Extent of injury depends on the amount of heat, the delivery medium (gas, liquid, solid, or vapor), and the duration of contact. Scald burns are most common in children and the majority of thermal injuries occurring within the home; 60% of pediatric burn patients are male.
Burns can be graded by depth and amount of damage (see Table 18.1).
| Thickness | Tissue Affected | Clinical Manifestations | |
|---|---|---|---|
| First degree | Partial | Epidermis | Redness, pain |
| Second degree | Partial | Epidermis/dermis | Redness, pain, fluid-filled blisters |
| Third degree | Full | Epidermis/dermis, hair follicles, sweat glands, other adnexal skin structures | Paresthesia (loss of tactile sensation) |
| Fourth degreea | Full | Cutaneous and subcutaneous structure, including muscle, fascia, bone | Paresthesia (loss of tactile sensation) |
All patients should receive analgesics as soon as possible. Minor burns involve <10% body surface area (BSA) and do not involve the airway, hands, face, or genitalia. They can be managed with local wound care in an outpatient setting. The wound should be irrigated with cool saline and patients not allergic to sulfa should apply silver sulfadiazine to burns below the clavicles while bacitracin should be substituted to burns of the head and neck to avoid potential skin discoloration cause by sulfa compounds. A sterile dressing should then be applied and the patient should be provided adequate analgesics and close follow-up.
For significant (>10% BSA) and major (>20% BSA) thermal injuries in patients with preexisting medical conditions, the possibility of multiorgan failure needs to be anticipated and screening labs such as a complete blood count (CBC), electrolytes, glucose, blood urea nitrogen (BUN), creatinine, creatine phosphokinase (CPK), and urinalysis ordered. Any history or signs of significant smoke inhalation (carbonaceous sputum, hoarse voice, or evidence of hypoxia) should prompt a chest radiograph. All patients who were in a fire should have a venous determination of their carboxyhemoglobin (CO-Hgb) concentration. A good pulse oximetry level (>96%) with no visual signs of oral burns and a normal venous CO-Hgb level (<5%) virtually rules out the possibility of inhalation injury. Patients with CO-Hgb levels above baseline should be placed on high-flow oxygen to help dissociate the carbon monoxide (CO) from their hemoglobin. Patients with significant CO-Hgb levels require transfer to a hyperbaric chamber. Hyperbaric oxygen has been shown to decrease the long-term neurologic sequelae associated with CO poisoning and should be employed even if the carboxyhemoglobin level has been returned back to normal with simple high-flow oxygen. Significantly, burned patients should be resuscitated in the emergency department (ED) and transferred to a burn center when possible. (Significant burns are burns that are greater than 10% BSA, >5% third-degree, or involve the hands, face, or genitalia.)
Figure 18.1 ▪ Electrical Burns.
(A) These burns to the hand were sustained by an electrician who was working on a high-voltage wire while constructing our new ED. (B) A third-degree burn in a child after biting on an electrical cord. (C) A 2-year-old child with a third-degree burn to the commissure of the mouth after chewing on an electrical cord. Such patients need to be followed very closely as they are prone to delayed bleeding because tissue necrosis can erode into the labial artery 5 to 10 days after the initial injury. (Photo contributors: Mark Silverberg, MD [A] and Binita R. Shah, MD [B, C].)
Figure 18.2 ▪ Inhalation Injuries Following Fire.
(A) Soot in the oral cavity is a clinical cue that a patient may have sustained a lung injury while in a fire. (B) Picture of a young man with second- and third-degree burns to the face and a CO-Hgb level of 32%. His oropharyngeal burns and carbonaceous sputum necessitated intubation on arrival in the ED. After resuscitation and stabilization, he was transported to a hyperbaric chamber. (Photo contributors: Mark Silverberg, MD [A] and Michael Lucchesi, MD [B].)
The Parkland formula (4 mL/kg × body weight in kilograms × percentage of BSA burned) is used for calculating the amount of Ringer lactate needed for initial resuscitation for burn shock. Half of this volume should be given in the first 8 hours after the burn occurred and half in the following 16 hours. Treating physicians should remember that this volume is in addition to regular maintenance fluids. A good way to evaluate resuscitation efficacy is to monitor urine output and keep it above 1 mL/kg/h as long as the patient is not in renal failure. Burns are considered traumatic injuries, so any patient with a significant burn should be evaluated by a trauma team. Circumferential burns of an extremity need to be monitored closely and should prompt urgent surgical evaluation should symptoms of compartment syndrome develop.
