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201606159

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Special Burns

Special Burns - Clinical Hub, References, Burn Basics

Focus

Electrical Burns

There are three kinds of burns associated with electricity: 1) True electrical burns where current flows through the body (the patient will tell you whether this happened or not); 2) Flash burns where no current actually passes, but the electric discharge heats up the air enough to cause flash burns; 3) Flame burns when the patient’s clothes catch fire. Flash and flame burns are like all thermal burns and are treated the same way. The following comments relate to electric current burns:

110-220 VOLTS

If the patient has no persistent symptoms and has a normal EKG and rhythm strip, he can go home. If there are any EKG or rhythm abnormalities, admit him or her for monitoring for 24 hours. In general, there will be little tissue destruction other than the contact points (no longer referred to as entrance and exit sites).

Usually at the time of the shock the heart either goes into ventricular fibrillation or remains in sinus rhythm. Fibrillation is pretty uncommon as only about four deaths occur out of 5,000,000 people each year that sustain electric shock. Delayed problems are very uncommon. Deep tissue loss is very uncommon at this voltage range although temporary nerve injury is frequent.

1000+ VOLTS

There are two types of high voltage injuries—those with severe tissue damage and those with little or none. For those with no tissue damage, we must decide what to do about cardiac monitoring. The data suggest not monitoring these patients although we usually do for about 24 hours. If there is any tissue loss they need to be admitted for that reason.

Check for visible myoglobin (brown or red urine, often the color of cola). Maintain a urine output of about 100 ml/hr. Frequently, increasing fluids alone will accomplish this.

There are two reasons to operate early on a patient with electrical burns. If there is persistent gross myoglobinuria (>8 hours) or a metabolic acidosis that doesn’t abate, then the dead tissue load needs to be decreased by operative means. Alternatively the extremity may need fasciotomy for decompression. If these two problems don’t pertain during the first 24 hours, then operation for tissue loss is usually delayed for at least 3-5 days.

All patients with an electrical current burn need formal neurology consult and a slit-lamp exam by ophthalmology prior to discharge for adequate documentation. Delayed, persistent, and recurrent neurologic symptoms are common, as well as premature cataracts. Since many electrical burns are work- related, it is important to have baseline exams from neurology and ophthalmology as noted above.

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Frostbite Management

Injury due to cold can occur any time of the year. The key to improving outcomes is to return the skin to normal temperature as safely and evenly as possible. The injury comes from cellular damage directly from the cold and ischemia due to lack of perfusion. The longer the time from the injury the lower the chance of tissue recovery, after 12 hours the likelihood that there will be reversible damage is much lower.‌

Pre-Burn Unit Frostbite Management (ED, EMS)

Frostnip Frostnip: All areas 1st degree (no blisters)

Mild frostbite Mild Frostbite: Some1st degree and clear-cut 2nd degree (clear blisters)

Moderate frostbite Moderate Frostbite: 2nd degree up to indeterminate-thickness, perhaps a small area of 3rd degree (mixture of clear and hemorrhagic blisters)

Severe frostbite Severe Frostbite: 3rd and 4th degree injuries (hemorrhagic blisters and black ischemic tissue)

OR

Discharge criteria:  Essentially unchanged

Labs obtained during IATT

Hgb

Q 6 hrs

antiXa

Q 6 hrs

Fibrinogen

Q 12 hrs

INR

Q am

Creat

Q am

Plt

Q am

Rapid Rewarming

Make every effort to immerse frozen extremity in 40°C water bath

Continue to exchange water as needed keep at 40°C

Other options include:

Rewarming on shower table in tub room

Removing all clothing and placing patient between an under body and over body bair hugger (this would be the preferred method for patients in the ED prior to admission to the burn center)

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‌Reviewed by Burn Director, May 2016