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) SpO 2 : 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 ▪ 1 st 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

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

Thank you