BURN EMERGENCIES

One of the most painful injuries that one can ever experience is a burn injury. When a burn occurs to the skin, nerve endings are damaged causing intense feelings of pain. Every year, millions of people in the United States are burned in one ay or another. Of those, thousands die as a result of their burns. !any re"uire long#term hospitali$ation. %urns are a leading cause of unintentional death in the United States, exceeded in numbers only by automobile crashes and falls. Serious burns are complex injuries. &n addition to the burn injury itself, a number of other functions may be affected. %urn injuries can affect muscles, bones, nerves, and blood vessels. 'he respiratory system can be damaged, ith possible air ay obstruction, respiratory failure and respiratory arrest. Since burns injure the skin, they impair the body(s normal fluid)electrolyte balance, body temperature, body thermal regulation, joint function, manual dexterity, and physical appearance. &n addition to the physical damage caused by burns, patients also may suffer emotional and psychological problems that begin at the emergency scene and could last a long time. *lassifying burns %urns are classified in t o ays+ !ethod and degree of burn. !ethods are+ 'hermal # including flame, radiation, or excessive heat from fire, steam, and hot li"uids and hot objects. *hemical # including various acids, bases, and caustics. Electrical # including electrical current and lightning. ,ight # burns caused by intense light sources or ultraviolet light, sunlight. -adiation # such as from nuclear sources. Ultraviolet light is also a source of radiation burns. .ever assume the source of a burn. /ather information and be sure. 0egrees are+ hich includes

1irst degree burns are superficial injuries that involve only the epidermis or outer layer of skin. 'hey are the most common and the most minor of all burns. 'he skin is reddened and extremely painful. 'he burn ill heal on its o n ithout scarring ithin t o to five days. 'here may be peeling of the skin and some temporary discoloration. Second degree burns occur hen the first layer of skin is burned through and the second layer, the dermal layer, is damaged but the burn does not pass through to underlying tissues. 'he skin appears moist and there ill be deep intense pain, reddening, blisters and a mottled appearance to the skin. Second degree burns are considered minor if they involve less than 23 percent of the body surface in adults and less than 24 percent in children. When treated ith reasonable care, second degree burns ill heal themselves and produce very little scarring. 5ealing is usually complete ithin three eeks. 'hird degree burns involve all the layers of the skin. 'hey are referred to as full thickness burns and are the most serious of all burns. 'hese are usually charred black and include areas that are dry and hite. While a third#degree burn may be very painful, some patients feel little or no pain because the nerve endings have been destroyed. 'his type of burn may re"uire skin grafting. 6s third degree burns heal, dense scars form. 0etermining the severity of burns Source of the burn # a minor burn caused by nuclear radiation is more severe than a burn caused by thermal sources. *hemical burns are dangerous because the chemical may still be on the skin. %ody regions burned # burns to the face are more severe because they could affect air ay management or the eyes. %urns to hands and feet are also of special concern because they could impede movement of fingers and toes. 0egree of the burn # the degree of the burn is important because it could cause infection of exposed tissues and permit invasion of the circulatory system. Extent of burned surface areas # &t is important to kno the percentage of the amount of the skin surface involved in the burn. 'he adult body is divided into regions, each of hich represents nine percent of the total body surface. 'hese regions are the head and neck, each upper limb, the chest, the abdomen, the upper back, the lo er back and buttocks, the front of each lo er limb, and the back of each lo er limb. 'his makes up 77 percent of the human body. 'he remaining one percent is the genital area. With an infant or small child, more emphasis is placed on the head and trunk. 6ge of the patient # 'his is important because small children and senior citi$ens usually have more severe reactions to burns and different healing processes.

8re#existing physical or mental conditions # 8atients

ith respiratory illnesses, heart

disorders, diabetes or kidney disease are in greater jeopardy than normally healthy people. 'reatment of burns *ool a burn ith ater. 0o hat you must to get cool ater on the burn as soon as you ater on the ater and ice

can. /o to the nearest burn. 8ut cool,

ater faucet and turn on the cold spigot and get cool

ater#soaked cloths on the burn. &f possible, avoid icy cold

cubes. Such measures could cause further damage to burned skin. .ever apply ointment, grease or butter to the burned area. 6pplying such products, actually confine the heat of the burn to the skin and do not allo had sufficient time to cool, it the damaged area to cool. &n essence, the skin continues to 9simmer.9 6fter the initial trauma of the burn and after it has ould then be appropriate to put an ointment on the burn. Ointments help prevent infection. 'he one exception to the 9*ool a %urn9 method is hen the burn is caused by lime po der. &n that case, carefully brush the lime off the skin completely and then flush the area ater. &n the event of any serious burns, call 7#2#2. ith

Burns, Chemical .'-O0U*'&O. %ackground+ 6cids are defined as proton donors :5;< and bases as proton acceptor :O5#<. %ases are also kno n as alkalis. %oth acids and bases can be defined as caustics, it gives up the proton= for bases, strength is determined by ho 'he p5 scale is used to define ho of 2>. 6 p5 of ? is neutral. 8athophysiology+ !ost acids produce a coagulation necrosis by denaturing proteins, forming a coagulum :eschar< that limits the penetration of the acid. %ases typically produce a more severe injury kno n as li"uification necrosis. 'his involves denaturing of proteins as ell as saponification of fats, hich does not limit tissue penetration. hich cause significant tissue damage on contact. 'he strength of an acid is defined by ho easy avidly it binds the proton. strong acids or bases are. 'he scale ranges from 2#2>

and is logarithmic. 6 strong acid ould have a p5 of 2 and a strong base ould have a p5

5ydrofluoric acid is some hat different than other acids in that it produces a li"uifaction necrosis. 'he severity of the burn is related to a number of factors, including the p5 of the agent, the concentration of the agent, the length of the contact time, the volume of the offending agent and the physical form of the agent. Solid pellets of alkaline substances result in a prolonged contact time in the stomach and more severe burns. &n addition, concentrated forms of some acids and bases generate significant heat thermal as ell as caustic injury. 'he long#term effect of caustic burns is scarring. 0epending on the site of the burn, this can be significant. Ocular burns can result in opacification of the cornea ith complete loss of vision. Esophageal and gastric burns can result in significant stricture formation. 1re"uency+ &n the U.S.+ 'here are over 244,444 exposures to acid)base type products every year. 'he majority of those involve household cleaning products. Exposures are nearly e"ual bet een adults and children. !ortality)!orbidity+ 'here ere @@ reported fatalities in 2773 and 27 in 277A resulting ere 2@B cases of ere >C hen diluted, resulting in both

from exposures to acid and base products. Of approximately @3,344 exposures to acid and base chemicals, there major toxicity and seven deaths in 277A. Of 3@,?34 exposure to bleaches, there and seven deaths in 3,244 exposures. *,&.&*6, 5istory+ *linical signs and symptoms vary depending on the route of exposure and the particular substances involved. 0ue to the variety of presentations, the emergency physician must be prepared to handle all possibilities. Some exposures, such as hydrofluoric acid, may present ithout immediate pain and should be considered in the patient ith complaints of slo #onset, deep pain after exposure to an appropriate product. 8atient history should include+

cases of major toxicity and no deaths. 0rain cleaners produced 37 cases of major toxicity

