Burn 2 DR. AXIEL YC SIU REVISED BY DR. CHAN MING YIN JULY, 2013 HKCEM College Tutorial.

Burn 2

DR. AXIEL YC SIU

REVISED BY

DR. CHAN MING YIN

JULY, 2013

HKCEM College Tutorial

Ambulance information

▪A 45 year old man was found unconscious while working with electric drill

History

▪ A 45 year-old man was found unconscious on ground.

▪He was using a electric hand drill before.

▪No convulsion was noticed by his colleagues.

▪No period of cardiac arrest was documented.

▪He regained consciousness in ambulance.

What are the possible differential diagnoses?

Differential diagnosis

▪CVS▪Cardiac arrhythmia▪ Ischaemic heart disease

▪CNS▪Syncope▪Epilepsy

▪ Endocrine▪Hypoglycaemia▪Electrolyte disturbance▪Addison’s disease

▪Others▪Electrocution▪Drug effect▪Substance abuse

Vital Signs

• Alert (GCS:15/15)

• BP: 140/89 mmHg

• Pulse: 84/min (Regular)

• SpO2: 100% (Room Air)

History

▪ A 45 year-old man was found unconscious on ground.

▪He was using a electric hand drill before.

▪No convulsion was noticed by his colleagues.

▪No period of cardiac arrest was documented.

▪He regained consciousness in ambulance.

Assessment

▪ Charred mark was noted at right palm

▪ No other external wound

▪ Heart sound was normal

▪ No neurological deficit was noted

▪ Mild tenderness was noted over both loin region

WHAT IS YOUR MANAGEMENT PRIORITY?

What is the most likely diagnosis?

WHAT IS YOUR MANAGEMENT PRIORITY?

Electrical Injury

Management Priority

▪ Airway with cervical protection

▪ Breathing

▪ Circulation

▪ Deficit and Disability

▪ Exposure

▪ Fluid Management and Foley

▪ Gastric tube (if indicated)

What Investigations will you order?

Baseline Investigations▪Chest X-ray

▪ Electrocardiogram

▪CBP, electrolytes, CPK, troponin I

What additional test you would like to order to guide your fluid management?

▪ Urine for myoglobin

▪ The fluid regime should be adjusted so that the urine output is maintained at least 100mL per hour

▪ Mannitol 25g ivi may be considered if the urine output is still not satisfactory

Myoglobinuria

How is the electrical burn wound different from other burn wound?

Electrical Burn

▪ Deep muscle necrosis and rhabdomyolysis causing acute renal failure may occur in relatively normal looking skin.

▪ Severe electric shock may cause fatal dysrhythmia

▪ 110V AC can produce ventricular fibrillation

▪ Involuntary muscle contractions forceful to cause fractures or joint dislocations

▪ Can induce respiratory arrest and seizures

Lightning injury

▪ >10,000,000V DC in 1-3ms

▪ Mainly involve skin giving rise to Lichtenberg figures

▪ Neurologically ▪ unconscious/ paralysis/ paraesthesia/ seizure

▪ Auditory ▪ tinnitus/vertigo/TM rupture

▪ Cardiac ▪ ECG arrhythmia/MI like pattern

Wound Management

▪ Fluid inside blister is sterile

▪ It will be re-absorbed by body with time

▪ Aspirate blister if it is too tense or too large

▪ Do not deroof the blister

Wound Management

▪ Promote wound healing

▪ Keep clean

▪ Prevent infection

▪ Keep dry but not too dry

▪Minimize pain ( each time of change dressing)

Wound Management

▪ 1st degree burn -> lotion would be enough

▪ Superficial partial thickness▪ Simple wound dressing or various dressing

materials

▪ Possible dressing methods:▪ Daily OPD dressing till fully granulated▪No topical agent is required

▪ Special dressing e.g. Hydrocolloid dressing▪Keep intact and renew every 2 to 3 days

Dressing materials

Dressing materials

▪ Some dressing aim to keep the wound intact till totally healed

▪ Some allow exudate to be absorbed without change of dressing

▪ Some aim to keep wound dry and inhibit bacterial growth

▪ Silver sulphadiazine is out of favor nowadays

▪ Most burn wound do not require antibiotic

Wound Management

▪For deep partial thickness▪ May need excision and skin graft / flap over

functionally or cosmetically important area

▪3rd/4th degree burn▪ Skin graft▪ Skin flap▪ Reconstruction surgery

Thank you