deaf.”
Patients found unconscious for no apparent reason in an open area should have lightning strike in the differential. (Lightning can strike even when it is not raining, during an event called a “dry” thunderstorm.) The concussive force of the strike can be sufficient to rupture tympanic membranes and cause inner ear damage.47 A thorough ENT examination is necessary.
4. “A patient was brought in by the police last night. He was ‘minding his own business’ and somehow ended up Tasered. He said it hurt to lift his arm. I x-rayed his humerus and elbow, both negative, with normal pulses and sensation, so I discharged him into police custody. Unfortunately, they brought him back 2 days later… he ended up being diagnosed with a scapular fracture.”
Taser (or other electroshock weapon) injuries are on the rise in the United States, and 1 out of 9 police-related injuries presenting to United States EDs are caused by these devices.76,77 The majority of injuries are minor abrasions, lacerations, and contusions. Forceful muscle contraction can cause fractures, including spinous process fractures and scapular injuries. Cardiac electrical capture with subsequent ventricular fibrillation and asystole is a rare complication.78
5. “I work at the regional burn center. EMS brought in a 45-year-old lineman who touched a high-voltage line. The shock entered his left arm and exited his right leg. I admitted him to burn ICU, gave IV fluids for his open injuries, but I didn’t have time to recheck him. He needed multiple doses of pain medicine. While he was holding in the ED his arm became tight, shiny, and pale…he had a delay in his emergent fasciotomy.”
Burn patients with significant orthopedic injuries are at high risk for compartment syndrome, and electrical burns are at even higher risk because of the full-thickness nature of many of these injuries. Frequent neurovascular checks are a must, especially in the first 12 hours. Your ED should have a protocol for neurovascular checks for these patients, and progressive or uncontrolled pain should prompt further investigation.
6. “The 2-year-old had a small burn on his face after playing with an electrical cord. There was no airway involvement, and I sent him home to follow up with a burn specialist. Then 24 hours later, he came back bleeding profusely from the mouth…that airway was touch-and-go.”
Oral burns in children who chewed on an electrical cord have up to 24% incidence of bleeding from the labial artery. Proper initial management is controversial, but ENT consultation should be obtained, and if the patient goes home, you must give strict discharge instructions and set patient/family expectations for the possibility of bleeding.48,49
7. “This patient was transferred to our burn center for evaluation of his high-voltage burns after he was cleared by the trauma center. We admitted him to the burn floor, where he had a seizure and then became obtunded. It turned out he had a basilar skull fracture. The surgeon asked me if I had looked behind his ears.’”
Initial traumatic injuries may not be apparent in high-voltage exposures, and you should do a thorough traumatic evaluation in these patients. In this case, early recognition of a skull fracture (which may reveal the Battle sign, with bruising behind the ears) could have prompted seizure prophylaxis, neurosurgical consultation, intracranial pressure monitoring, etc.
8. “My patient had a high-voltage burn that had entry at his head and exit from the right arm. He had some minor facial burns and an arm fracture. We admitted him to the floor, but he boarded in the ED for a while. I’m glad he did, because he became progressively more dyspneic and needed emergent intubation. He had a lot of edema; I barely got the tube passed.”
Remember that the extent of burn seen on the skin in high-voltage burns may not give an accurate picture of underlying burn injury. You cannot use traditional burn metrics of soot in the mouth or nares, facial hair singeing, or burns to the lips as risk factors for intubation. Maintain a high index of suspicion for airway involvement and consider fiberoptic laryngoscopy or early intubation in electrical burns involving the face or neck.
9. “We saw a patient who grabbed a low-voltage line with both hands. She said that her left arm hurt, but there was no sign of trauma, x-ray was negative, and her ECG was completely normal. That night she returned, and her arm was cold and pale.”
There is a risk of acute arterial and venous thrombosis in patients injured by electric current. This is hypothesized to be due to both thermal damage and electrical damage to the intima of the vessel. In a patient with unexplained pain in a limb after electrical injury, you must document neurovascular status and serial examinations. If pain persists, further workup is necessary, which may include ultrasound, CT angiography, or formal angiography.
10. “This high-voltage injury patient came to the ED with 10% total body surface area burns. I followed the Parkland formula for fluids, but she stayed hypotensive and, during her hospital course, developed acute renal failure. I thought that formula was solid for taking care of a burn patient.”
Electrical burns on the skin do not necessarily give a clear picture as to how much tissue was actually damaged by thermal and electrical energy. Isotonic IV fluids sufficient to maintain urine output at 1.0 to 1.5 cc/kg/ hr must be given to these patients. Continue fluid resuscitation until you reach that urine output and urine myoglobin has cleared. Fluid requirements may be much higher than specified by the Parkland formula. CK levels and myoglobinuria should be monitored.
4 Time- and Cost-Effective Strategies
- Cardiac monitoring in patients with no arrhythmia, syncope, or ECG changes is unnecessary.
- Do not delay transfer to a burn center; once you have determined that transfer is necessary and the patient is stabilized, further diagnostic testing may delay definitive care.
- Many low-voltage exposures may be safely discharged home if there are no or only minor burns, no ECG changes, and no worrisome findings on examination.
- A urinalysis can screen for the presence of myoglobin, leading to a search for rhabdomyolysis.
39. Singerman J, Gomez M, Fish JS. Long-term sequelae of low voltage electrical injury. J Burn Care Res. 2008;29(5):773-777. (Retrospective study; 38 patients)
40.* Bailey B, Gaudreault P, Thivierge RL. Neurologic and neuropsychological symptoms during the first year after an electric shock: results of a prospective multicenter study. Am J Emerg Med. 2008;26(4):413-418. (Prospective cohort study; 86 patients)
41. Tondel M, Blomqvist A, Jakobsson K, et al. [Immediate and delayed outcomes after electrical injury. A guide for clinicians]. Lakartidningen. 2016 Dec 1;113. (Descriptive study and review of Swedish national data; 300 patients)
47. Modayil PC, Lloyd GW, Mallik A, et al. Inner ear damage following electric current and lightning injury: a literature review. Eur Arch Otorhinolaryngol. 2014;271(5):855-861. (Meta-analysis; 35 articles)
48. Canady JW, Thompson SA, Bardach J. Oral commissure burns in children. Plast Reconstr Surg. 1996;97(4):738-744. (Descriptive study; 24 patients)
49. Thomas SS. Electrical burns of the mouth: still searching for an answer. Burns. 1996;22(2):137-140. (Review and case report; 5 patients)
76. Cherington M. Lightning injuries. Ann Emerg Med. 25(4):516-519. (Practice guidelines)
77. Pfortmueller CA, Yikun Y, Haberkern M, et al. Injuries, sequelae, and treatment of lightning-induced injuries: 10 years of experience at a Swiss trauma center. Emerg Med Internat. 2012;2012:167698. (Retrospective study; 9 patients)
78. Gluncic I, Roje Z, Gluncic V, et al. Ear injuries caused by lightning: report of 18 cases. J Laryngol Otol. 2001;115(1):4-8. (Case series; 18 patients)