Offending agent, concentration, physical form, p5 -oute of exposure 'ime of exposure Dolume of exposure 8ossibility of coexisting injury 8hysical+ &f the exposure as an ingestion, the main immediate concern is the patients ability to

protect her)his air ay. &f there is evidence of air ay compromise :oropharyngeal edema, stridor, use of accessory muscles<, consider establishing a definitive air ay. 0ermal Exposures+ Si$e, depth, location, any circumferential burns Ocular Exposures+ Disual acuity 8resence of periorbital dermal lesions Scleral and corneal lesions including ulcerations, fluorescein uptake ,eakage of vitreous humor &ngestions+ 8resence of oral burns or edema, drooling 0ysphagia, stridor, hee$ing, dyspnea, tachypnea 6bdominal tenderness, guarding, rebound crepitus, subcutaneous air :5aman(s crunch< *auses+ 6 large number of industrial and commercial products contain potentially toxic concentrations of acids or bases. Some of the more common are listed as follo s+ 6cids+ Sulfuric 6cid+ *ommon uses include toilet bo l cleaners, drain cleaners, metal cleaners, automobile battery fluid, munitions and fertili$er manufacture. *oncentrations range from BE up to almost pure acid. 'he concentrated acid is very viscous and more dense than

ater. &t also generates significant heat hen diluted. 'hese attributes make it a good drain cleaner. .itric 6cid+ *ommon uses include engraverFs acid, metal refining, electroplating and fertili$er manufacture. 5ydrofluoric 6cid+ *ommon uses include rust removers, tire cleaners, tile cleaners, glass etching, dental ork, tanning, semiconductors, refrigerant manufacture, fertili$er manufacture and petroleum refining. 'his is actually a immediate burning and pain on contact. 5ydrochloric 6cid+ *ommon uses include toilet bo l cleaners, metal cleaners, soldering fluxes, dye manufacture, metal refining, plumbing applications and laboratory chemicals. *oncentrations range from 3E#>>E. 8hosphoric 6cid+ *ommon uses include metal cleaners, rustproofing, disinfectants, detergents and fertili$er manufacture. 6cetic acid *ommon uses include printing, dyes, rayon and hat manufacture, disinfectants and hair ave neutrali$ers. Dinegar is dilute acetic acid. 1ormic 6cid+ *ommon uses include airplane glue, tanning and cellulose manufacture. *hloroacetic 6cids+ !onochloroacetic acid is used in the production of carboxymethylcellulose, phenoxyacetates, pigments and some drugs. &t has significant systemic toxicity by highly corrosive. ay of entering and blocking the tricarboxylic acid cycle and inhibiting cellular respiration. &t is eak acid that in dilute form ill not cause

'richloroacetic acid is used in laboratories and in chemical manufacture. &t is highly corrosive and 9fixes9 tissues it comes into contact respiration. 0ichloroacetic acid is used in chemical manufacture. &t is a trichloroacetic acid and does not inhibit cellular respiration. %ases+ Sodium 5ydroxide and 8otassium 5ydroxide+ Used in drain cleaners, oven cleaners, *linitestG tablets and denture cleaners. 'hey are extremely corrosive. *linitestG tablets contain >3#34E .aO5 or HO5. Solid or concentrated .aO5 or HO5 is more dense than ater and generates significant heat hen diluted. %oth the heat generated and the alkalinity contribute to burns. *alcium 5ydroxide+ *alcium hydroxide is also kno n as slaked lime. &t is used in mortar, plaster and cement, but is not as caustic as potassium and sodium hydroxide or calcium oxide. Sodium and *alcium 5ypochlorite+ 'his is the common ingredient in household bleach and pool chlorinating solution. 8ool chlorinators also contain sodium hydroxide and have a p5 around 2C.3, thus they are very caustic. 5ousehold bleach has a p5 around 22 and is much less corrosive. *alcium Oxide+ *alcium oxide is also called lime and is the caustic ingredient in cement. &t generates heat hen diluted ith ater and can produce a thermal and caustic burn. 6mmonia+ 6mmonia is used in cleaners and detergents. 'he dilute form is not highly corrosive. /aseous anhydrous ammonia is used in a number of industrial applications, particularly in fertili$er manufacturing. &t is very hygroscopic # has a high affinity for severe skin burns as ell as pulmonary injury. 8hosphates+ ater. &t produces injury by desiccation and heat of dilution in addition to a chemical burn. &t can cause eaker acid than ith. &t does not inhibit cellular

8hosphates are commonly used in many types of household detergents and cleaners. Substances include tribasic potassium phosphate, trisodium phosphate and sodium tripolyphosphates. Silicates+ 'hese include sodium silicate and sodium metasilicate. 'hey are used to replace phosphates in detergents. 0ish ashing detergents are alkaline, primarily to builders such as silicates and carbonates. 'hey are moderately corrosive. Sodium *arbonate+ Sodium carbonate is used in detergents. &t is moderately alkaline, depending on the concentration. ,ithium 5ydride+ ,ithium hydride is used to absord carbon dioxide in space technology applications. &t vigorously reacts ith ater to generate hydrogen and lithium hydroxide. &t can produce thermal and alkaline burns. 0&11E-E.'&6,S %urns, Ocular %urns, 'hermal *austic &ngestions 5a$mat

WO-HU8 ,ab Studies+ ,ab studies depend on the burn type and extent of exposure. Severe %urns+ Electrolytes, creatinine, %U. and glucose

U6, *omplete blood count :*%*< *8H *oagulation profile ,ocali$ed %urns+ .one usually re"uired 5ydrofluoric 6cid %urns+ *alcium, magnesium and potassium &ngestions of *austics+ 5emoglobin)hematocrit 8ulse#oximetry or %lood /as 6nalysis if respiratory symptoms Oxalic 6cid %urns+ *alcium *hromic 6cid+ %U., creatinine !onofluoroacetic 6cid %urns+ Electrolytes, %lood /as 6nalysis &ngestions+ *hest x#ray :*I-< if any respiratory symptoms 6bdominal x#ray :flat and upright< if signs of peritonitis are present Other 'ests+ Endoscopy for &ngestions+ Esophagoscopy and gastroscopy should be performed for all symptomatic ingestions and asymptomatic patients ith history of significant ingestion. 1indings on esophagoscopy do not correlate ell ith physical signs and symptoms. Up to C4E of patients ith no evidence of oral burns ill have esophageal injuries. %urn findings are classified as superficial, transmucosal or transmural. Esophagoscopy findings are used to guide further treatment. 'he presence of full# thickness or circumferential burns is associated ith future stricture formation. &t is not necessary to stop the exam at the first burn noted. 8rocedures+ Endotracheal &ntubation+ &ntubation is re"uired for severe respiratory symptoms. 0irect visuali$ation is recommended to assess the degree of injury. '-E6'!E.'

