Advanced Trauma Life Support ATLS Student Course Manual 2018

180
CHAPTER 9 n Thermal Injuries
Immediate treatment of a patient with a significant
electrical burn includes establishing an airway and
ensuring adequate oxygenation and ventilation,
placing an intravenous line in an uninvolved extremity,
ECG monitoring, and placing an indwelling bladder
catheter. Electricity can cause cardiac arrhythmias that
may produce cardiac arrest. Prolonged monitoring is
reserved for patients who demonstrate injury from the
burn, loss of consciousness, exposure to high voltage
(>1,000 volts) or cardiac rhythm abnormalities or
arrhythmias on early evaluation.
Because electricity causes forced contraction of
muscles, clinicians need to examine the patient for
associated skeletal and muscular damage, including
the possibility of fracture of the spine. Rhabdomyolysis
from the electricity traveling through muscle results
in myoglobin release, which can cause acute renal
failure. Do not wait for laboratory confirmation before
instituting therapy for myoglobinuria. If the patient’s
urine is dark red, assume that hemochromogens are
in the urine. ABA consensus formula guidelines are
to start resuscitation for electrical burn injury at 4
mL/kg/%TBSA to ensure a urinary output of 100
mL/hr in adults and 1–1.5 mL/kg/hr in children
weighing less than 30 kg. Once the urine is clear of
pigmentation, titrate the IV fluid down to ensure a
standard urine output of 0.5cc/kg/hr. Consult a local
burn unit before initiating a bicarbonate infusion or
using mannitol.
Tar Burns
In industrial settings, individuals can sustain injuries
secondary to hot tar or asphalt. The temperature of
molten tar can be very high—up to 450°F (232°C)—
if it is fresh from the melting pot. A complicating
factor is adherence of the tar to skin and infiltration
into clothing, resulting in continued transfer of heat.
Treatment includes rapid cooling of the tar and care
to avoid further trauma while removing the tar. A
number of methods are reported in the literature;
the simplest is use of mineral oil to dissolve the tar.
The oil is inert, safe on injured skin, and available in
large quantities.
Burn Patterns Indicating Abuse
It is important for clinicians to maintain awareness
that intentional burn injury can occur in both children
and adults. Patients who are unable to control their
environment, such as the very young and the very
old, are particularly vulnerable to abuse and neglect.
Circular burns and burns with clear edges and unique
patterns should arouse suspicion; they may reflect a
cigarette or other hot object (e.g., an iron) being held
against the patient. Burns on the soles of a child’s
feet usually suggest that the child was placed into hot
water versus having hot water fall on him or her, as
contact with a cold bathtub can protect the bottom of
the foot. A burn to the posterior aspect of the lower
extremities and buttocks may be seen in an abused
elder patient who has been placed in a bathtub with
hot water in it. Old burn injuries in the setting of a
new traumatic injury such as a fracture should also
raise suspicion for abuse. Above all, the mechanism
and pattern of injury should match the history of
the injury.
Pitfall
Patient with an
electrical burn
develops acute
renal failure.
prevention
• Remember, with electrical burns,
that muscle injury can occur with
few outward signs of injury.
• Test urine for hemochromogen,
and administer proper volume to
ensure adequate urine output.
• Repeatedly assess the patient
for the development of
compartment syndrome,
recognizing that electrical burns
may need fasciotomies.
• Patients with electrical injuries
may develop cardiac arrhythmias
and should have a 12-lead ECG
and continuous monitoring.
Patient Transfer
The criteria for transfer of patients to burn centers has
been developed by the American Burn Association.
Criteria for Transfer
The following types of burn injuries typically require
transfer to a burn center:
1. Partial-thickness burns on greater than
10% TBSA.
2. Burns involving the face, hands, feet, genitalia,
perineum, and major joints
3. Third-degree burns in any age group
4. Electrical burns, including lightning injury
n BACK TO TABLE OF CONTENTS