You are the physician working in a rural emergency room when a child arrives by Emergency Medical Service (EMS). The paramedics tell you that 8-year-old Donny McMaster was playing near an electrical transformer when a loud spark was heard and the child was knocked about 10 yards. His shirt was on fire but his friends extinguished it by rolling him on the ground.
What is the initial priority in the care of Donny?
As in all trauma, immediately assess the ABCs (airway, breathing, and circulation) Airway compromise is common with severe burn and electrical injuries, usually associated with edematous occlusion of the upper airway as appropriate fluid resuscitation is given. Likewise, breathing may be compromised from either detriment in mental obtundation or a constrictive burn eschar circumscribing the chest with an impedance to thoracic excursion and ventilation.
Circulatory arrest is frequent following electrical injury and is apparently associated with the abnormal electrical conduction through the heart and subsequent cardiac arrhythmias. Circulation is also compromised until fluid resuscitation can replenish and then maintain plasma lost from the extensive edema within the injured tissue. Therefore, establishing intravenous (IV) access is an important early step in the management of a burn patient.
An index to the adequacy of fluid resuscitation, the Foley catheter is essential for monitoring. Other monitors, such as pulse oximetry and electrocardiography (ECG), are important (1). Furthermore, removal of all clothing and jewelry and a thorough inspection to assess the extent of wounding and to look for other injuries is important.
On initial assessment, Donny’s airway was patent, his respiratory rate was 24 breaths per minute and comfortable, his pulse was 110 beats per minute, and his blood pressure was 108/64 mm Hg. He had a deep white burn about the size of a quarter on the lateral aspect of his left hand and another wound on his right knee. The skin on his chest, neck, face, and left arm was erythematous with patches of blisters.
What is the significance of the deep burns on the hand and knee?
These small but deep wounds are most likely the entrance and exit sites for the high-voltage electrical current. The extent of injury associated with the electrical current is often deceptive because the overlying skin appears normal. Bone, however, has a high resistance to electrical conductivity, and thus a tremendous amount of heat is generated around the bone, which damages adjacent muscle.
What is the fluid formula for the resuscitation of Donny?
There is no fluid formula for electrical injuries. As noted earlier, the extent of tissue damage is not readily apparent. The best management is to promptly place a Foley catheter and closely monitor the urine output, adjusting the rate of fluid infusion to maintaining an adequate urine output of no less than 0.5 mL per kg body weight per hour.
Since placement of the Foley catheter 40 minutes ago, there has been only 5 mL of dark tea-colored urine despite 3 L of normal saline given to this 33-kg child.
What is the significance of the dark urine?
Damaged muscle releases myoglobin. If the damaged muscle remains compartmentalized, the myoglobin enters the circulation. This myoglobin coagulates within the glomeruli and renal tubules, precipitating renal dysfunction and possibly failure (2). Initial management advocates infusion of large quantities of crystalloid. In cases in which urine output is unresponsive to fluid administration, mannitol and sodium bicarbonate may also be helpful in maintaining renal tubular patency. Loop diuretics are contraindicated because they may diminish renal tubular perfusion and may exacerbate precipitation of myoglobin. One concern is that any renal dysfunction may impede the excretion of the large quantity of fluids given. Therefore, monitoring of central venous pressure is often helpful.
One hour after Donny’s arrival in the emergency room, his left, burned forearm is now tight and pulses at the wrist are no longer palpable.
What is the significance of this finding and what procedure is urgently required?
Edema is obligatory in damaged tissue. The electrical current and heat generated from the conduction through bone has damaged the muscle. The muscle is confined within a fascial compartment, thereby limiting the edematous expansion of the muscle. As the pressure within this muscle compartment rises, first venous and then arterial perfusion diminishes. This could lead quickly to a nonviable extremity. The appropriate emergency procedure is a fasciotomy, in which incisions are made through the skin and the fascia of each muscle compartment (3). The muscle then bulges out through the fascial incision, lowering the compartment pressure with a return of perfusion to the extremity.
This rural county 40-bed hospital is ill-equipped to handle this severe injury.
What are some of the appropriate management steps to safely transfer Donny to an established burn facility?
As in the initial care, assurance of the ABCs of Trauma is essential for the safe transport of a patient to a designated trauma facility (4). If there is any concern about airway patency and breathing, intubation and ventilatory support are appropriate. To maintain circulation, sew into place two large-bore IVs. Adhesive tape does not stay well on sloughing, blistered, and burned skin, whereas suturing the IVs is a reliable way to secure placement. Two IVs are recommended as a precaution because at least one IV frequently fails.
The Foley catheter is also important because it allows ongoing monitoring, and the transport personnel can be instructed to adjust fluids to maintain the appropriate urine output. Immediately addressing the wound is not a priority concern. But because burn patients often lose their ability to thermally regulate, they can become very cold. It is imperative that a warm environment be ensured by using multiple warm blankets, by engaging a Bair-Hugger warming system, or by simply increasing the ambient temperature in the helicopter or ambulance to very hot. Also, frequent communication between the transferring and receiving physicians and the transport team is also important.
You are the resident physician in charge of the Burn Unit when EMS arrives with Jerry Folino, a 60-year-old man who was found unconscious on the bedroom floor during a house fire. He was intubated on the scene and arrives with pulse oximetry of 88%.
What are the priorities in care?
As with all initial trauma evaluations, follow the ABCs. Although this scenario notes that the patient was intubated, endotracheal tubes can be either placed poorly or dislodged en route. Because airway patency is the highest priority, make sure that the endotracheal tube is placed properly. This can be readily accomplished by either auscultation of the chest during insufflation or confirmation of the presence of end tidal CO2 in the expired breath.
After airway patency is secured, the next priority is breathing. This also can be quickly assessed by auscultation of the chest. Disparity of breath sounds between sides of the chest can be explained by poor endotracheal tube placement into a main stem, bronchus, pneumothorax, hemothorax, or aspiration of a foreign body.
The third priority is circulation. This is most readily monitored by blood pressure, heart rate, palpation of the pulse, and pulse oximetry. For burn victims, massive volumes of IV fluids are sometimes needed to maintain blood volume and support circulation.
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