8rehospital *are+ Wound irrigation should be done as soon after the exposure occurs since it is critical in the limitation of tissue destruction. 'he removal of contaminated clothes and not allo ing contaminated irrigation solution to run onto unaffected skin is important. Emergency 0epartment *are+ 'he first priority in treatment is to remove the offending agent. 'horough decontamination is the key. &t is difficult to define ade"uate irrigation and this ill depend on the amount of exposure and the agent involved. ,itmus paper to measure the p5 of the affected area or of the irrigating solution is helpful. &f there is a "uestion of air ay compromise the air ay should be secured. 0ermal Exposure+ 0econtamination is again the most important aspect of initial treatment. 'his is accomplished ith copious fluids. 'ap ater is sufficient for irrigation. 6fter initial decontamination, the full extent of the injury must be ascertained and the patient treated as a typical burn patient. %ased on the degree of injury, ade"uate fluid resuscitation and precautions for complications, including hypothermia, infection and rhabdomyolysis, should be performed. 5ydrofluoric 6cid %urns+ 'hese burns re"uire special consideration. 'hey should initially be treated as any other burn, ith thorough irrigation. 5o ever, due to the penetrating po er of the fluoride ion, specific neutrali$ation procedures are indicated. 1luoride can be neutrali$ed by either calcium or magnesium. 1or small superficial burns, topical calcium or magnesium gels can be applied. 0eeper burns usually re"uire subcutaneous injections of calcium gluconate. 5and burns can be difficult. 'hese can be treated ith subcutaneous injections of calcium, intra#arterial calcium infusions or a %ier#type calcium infusion. 'here are no objective comparative studies on these different treatments. Studies on animals demonstrated that &D magnesium is as effective or more effective than subcutaneous injections of calcium for local hydrofluoric burns. &n situations here local treatment of hydrofluoric burns is not arm and possible, this treatment is safe and should be considered. Heeping the extremity

treating pain magnesium.

ill maximi$e blood flo

and delivery of the body(s intrinsic calcium and

Ocular Exposures+ 'he goal for decontamination should be to achieve a p5 :of the eye ?.@. &f p5 paper is not available, an ade"uate guideline ash< of at least ould be 2#@ , of irrigation fluid

over C4#A4 minutes. 6 !organ lens is recommended for irrigation. Use a topical anesthetic prior to use. 8atching of the eye may encourage corneal re#epitheliali$ation, although this has not been proven. *austic &ngestions+ /astric emptying is contraindicated. 6ctivated charcoal is not useful and may interfere ith subse"uent endoscopy. 0ilution ith milk or ater is contraindicated if there is any ith subse"uent endoscopy. Water is degree of air ay compromise. !ilk may interfere the effectiveness of neutrali$ation. *onsultations+ 1or severe dermal burns consult general surgery or a burn service. %urns to the hands, face or perineum may re"uire the appropriate specialties. Ophthalmologic consultation is recommended for patients ith ocular burns from acids or bases if there is any significant degree of corneal or scleral injury. *austic ingestions may re"uire multiple specialties, including gastroenterology, /& surgery, E.' and pediatric surgery for children. 0o not forget psychiatric consultation for suicide attempts. !E0&*6'&O. !edications have a limited role in the treatment of most chemical burns. 'opical antibiotic therapy is usually recommended for dermal and ocular burns. *alcium and magnesium salts are used for hydrofluoric acid burns. 8ain medications are important for subse"uent burn care.

benign, although large "uantities should be avoided. 6lthough there is no data to support ater dilution, small amounts are not unreasonable. 0o not attempt to neutrali$e the caustic agent. 'his generates excessive heat from the exothermic reaction of

Steroid therapy is controversial for caustic ingestions, but they may be helpful for treating upper air ay inflammation. 'here is no evidence that steroid therapy ill decrease the incidence of stricture formation. Steroids may predispose to infection and may mask signs of perforation. 'here has been some use of aloe products on mild burns. 'here is currently no definitive information on the use of these for chemical burns. .onsteroidal antiinflammatory agents do provide some degree of pain relief for mild burns by inhibition of prostoglandin mediators. 'hese also have not been evaluated for chemical burns and should be avoided in all cases of /& burns from ingestions. *hemical burns affecting a significant portion of thebody should recieve standard iv fluid and narcotic therapy as used for thermal burns after decontamination is performed. 1or additional information, see the chapter on thermal burns.

0rug *ategory+ 6ntibiotics # 'opical antibiotics are routinely used for dermal and ocular burns. 'he injured tissues have lost many of their protective mechanisms and are at increased risk of infection. 0rug .ame Silver sulfadia$ine :Silvadene< # &s used topically for dermal burns. &s useful in the prevention of infections from second or third degree burns. &t has bactericidal activity against many gram#positive and gram#negative bacteria including yeast. 6dult 0ose 6pply once or t ice daily to a thickness of 2)2Ath. 'he burned area should be covered ith this medication continuously. 8ediatric 0ose Use the same regimen as in adults. *ontraindications

6void use in patients medication or related

ith documented hypersensitivity to this

products, neonates and infants younger than @ years of age. &nteractions 'he effect of proteolytic en$ymes is reduced hen used concomitantly ith this product. 8regnancy % # Usually safe but benefits must out eigh the risks. 8recautions Exercise caution in patients insufficiency. 0rug .ame Erythromycin Ophthalmic Ointment 4.3E # Use prophyactically to prevent infections follo ing ocular burns. 'his ointment has a very lo allergic reactions. Other possible agents include polymyxin %, bacitracin or ciprofloxacin solutions. 6dult 0ose 6pply to affected eye topically tid or "id. 8ediatric 0ose 6pply to affected eye topically tid or "id. *ontraindications 6void use in patients eye. 8atients using steroid combinations after the uncomplicated removal of a foreign body from the cornea should also avoid using this product. &nteractions ith documented hypersensitivity to this drug, or related products and those diagnosed ith viral, mycobacterial, and fungal infections of the incidence of ith /#A#80 deficiency and renal

.o significant interactions are reported medication. 8regnancy

ith the topical use of this

% # Usually safe but benefits must out eigh the risks. 8recautions 0o not use topical antibiotics to treat ocular infections that may become systemic. 8rolonged or repeated antibiotic therapy may result in bacterial or fungal overgro th of nonsusceptible organisms and may lead to a secondary infection. 'ake appropriate measures if superinfection occurs. 6llergy and irritation may occur but are rare. 0rug *ategory+ 6nalgesics # 8ain control is essential to "uality patient care. 'hey ensure patient comfort and have sedating properties, sustained injuries to the eye. &n the E0 morphine is recommended. 1or outpatient treatment, combinations of hydrocodone or oxycodone and acetaminophen are usually sufficient. *odeine is not recommended. 0rug .ame !orphine sulfate :0uramorph, 6stramorph, !S *ontin< # &s the 0O* for narcotic analgesia due to its reliable and predictable effects, safety profile, and ease of reversibility ith naloxone. !orphine sulfate administered iv may be dosed in a number of ays and is commonly titrated until the desired effect is obtained. Use iv :preferred< or im during the E0 treatment of the acute burn for moderate or severe pain. 6dult 0ose hich are beneficial for patients ho have

,oading dose for severe burns is 3#24 mg iv. Subse"uent doses of >#A mg iv are given "24#23min prn. 8ediatric 0ose 6dminister 4.43#4.@ mg)kg "@#>h iv or im. !ay need to titrate as in adults. *ontraindications 6void use in patients ith documented hypersensitivity to morphine and those diagnosed ith hypotension or a potentially compromised air ay establishing rapid air ay control ould be difficult. &nteractions 8henothia$ines may antagoni$e the analgesic effects of opiate agonists. 'ricyclic antidepressants, ben$odia$epines, !6O inhibitors and other *.S depressants may potentiate the adverse effects of morphine hen used concurrently. 8regnancy * # Safety for use during pregnancy has not been established. 8recautions 6void using this drug in patients diagnosed ith hypotension, respiratory depression, nausea, emesis, constipation, and urinary retention. Exercise caution in patients diagnosed ith atrial flutter and other supraventricular tachycardias. !orphine has vagolytic action and may increase the ventricular response rate. 6ssess the respiratory status before dosing. here