Figure 18.3 ▪ Second-Degree Burns.
(A) This child sustained second-degree burns to his trunk and upper arm after accidentally pulling down a cup of hot soup from the table and required a transfer to a burn center. (B) An image of a 10-year-old boy who sustained a second-degree burn with blistering to the anterior surface of the upper thigh from an accidental spilling of hot cooking oil from a frying pan. The hot oil penetrated through the jeans that he was wearing, causing these burns. (Photo contributors: Barry Hahn, MD [A] and Binita R. Shah, MD [B].)
Electrical burns to the corner of the mouth caused by chewing on an electrified wire deserve special mention. They need to be followed closely as they are prone to delayed bleeding as tissue necrosis can erode into the labial artery 5 to 10 days after the initial injury.
All burn patients should initially receive supplemental oxygen until it is determined that they do not need it.
Children with a large percentage of BSA burned often become hypothermic and need to be kept warm.
Children with significant burns need maintenance fluids plus that called for by the Parkland formula for burn shock.
Ten percent of burns in children are secondary to abuse.
Figure 18.4 ▪ Circumferential Burns.
(A) A 9-month-old infant sustained circumferential burns to the ankle, calf, and thigh after accidentally pulling hot soup from the table while in grandmother’s lap. Inflicted burns from child abuse need to be considered in such cases. The pattern of the burn seen here is consistent with a splash injury and not a submersion injury. (B) Circumferential burns to an extremity put the patient at risk for a compartment syndrome and may require a fasciotomy should contracture of the eschar develop. (Photo contributors: Binita R. Shah, MD [A] and Mark Silverberg, MD [B].)
The authors acknowledge the special contributions of Michael Lucchesi, Ronak Shah, Karen Santucci, M. Douglas Baker, Binita R. Shah, and Lewis Kohl, to prior edition.
Cold injuries range from frostnip to frostbite (see Table 18.2). History should focus on exposure temperature, duration, wind velocity, clothing, and underlying comorbidities. Distal areas are always affected first, which usually include fingers, toes, extremities, nose, and ears and even the cornea. Caretakers should focus on vital signs, assessment of the degree of hypothermia, and resuscitation. Retained sensation, normal skin color, and clear fluid within blisters (if present) indicate positive prognosis. Nonblanching cyanotic, firm skin, and dark fluid-filled blisters indicate poor prognosis. Risk factors include extremes of age, homelessness, altered mental status (drug/alcohol use, head trauma), nicotine or other vasoconstrictive drug use, preexistence of peripheral vascular disease, and diabetes.
| Thickness | Clinical Manifestations | Sequelae | |
|---|---|---|---|
| Frostnip | Superficial |
| None |
| Chilblain | Superficial |
| None |
| Frostbite: first degree | Partial |
| |
| Frostbite: second degree | Partial |
| |
| Frostbite: third degree | Full |
| Eschar formation |
| Frostbite: fourth degree | Full |
| Tissue loss |
Rewarming begins in the field after it is assured that frozen regions will not be re-exposed. Refreezing causes considerably more tissue damage than if the limb was left cold and rewarmed later. Upon ED arrival, stabilize airway, breathing, and circulation (ABCs) including management of hypothermia, cardiac dysrhythmias, intoxication, head injury, and hypoglycemia—all of which could have caused the cold exposure. Remove all restrictive or wet garments, which can cause continued heat loss. Initiate rapid active rewarming of affected areas with immersion in 40°C to 42°C water for 10 to 30 minutes. Analgesia should be provided for reperfusion pain. Clear blisters may be aspirated to remove inflammatory mediators that can worsen tissue destruction but hemorrhagic blisters should be left intact. The affected extremity should be elevated, splinted, and dressed with a dry sterile dressing.
Figure 18.6 ▪ Second-Degree Frostbites.
(A) Clear fluid-filled blisters are the hallmark of second-degree frostbite. This patient’s rings must be cut off soon because they are already incarcerated. (B) A 5-year-old child who was playing in the snow for several hours sustaining frostbites to the second, third (with clear fluid blister), and fourth digits. The picture was taken several hours after the injury occurred. (Photo contributors: Mark Silverberg, MD [A] and Binita R. Shah, MD [B].)
Laboratory studies such as a CBC, electrolytes, CPK, and serum myoglobin values should initially be obtained to identify a baseline and evaluate for rhabdomyolysis. Surgery may be consulted but debridement should never take place until definite demarcation has occurred. Patients should be admitted for observation and supportive care unless frostbite is very superficial and painless.