0rug .ame 5ydrocodone bitartrate and acetaminophen :Dicodin, ,orcet, ,ortab, .orco< # &s for outpatient use. &s a drug combination indicated for the relief of moderate to severe pain. 'he follo ing formulations of hydrocodone)acetaminophen are available+ Dicodin#3)344, ES#?.3)?34, 58#24)A44 ,orcet#24)A34, 8lus#?.3)A34 ,ortab#@.3)344, 3)344, ?.3)344, 24)344 .orco#24)C@3 6dult 0ose 6dminister 2#@ tabs or caps po ">#Ah prn pain. 8roducts containing more than 344 mg of acetaminophen per tablet should only be prescribed one tablet per dose. 8ediatric 0ose 'ypical elixirs contains @.3 mg hydrocodone and 2A? mg acetaminophen per 3 ml. 6 dose of 4.C ml)kg ">h 4.23 mg)kg of hydrocodone. 6 dose of 4.3 m,)kg ">h 4.@3 mg)kg of hydrocodone. *ontraindications 6void use in patients ith documented hypersensitivity to acetaminophen or hydrocodone bitartrate and patients ith elevated intracranial pressure. &nteractions ill provide 2A mg)kg of acetaminophen and ill provide 24 mg)kg of acetaminophen and

8henothia$ines may decrease its analgesic effects. *onversely, the toxicity of this drug increases ben$odia$epines, or tricyclic antidepressants. 8regnancy * # Safety for use during pregnancy has not been established. 8recautions Withold for dro siness. 5epatic toxicity may occur in overdose. Use .orco or a product that does not contain acetaminophen in patients ith a history of severe hepatic disease. &t may cause constipation and stomach upset. 0rug .ame Oxycodone and acetaminophen :'ylox, 8ercocet< # &s a drug combination indicated for the relief of moderate to severe pain. &t is the drug of choice for aspirin hypersensitive patients. 'he follo ing formulations of hydrocodone)acetaminophen are available+ 'ylox#3)344 8ercocet#3)C@3 6dult 0ose 6dminister 2#@ tabs or caps po ">#Ah prn pain. 8roducts containing more than 344 mg of acetaminophen per tablet should only be prescribed one tablet per dose. 8ediatric 0ose 6dminister 4.43#4.23 mg)kg)dose oxycodone. 0o not exceed 3 mg)dose of oxycodone ">#Ah prn. *ontraindications hen administered concurrently ith *.S depressants,

6void use in patients related products. &nteractions

ith documented hypersensitivity to this drug or

8henothia$ines may decrease the analgesic effects of this medication. *onversely, its toxicity increases hen administered concurrently ith either *.S depressants or tricyclic antidepressants. 8regnancy * # Safety for use during pregnancy has not been established. 8recautions 0uration of action may increase in the elderly. %e a are about the total daily dose of acetaminophen that the patient is getting. 'he maximum dose of acetaminophen is >,444 mg)@>hr. 5igher doses may cause liver toxicity. 0rug *ategory+ .onsteroidal 6nti#inflammatory agents :.S6&0S< # 6re most commonly used for the relief of mild to moderate pain. 6lthough the effects of .S6&0s in the treatment of pain tend to be patient specific, ibuprofen is usually the 0O* for the initial therapy. Other options include flurbiprofen, ketoprofen, and naproxen. 0rug .ame &buprofen :&buprin, 6dvil, !otrin< # &s usually the 0O* for the treatment of mild to moderate pain, if there are no contraindications. &t inhibits inflammatory reactions and pain probably by decreasing the activity of the en$yme cyclo#oxygenase, synthesis. &t is useful for outpatient oral use preferred. &t also has the advantage of anti#inflammatory effect. 6dult 0ose here non#sedating drugs are hich results in the inhibition of prostaglandin

6dminister >44#A44#B44 mg po, roughly 244 mg)h :e.g. >44 mg ">h, A44 mg "Ah<. 8ediatric 0ose 6dminister 3#24 mg)kg po ">#Ah. *ontraindications 6void use in patients ith documented hypersensitivity to ibuprofen. %ecause of potential cross#sensitivity to other .S6&0s, do not give these agents to patients hom aspirin, iodides or other .S6&0s induce hypersensitivity. 0o not administer to patients diagnosed ith peptic ulcer disease, recent /& bleeding or perforation, blood dyscrasias, renal insufficiency, and those taking anticoagulants. &nteractions 8robenecid may increase the concentrations and possibly the toxicity of .S6&0s. &buprofen may decrease the effect of loop diuretics concurrently. 8rothrombin time :8'< may increase concurrently ith anticoagulants. !onitor 8' closely and instruct patients to signs and symptoms of bleeding. &buprofen and other .S6&0s may increase serum lithium levels and the risk of methotrexate toxicity. 8regnancy % # Usually safe but benefits must out eigh the risks. 8recautions Use ith caution in patients ith congestive heart failure, hypertension, and decreased renal and hepatic function. 0rug .ame atch for hen ibuprofen is administered hen administered

Hetoprofen :Oruvail, Orudis, 6ctron< # &s used for the relief of mild to moderate pain and inflammation. 6dminister small dosages initially to patients ith a small body si$e, the elderly and those ith renal or liver disease. When administering this medication, doses higher than ?3 mg do not increase its therapeutic effects. 6dminister high doses observe the patient for response. 6dult 0ose 6dminister @3 to 34 mg "A#Bh prn. 0o not exceed C44 mg)d. 8ediatric 0ose *hildren bet een C mo and 2> yrs of age+ 6dminister 4.2J2 mg)kg "A# Bh. Older than 2@ years of age+ 6dminister the same regimen as in adults. *ontraindications 6void use in patients related products. &nteractions 8robenecid and lithium, may increase the concentrations, and possibly, the toxicity of .S6&0s. *onversely, the effect of loop diuretics may decrease administered concurrently ith this drug. 8rothrombin time :8'< may increase concurrently ith anticoagulants. !onitor 8' closely and instruct patients to signs and symptoms of bleeding. atch for hen ketoprofen is administered hen ith documented hypersensitivity to this drug or ith caution and closely

*oncurrent administration

ith phenytoin may increase serum

phenytoin levels, resulting in an increase in pharmacologic and toxic effects of phenytoin. 8regnancy % # Usually safe but benefits must out eigh the risks. 8recautions 6void use in patients diagnosed ith /& disease, cardiovascular disease, renal or hepatic impairment, and patients receiving anticoagulants. 0rug .ame 1lurbiprofen :6nsaid, Ocufen< # 5as analgesic, antipyretic and anti# inflammatory effects. &t may inhibit cyclo#oxygenase en$yme, causing the inhibition of prostaglandin biosynthesis that may in turn result in analgesic and anti#inflammatory activities. 6dult 0ose 6dminister @44#C44 mg)d po divided bid#"id. 8ediatric 0ose Safety and efficacy in children have not been established. *ontraindications 6void use in patients related products. &nteractions 8robenecid and lithium, may increase the concentrations, and possibly, the toxicity of .S6&0s. *onversely, the effect of loop diuretics may decrease administered concurrently ith this drug. *oadministration !onitor 8' and ith anticoagulants may prolong prothrombin time. hen ith documented hypersensitivity to this drug or

patients closely, and instruct them to atch for signs and symptoms of bleeding. .ephrotoxicity of both cyclosporine and flurbiprofen may be increased. *oncurrent administration phenytoin levels, resulting in an increase in pharmacologic and toxic effects of phenytoin. 8regnancy * # Safety for use during pregnancy has not been established. 8recautions Severe /& tract ulceration and bleeding can occur. !onitor patients closely hen administering prolonged treatments. .S6&0s can inhibit platelet aggregation, but at a lo er degree than that seen ith aspirin. Exercise caution in patients that have anticoagulation defects or are receiving anticoagulant therapy. ,o therapy continues. -e#evaluate the therapy if persistent leukopenia, granulocytopenia or thrombocytopenia occur. hite blood cell counts can occur but usually return to normal as ith phenytoin may increase serum

0rug .ame .aproxen :6naprox, .aprelan, .aprosyn< # &s used for the relief of mild to moderate pain. &t inhibits inflammatory reactions and pain by decreasing the activity of the en$yme cyclo#oxygenase hich results in a decrease of prostaglandin synthesis.

6dult 0ose 6dminister 344 mg, follo ed by @34 mg "A#Bh. 0o not exceed a 2.@3 g)d. 8ediatric 0ose Older than @ yrs of age+ 6dminister @.3 mg)kg)dose. 0o not exceed 24 mg)kg)d. Kounger than @ yrs of age+ Safety and efficacy have not been established. *ontraindications 6void use in patients related products. 0o not administer to patients diagnosed ith peptic ulcer disease, recent /& bleeding or perforation, renal insufficiency, and those at high risk of bleeding. &nteractions 8robenecid and lithium, may increase the concentrations, and possibly, the toxicity of .S6&0s. *onversely, the effect of loop diuretics may decrease hen administered concurrently ith this drug. 8rothrombin time :8'< may increase concurrently ith anticoagulants. !onitor 8' closely and instruct patients to atch for signs and symptoms of bleeding. *oncurrent administration levels, resulting in an increase in pharmacologic and toxic effects of phenytoin. ith phenytoin may increase serum phenytoin hen naproxen is administered ith documented hypersensitivity to this drug or

8regnancy % # Usually safe but benefits must out eigh the risks. 8recautions 6cute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis may occur. &t increases the risk of acute renal failure in patients ith preexisting renal disease or compromised renal perfusion. ,o ongoing therapy. 0iscontinuation of the therapy may be necessary if there is persistent leukopenia, granulocytopenia, or thrombocytopenia. 8erform ophthalmological studies in patients ho develop eye complaints during therapy and therapy discontinued if changes are noted. *hanges may include blurred or diminished vision, corneal deposits and retinal disturbances, scotomata, changes in color vision, and macula degeneration. 1O,,OW#U8 1urther &npatient *are+ 6dmission is recommended for significant dermal burns or eye injuries. 6dmission follo ing caustic ingestions depend on symptoms and endoscopic findings. 1urther Outpatient *are+ 0ermal burns treated on an outpatient basis should be rechecked every @#C days. 6ny ocular burns treated as on an outpatient basis should be rechecked in @> hours. Endoscopic examination of all transmucosal or transmural esophageal burns should be repeated in @#C eeks. hite blood cell counts occur rarely, and usually return to normal in

&n)Out 8atient !eds+ Significant dermal burns re"uire ade"uate &D fluid resuscitation and analgesics :morphine sulphate<. *onsider the use of patient#controlled analgesia pumps. 'ransfer+ 'ransfer all significant dermal burns that cannot be handled locally to a regional burn center. 6l ays decontaminate and initiate fluid resuscitation prior to transfer. 6ny significant scleral or corneal injury should be transfered to a facility ophthamologic care is available. 6l ays irrigate eyes first. &f endoscopy is not available, caustic ingestions should be transfered to a facility that can perform this. 0eterrence)8revention+ 1or pediatric exposures, counsel the family on keeping dangerous substances out of the reach of children. 1or suicide attempts, psychiatric consultation should be obtained. 'he OS56 in many states re"uires reporting of industrial injuries. Employers should provide the necessary training and protective e"uipment for employees orking ith potentially ha$ardous materials. *omplications+ Scarring, infection and poor healing may occur ith dermal burns. Skin grafting may be re"uired. Ocular burns, especially from alkali substances and hydrofluoric acid, can result in cataract formation and)or complete vision loss. Stricture formation is the main complication associated esophagus. 8rognosis+ 'he prognosis depends entirely on the extent of tissue injury. Small lesions ell, hether dermal or esophageal. ill heal ith caustic burns to the here

,arger dermal burns can produce significant scarring. Extensive esophageal lesions can result in future stricture formation. 5ydrofluoric acid burns can cause progressive tissue injury and even result in loss of digits. Even moderate corneal burns can result in scarring and loss of vision. Sometimes this can be remedied by corneal transplantation. 8atient Education+ 1or occupational exposures, the patient should be educated on the proper safety precautions hen orking ith ha$ardous materials. 6ll industries are re"uired to inform ith in the hen orkplace orking ith ade"uate training and protective e"uipment employees of any dangerous materials they may come into contact and must provide them ith these. When children suffer chemical burns, the parents must be counseled on ho something like automatic dish ashing detergent may be a danger to children. 'hey need to be educated on the various substances in the home that are potentially dangerous. !&S*E,,6.EOUS !edical),egal 8itfalls+ 1ailure to evaluation a patient ith a caustic ingestion because no oropharyngeal lesions are seen 1ailure to evaluate and treat a burn and not obtaining psychiatric evaluation in a suicide attempt 'reatment of a hydrofluoric acid burn as a general acid burn 'ES' LUES'&O.S *!E Luestion 2+ 6 >4 year old construction pain. 5e had been pouring cement all day. orker presents complaining of bilateral foot to keep

medications and chemicals out of the reach of children. 8arents may not think that

6fter

ashing, his feet are irritated and erythematous appearing. Which of the follo ing is

the most likely causeM 6+ *ontact dermatitis %+ 6llergic dermatitis *+ 1ungal infection 0+ *austic burn E+ 6cid burn Kour *hoice+ *!E Luestion @+ 6 mother brings in her @ year old child after finding her playing ith the automatic dish ashing crystals. 'he child is coughing and drooling. .o burns are noticed in the mouth. 'his child is likely suffering from hich of the follo ingM 6+ -espiratory tract irritation from the detergents and en$ymes used in the dish ashing formulation %+ 6n allergic reaction from the detergents and en$ymes used in the dish ashing formulation *+ 6 caustic burn secondary to the phosphates, carbonates and silicates used in the dish ashing formulation 0+ 6n upper respiratory infection E+ Epiglottitis Kour *hoice+ 8earl Luestion 2+ What is the typical burn mechanism associated ith alkali :basic< burnsM 8earl Luestion @+ What is the typical burn mechanism associated ith most acid burnsM 8earl Luestion C+ What type of acid burn acts by a different mechanism than that of other acidsM 8earl Luestion >+ When ingested, concentrated acids and bases :or granular forms< produce damage to the intestinal mucosa by an additional mechanism, other than the direct acid or base damage. What is the mechanismM Electric Injuries .'-O0U*'&O.

%ackground+ Electrical injuries are infre"uent but

ill be eventually encountered by most voltage and high

practitioners of emergency medicine. 'hese injuries run a gamut of both diagnostic and treatment modalities. /enerally, they may be classified as lightning, lo voltage. 8athophysiology+ Electrons flo ing abnormally through the body of a person produce injury and)or death by depolari$ing muscles and nerves, by initiating abnormal electrical rhythms in the heart and brain, and by producing electrical burns by both heating and by poration of the cellular membranes. *urrent passing through the brain, in both lo and high voltage circuits, produces

unconsciousness instantly and directly due to the depolari$ation of the brain(s neurons. 6lternating current may produces ventricular fibrillation if the path of the current involves passage through the chest, arm to arm, arm to leg, head to arm, etc. *ircuits through a person hich last for a protracted periods :minutes< produce ischemic

brain damage if respiratory movement is interfered ith. 6ll circuits may produce myonecrosis, myoglobinemia and myoglobinuria and their attendant complications. *ircuits may produce electrical burns ith relatively massive amounts of tissue destruction by heating of the tissues due to the physical property of friction from the passage of electrons :Noule heating< and by destruction of cell membranes by producing holes in the membranes :poration<. &n addition, thermal burns resulting from electrical flashes are generally considered electrical injuries, although such injuries may not involve a circuit through a person. 1re"uency+ &n the U.S.+ 'here are estimated to be over 344 lightning deaths and generated electrical deaths per year. %et een C#3E of burn unit admissions are from electrical burns. !ortality)!orbidity+ 'he morbidity and mortality depend upon a broad range of factors uni"ue to each exposure.

,ightning+ Overall, the survival from lightning strike is over 34E. &f cardiac)respiratory arrest has occurred, prolonged *8- may effect recovery. Unfortunately, prolonged arrest comes death. ,o Doltage Electrical &njury+ Without cardiac)respiratory 6rrest 'his situation is encountered fre"uently in children ho bite extension cords. 'he burns of the mouth are often severe and re"uire extensive plastic revision. 5o ever, systemic problems are infre"uent. With *ardiac)respiratory 6rrest 'hese patients often are not transported to the E0, as they are pronounced dead at the scene. &f they are transported and, if the *8- has been prompt and effective, complete and total recovery, usually ith no apparent injury may occur. Unfortunately, as ith lightning, protracted periods ithout brain perfusion result in permanent brain damage. 5igh Doltage+ /enerally, patients ho have been in high voltage circuits do not arrest but have orse than ith an increasing probability of permanent brain injury, persistent vegetative states and brain

extensive injuries from burns and have risk of acute and chronic problems from myoglobinuria. Electrical burns from high voltage circuits generally are much they appear in the E0. -ace+ 'here appears to be no racial variation in electrical injury susceptibility. 5istorically, tradespersons in the United States have been predominately *aucasian, thus, the numbers of injuries has sho n a hite predominance. Sex+ 6ccording to one researcher :0al$iel<, females are more perceptive of lo probably due to lack of exposure. intensity

electrical current. 'hey are markedly under#represented in injury and death, ho ever,

6ge+ Electrical injuries are most fre"uent in young adult males bet een the ages of @4#>4. 'his probably reflects exposure opportunities more than differences in susceptibility. *,&.&*6, 5istory+ 0ue to multiple causes in electrical injury cases, the history can be either very obvious or extremely subtle. ,ightning+ 8atients ho come to the E0 are generally observed to have been struck by lightning

ith the characteristic flash and boom. Usually they are rendered unconscious or arrest and history must be obtained from bystanders. ,o Doltage 6lternating *urrent+ ,o voltage is A44 volts or less, the sort of voltage encountered in domestic and ith and those ithout cardiac)respiratory arrest industrial iring. &njury from ,o Doltage 6* can be subcatergi$ed into those and)or loss of consciousness. ,o Doltage Without ,oss of *onsciousness and)or 6rrest+ 'ypically these patients are infants and young children to relate that the child as found ith the cord in his or her mouth. Older children and adults may be injured this appliances or home electrical circuits, hen the circuit does not involve the heart or brain. ,o Doltage With ,oss of *onsciousness and)or 6rrest+ 'he presentation may be so subtle, that the correct diagnosis may be missed. 6l ays be alert to the possibility that a sudden arrest might be the result of an electric circuit. -escue orkers, co# orkers, family and friends should be "ueried about this possibility. 5igh Doltage 6lternating *urrent+ 'hese cases involve voltages higher than A44. /enerally, the injuries are so characteristic that history taking is less important than in lo there are t o possibilities. 5igh Doltage Without ,oss of *onsciousness and)or 6rrest+ 'his is the characteristic situation ith an electrical injury from high voltage. Unless there is a very high resistance path ay in the circuit, voltages of more than A44 usually do voltage injuries. 5o ever, ay hile orking on electrical ho bite into appliances cords. 'he circuit is generally restricted to the mouth. 'he adult ill almost al ays be able

not cause cardiac)respiratory arrest. 'hus, the history obtained from the patient should tell you ho company. 5igh Doltage ith 6rrest and)or ,oss of *onsciousness+ 'his is the more unusual presentation from high voltage circuit injuries presenting to the E0. &f the circuit traverses the head, there ill be loss of consciousness and amnesia for the events immediately prior to the injury. 'hus, history taking should be directed to rescue personnel, co# orkers, family or friends ho have kno ledge of the circumstances. 0etails of the voltages can be obtained from the po er company. 0irect *urrent+ 0irect current electrical injuries are generally seen in electrical train circuits. 'hese often involve risk taking behavior by young males. 6rrest and coma are rarely, if ever, seen. 'he history can be obtained from the patient. 8hysical+ 'he physical examinations should include a careful documentation of injuries. 'here is a bit of difference depending upon the voltage. 5igh Doltage :and, Occasionally, ,o assist in treatment. 1lash or 'hermal %urns+ 'hese are seen in some lo voltage and occasionally in high voltage injuries. 'hese burns appear to be indistinguishable from ordinary thermal burns and often do not have an internal electrical component. Using the same techni"ues as severity. 6rc %urns+ 6rc burns characteristically have a dry parchment center and a rim of congestion about them. 'he central parchment area may be less than 2 mm or may be as large as ith any burn case, diagram the body areas and estimate Doltage With 1lash %urns<+ 'hese cases are ill the injury occurred. 0etails of the voltages can be obtained from the po er

characteri$ed by burns. Some attention to the characteristics and nature of the burns

several centimeters. -ecognition of these injuries is important in assessing the extent of internal damage. *ontact %urns+ *ontact electrical burns generally have a pattern from the contacted item and are more limited in si$e than flash burns, although their appearance other ise is nearly identical to a flash burn. One means of distinguishing is that in skin burn of apparent full thickness ill have unburned hair, have the hair singed and generally gone. 0ocumenting the 'ypes of %urns+ 6rc and contact burns are associated current has no such ith internal electrical injury= flash burns are ith hair, a contact ill al ays hereas a flash burn

not. Entrance and exit burns in alternating electrical injuries are not possible, as alternating ounds. 5o ever, there are arcing and contact burns. 'hese are markers to here the circuit traversed the body. ,o Doltage+ &n lo voltage injuries, there may be flash burns from various sources that ill behave

exactly as ordinary thermal burns and should be documented as such. 5o ever, there are electrical burns that should be documented. 6rcing %urns+ 'hese are not seen in lo voltage. 'hermal burns from arcs, here the arc as from an energi$ed conductor to a grounded conductor are seen. 'hese are the flash type. 0irect *ontact %urns+ 'hese ill be seen only if the circuit through the person as prolonged for more than a fe seconds. &n lo voltage there is insufficient heat to produce skin burns "uickly. 'hus, the areas here there as electrical contact ill often not be distinguishable on physical examination or ill only sho focal erythema. ,ightning+

'here is ide variability of findings in a lightning strike victim. %urns are generally not significant, but should be documented. 'hey ill generally be of the flash type. Singeing of the hair, ithout burning is characteristic. 'here are a fe things to look for hich are out of the routine+ Scrotal and 8enile %urns+ &n males, there is occasional burning on the undersurface of the scrotum. 'his injury needs to be identified for early treatment. 'he postictal state that the usual lightning patient presents unlikely. Ear ,esions+ 'he presence of perforation of the eardrum is an occasional feature of a lightning struck patient. 5emorrhage behind the intact drum is probably more common. 'he examinations of the lightning struck patient should include an otoscopic exam. *auses+ Electrical injuries are caused hen a person becomes part of an electrical circuit or is affected by the thermal effects of a nearby electrical arc. 'he most common classifications of these injuries are lightning, and high and lo :6*< and direct current :0*<. ,ightning+ ,ightning injuries occur hen the patient is part of or is near the lightning bolt. voltage alternating current ith often makes early identification of these lesions from complaints of pain

/enerally, the patient ill have been the tallest object around or near a tall object, such as a tree. 'here is al ays a thunderstorm in the vicinity but oddly, the overhead sky can be clear. 5igh Doltage 6*+ 5igh voltage injuries most commonly occur hen a conductive object touches an hich are insulated by air. &f the

overhead high voltage po er line. &n 6merica, most electric po er is distributed and transmitted by bare aluminum or copper conductors, multiple feet of air are breached by a conductor, such as an aluminum pole, antennae,

sailboat mast or crane and a person is on the ground at the time the conductor becomes energi$ed, that person ill be injured. -arely, patients ill get into electrical s itching e"uipment and directly touch energi$ed components. ,o Doltage 6*+ /enerally, there are @ types+ the child ho bites into the cord producing severe lip, face and tongue injuries and the child or adult appliance or other object that is energi$ed. 'he latter type is declining in fre"uency in .orth 6merica due to the use of ground fault circuit interrupters :/1*&s< in any circuits /1*&s stop current flo hich supply kitchens, bathrooms or the outside, as these are places here persons may become easily grounded. if there is a leakage current :ground fault< or more than 4.443 amps :4.A atts at 2@4 volts<. 0*+ 0irect current injuries are generally encountered hich produces myonecrosis and electrical burns. 0&11E-E.'&6,S Status Epilepticus WO-HU8 ,ab Studies+ &n all patients ho by history or physical examination appear to have more than a trivial electrical injury)exposure, obtain the follo ing+ *%* :hemoglobin, hematocrit, hite count, red cell indices<, electrolytes :sodium, hen young males inadvertently ho becomes grounded hile touching an

contact the energi$ed rail of an electrical train system hile grounded. 'his sets up a circuit

potassium, chloride, carbon dioxide, urea and glucose<,creatinine, and urinalysis :specific gravity, p5, color and tests for glucose and hemoglobin<. 'his set gives important baseline values for future treatment.

&n addition to the more common tests, an assessment of muscle damage should be done by ordering+ *8H, total and fractionated, if elevated Urine myoglobin, if urine gives positive hemoglobin test Serum myoglobin if the urine is positive for myoglobin 'hese tests measure the extent of muscle damage in a very effective ay. 5igh levels of *8H, identified as muscle cause an elevation. &f there is extensive muscle damage, there ill be myoglobinemia and myoglobinuria. &n any cases &maging Studies+ *hest I#-ay: *I- <+ &f clinically indicated due to chest trauma , shortness of breath or history of *8- at the scene. %lunt trauma directly from involuntary contraction of muscles or indirectly from falling secondary to involuntary contraction of muscles, 'hese should be approached in the same fashion as causes and appropriate testing should be ordered as indicated. Other 'ests+ Electrocardiogram :E*/<+ 6n E*/ is indicated in any person ho is suspected to have electrical injury. &f arrhythmias are encountered or if patient had a high voltage injury, monitoring is indicated. &f no arrhythmias are encountered, further E*/ studies are not necessary. Electroencephalogram :EE/<+ 6n EE/ may be indicated in a person ho is unconscious or in arrest. Whether it 8rocedures+ 6n intravenous access should be obtained in all persons *onsider a central line in those unconscious or arrested in order to monitor fluid status. ho have electrical injury. ho ere ith more than trivial burns and in those ill need to be done in the E0 depends on a number of institutional factors. &t is not critical to early care decision making. ill re"uire imaging studies ith blunt trauma by other directed to ard discovering possible fractures or even internal injuries. here there is arrest or loss of consciousness, arterial blood gas analysis and a complete drug screen test should strongly be considered. ith often some elevation in the myocardial component, are and high voltage circuits. ,ightning rarely ill seen in any significant exposure to lo

1asciotomies of burned extremities may be re"uired in high voltage injuries. *onsultation ith surgeons ith experience in electrical burn injury should be obtained early in the high voltage burned patient, as appropriate early fasciotomy may save a limb. '-E6'!E.' 8rehospital *are+ 'he first thing that must be done is to remove the patient from the circuit. 'hen, patients ho are in arrest re"uire %asic and 6dvanced *ardiac ,ife Support ith success more often regimens. -emember, in electrically induced arrest, there is no underlying disease causing the arrest. 'herefore, protracted efforts of resuscitation are met than usual. 8atients ho are unconscious but not in arrest, re"uire careful ventilatory observation and assistance, if indicated. 8atients ith burns above the neck need supplemental oxygen because of the high probability of air ay and lung damage. Secondary blunt trauma is often encountered due to falls caused by involuntary muscular contraction. &t is dealt ith identically to any other blunt trauma. Emergency 0epartment *are+ 8atients available, physicians ith electrical burns should be stabili$ed and

considered for immediate transfer to the nearest burn center. &f such facilities are not ith experience in burns, preferably in electrical burns, should assume care of the patient. 6ll patients ith burns and no apparent *.S abnormality should be hydrated. Using the ordinary rule of thumb for treating the ordinary burn patient may result in significant dehydration. &n *.S normal patients, administration of physiologic fluids such as -inger(s ,actate at a rates of 24 ml)kg)hour are reasonable during the initial resuscitation. &n patients ith *.S abnormality, hydration must be tempered ith the possibility of

orsening cerebral edema. 'here is no easy ay to titrate this clinically difficult area. 8atients ho have elevated *8H(s and)or myoglobinemia should have mannitol or

furosemide added to their regimen to provide diuresis for the toxic myoglobin. 'his can help to prevent acute tubular necrosis and renal failure secondary to myoglobinuria. 'he lightning strike patient should be treated based on the *.S symptoms. &f consciousness is present on admission or returns in the E0, in#patient therapy may not be re"uired. &f *.S abnormalities persist, hospitali$ation is indicated.

'he successfully resuscitated patient exposed to lo

voltage

ithout significant burns ith negative

may also be handled primarily on the basis of *.S symptoms and *8H results. &f consciousness returns, the *8H is no more than t o times normal periods. &rregularities of pulse, electrocardiographic changes, myoglobinuria or *.S abnormalities all re"uire hospitali$ation. *onsultations+ 8atients ith electrical burns re"uire treatment by burn specialists. 8rompt hemoglobin in the urine and the pulse is regular, hospitali$ation may be only for brief time

transfer to the care of such an individual is indicated. &n high voltage electrical burns, early fasciotomy may be indicated to improve circulation. 'hus, guidance, as rapidly as possible, should be sought concerning hen to initiate this procedure in the emergency department. 'rauma)*ritical *are /eneral Surgery 8lastic)%urn Surgery !E0&*6'&O. 5ydration is the key to reducing the morbidity of electrical injury. &f muscle damage is significant, the use of an osmotic diuretic is also indicated. 0rug *ategory+ 1luids # ,oss of intravascular volume through the damaged epithelium, as ell as loss into extravascular spaces re"uires fluid resuscitation. 'his is best be acheived ith ,actated ringers. 0rug .ame ,actated ringers # &t is essentially isotonic and has volume restorative properties. 6dult 0ose /enerally administer 24 ml)kg)h during initial resuscitation.

8ediatric 0ose Use the same regimen as in adults. *ontraindications 'he major complication of isotonic fluid resuscitation is interstitial edema. Edema in an extremity is unsightly, but not a significant complication. Edema in the brain or lungs is potentially fatal. 'he major contraindication to isotonic fluid resuscitation is pulmonary edema in hich the added fluid promotes more edema. &nteractions .o significant drug interactions have been reported ith this product. 8regnancy * # Safety for use during pregnancy has not been established. 8recautions 1luid resuscitation ill be expected to exacerbate cerebral edema. 1luids should be stopped hen the desired hemodynamic response is seen or pulmonary edema develops.

0rug *ategory+ Osmotic 0iuretics # &f myoglobinemia and myoglobinuria are present, acute renal failure can be minimi$ed by the addition of mannitol to the regimen of fluid resuscitation. 0rug .ame !annitol :Osmitrol< # &t is an osmotic diuretic significantly metaboli$ed and hich passes through the glomerulus ithout being reabsorbed by the kidney. 6dult 0ose hich is not

34#@44 g)@> h &D 6djust the dose to maintain a urinary output of C4#34 m,)h 8ediatric 0ose Under 2@ y+ Safety and efficacy have not been established. 5o ever, trial doses of 4.@g)Hg &D follo ed by careful monitoring of urinary output may be prudent, again ith the goal of producing diuresis in the child ith myoglobinuria *ontraindications Well established anuria due to severe renal disease. Severe pulmonary edema. 6ctive intracranial bleeding except during craniotomy. Severe dehydration. 8rogressive renal damage or dysfunction after institution of mannitol therapy, including increasing oliguria and a$otemia. 8rogressive heart failure occurring after institution of mannitol therapy &nteractions .o significant drug interactions have been reported ith the use of this product. 8regnancy * # Safety for use during pregnancy has not been established. 8recautions Severe electrolyte imbalance and dehydration can ensue if a careful monitoring of electrolyte status is not performed. 1O,,OW#U8 1urther &npatient *are+

&npatient care ill be re"uired for burns and for patients ith *.S abnormalities. %urns re"uire case specific treatment done by persons ith experience and training. 1urther Outpatient *are+ ,ightning+ 8atients released from the E0 ith good *.S function but ith otoscopic abnormalities should be referred to a person experienced in treating ear disease and injury. 6ll patients should be referred to an ophthalmologist for evaluation of possible cataract formation, after lightning strikes. 8atients ithout *.S abnormalities, massively elevated *8Hs or ith electrical burns hich is reported to occur

need no further follo #up. *omplete and full recovery is to be expected. 'ransfer+ 6ll patients lo ith history of exposure to high voltage should be transferred for inpatient

treatment, preferably by a burn center, on this criterion alone. &n addition, mouth burns in a voltage situation should receive speciali$ed treatment generally available only in burn centers. 'ransfer to an in#patient treatment area should be done if there has not been full return of *.S function, there has been a greater than three#fold elevation in *8H or the presence of myoglobinemia)uria, or there is a persistent arrhythmia. 0eterrence)8revention+ 8revention of high voltage electrical injuries re"uires on#going public education, directed particularly to those in construction trades, using cranes and lifts or exposed to the extreme danger of overhead po erlines. &t is particularly important to educate adolescent males regarding the serious nature of electrical distribution e"uipment. ,ightning+

When thunderstorms are in the area, never ever be the tallest object. 6void golf courses and open fields. 0o not stand besides trees. Seek shelter in buildings or cars. &f caught outdoors, lie on the ground. ,o voltage+ .ever ever use appliances the use of /1*&(s on all outlets hich give you a shock, until they are repaired. Encourage here a person may be grounded but al ays in bathrooms,

kitchens and outside. &f using e"uipment ith no built in /1*&, use a /1*& extension cord. *omplications+ ,ightning+ &f consciousness is regained before arriving, or inside the E0, a full recovery is expected. 8rolonged unconsciousness leads to a graver prognosis. 1ull recovery is not expected if unconsciousness persists for @> hours. ,o Doltage+ &f there are not significant burns, and if consciousness returns before arriving to or in the E0, full recovery is usual. -arely, persistent arrhythmias have been recorded. 8ersistence of unconsciousness leads to a graver prognosis. 1ull recovery is not expected if unconsciousness persists for @> hours. ,o Doltage !outh %urns+ With proper treatment, the disfigurement of lo voltage mouth injuries can be

minimi$ed. Scarring ill al ays be present but not extremely disfiguring. 5igh Doltage+ Survival ith massive burns is no the exception rather than the rule. 'he incidence of extremity loss has been reduced ith improved treatment but has not been eliminated. hen extremities are preserved due to the massive Severe disfigurement is the rule, even

irreparable destruction of nerve and muscle.

8rognosis+ 1or those ithout burns, prognosis is based upon *.S function. &f it promptly returns,

prognosis is excellent, even in patients ho arrest. 1or those ith burns, survival continues to improve ith the improvement of burn care. 0isfigurement continues to be a major problem. 8atient Education+ &f the cause of the injury is established, obviously counseling concerning avoiding such ha$ards is important. /enerally, the injury speaks more elo"uently than e do. !&S*E,,6.EOUS !edical),egal 8itfalls+ ,itigation over the injury is to be expected. &t is extremely helpful if you document the presence and absence of electrical burns. 0iagramming these injuries is al ays indicated. 8hotographing the injured and uninjured areas of the body is extremely helpful. &t is al ays proper to have ritten consent for photographs. /enerally in electrical injuries, there is a solvent defendant other than the medical practitioner. 'hus, suits against practitioners in such cases are rare. 0ocumenting the extent of the injuries is, ho ever, extremely helpful should the practitioner end up being the only defendant. 8&*'U-ES *aption+ 6rcing electrical burns, through shoe around rubber sole. 5igh voltage ?,A44v 6* nominal. .ote cratering. 8icture 'ype+ 8hoto

*aption+ *ontact electrical burn, this vesicle easily distinguished. 8icture 'ype+

as the ground of a 2@4v 6* nominal circuit. .ote

ith surrounding erythema. .ote thermal and contact electrical burns cannot be

*aption+ *ontact electrical burns 2@4v 6* nominal. 'he right knee and the left .ote entrance and exit are not viable concepts in alternating current. 8icture 'ype+ 'ES' LUES'&O.S

as the energi$ed side

as ground. 6gain these are contact and difficult to distinguish from thermal.

*!E Luestion 2+ ,aboratory analysis of a person thought to be electrically injured should include hich of the follo ingM 6+ Serum iron %+ Urine magnesium *+ ,05 0+ 6,' E+ *8H Kour *hoice+ *!E Luestion @+ Which of the follo ing is an important part of the physical examination in a patient struck by lightning, hich is often overlookedM 6+ *hest auscultation %+ 6bdominal palpation *+ Otoscopic examination 0+ 0igital rectal examination E+ &ndirect laryngoscopy Kour *hoice+

8earl Luestion 2+ What is the most common age and sex for electrically injured patientsM 8earl Luestion @+ 6 @@#year#old male comes in undergoing *8-. 5e as outside orking

ith a drill, as heard to scream and then collapsed. What is on your differential listM 8earl Luestion C+ What does the finding of hemoglobin positive in the urine of a ne ly arrived electrical injury patient indicateM 8earl Luestion >+ Why is the diagnosis of myoglobinuria important in an electrically injured patientM