Treat hypothermia aggressively as it can lead to malignant arrhythmias.
Rewarming should not be initiated if there is a possibility of refreezing.
Dry rewarming (such as near an open fire) is uneven, dangerous, and should be avoided if possible.
Active rewarming should take place in 40°C to 42° (104°F–108°F) water for 15 to 30 minutes or until thawing is complete.
The true extent of frostbite may take up to 6 months to demarcate. Escharotomy/fasciotomy may be indicated in the acute setting.
Figure 18.8 ▪ Fourth-Degree Frostbites.
(A) An image of the index finger of a 6-year-old child with frostbite several weeks after the injury. He had gone sleigh riding wearing a torn glove on that hand and had gone unsupervised for several hours with his family at night. (B) An image of the foot of 17-year-old male several weeks after he sustained frostbite to his second, third, fourth, and fifth toes. Note the irregular pattern of demarcation which required eventual surgical debridement. (Photo contributors: Michael Stracher, MD [A] and Michael Lucchesi, MD [B].)
Figure 18.9 ▪ Electrocardiography in Hypothermia.
This ECG of a patient with a core temperature of 91°F depicts the classic J-waves (Osborn waves or camel-hump sign, arrows) of hypothermia as described by JJ Osborn in 1953. Note also the jagged baseline caused by shivering. (Photo contributor: Mark Silverberg, MD.)
Anaphylaxis is a type I IgE-mediated hypersensitivity reaction caused by mast cell degranulation following antigen exposure in a previously sensitized individual. Anaphylactoid reactions are indistinguishable from true anaphylaxis except that no prior sensitization exists. Two or more organ systems must be involved to make the diagnosis of true anaphylaxis. The most frequent triggers include medications, food, and insect envenomation. Diffuse pruritus, sweating, urticaria, and lip, face, and mouth swelling are often the first signs of anaphylaxis, with hypotension, or even total cardiovascular collapse occurring if not addressed rapidly. Excessive pulmonary secretions and bronchospasm result in wheezing and difficulty breathing. Diarrhea, nausea, and gastrointestinal (GI) upset are also common. About 80% of patients present with a predictable uniphasic course, in which signs and symptoms occur early and respond to therapy. A biphasic pattern can also be seen with a second episode of anaphylaxis occurring up to 8 hours after apparent recovery. Rarely, symptoms persist for days to weeks.
Figure 18.10 ▪ Anaphylaxis.
Right-sided periorbital and facial swelling and lip swelling (angioedema), wheezing, hoarseness of the voice, and urticaria were the presenting complaints in this child after eating peanuts. Angioedema usually involves the loose connective tissues of the ear or the periorbital or perioral areas, but may involve the oropharynx or extremities. (Photo contributor: Binita R. Shah, MD.)
The antigen must be removed whenever possible, that is, stop the medication infusion or remove the insect’s stinger. A credit card can be used to “flick” the stinger out as tweezers or forceps may actually instill more antigen if the venom sac is compressed. A tourniquet may be applied to delay systemic absorption of the allergen in the case of injection or sting.
All patients should receive an immediate assessment of their ABCs. If there is tongue or pharyngeal edema, establish a secure airway and administer 100% oxygen. Inhaled β2-agonist and anticholinergics (nebulized albuterol and ipratropium respectively) aide breathing by reversing bronchospasm and decreasing pulmonary secretions. Hypotension should be treated initially with an IV crystalloid bolus (20 mL/kg), but pressors may become necessary in the setting of refractory hypotension. Repeat fluid boluses may be administered to compensate for the marked peripheral vasodilation and third-spacing that may accompany anaphylaxis. Parenteral epinephrine is the drug of choice for life-threatening anaphylaxis given subcutaneously or IM and can be repeated every 15 to 20 minutes as needed for persistent symptoms. Patients undergoing previous treatment with β-blocking agents may not respond to epinephrine and may require glucagon to bypass the adrenergic receptor complex. Intravenous aminophylline may also be used in very severe cases although very few patients progress this far. Antihistamines do not reverse end-organ effects or hypotension in patients with anaphylaxis. They block further release of histamine and vasoactive mediators and provide symptomatic relief in anaphylactic reactions accompanied by urticaria and angioedema. A combination of H1– and H2-receptor blocking agents such as diphenhydramine and famotidine, respectively, can be synergistic in effect and should be utilized. Corticosteroids do not play a role in the immediate reversal of anaphylaxis because their onset of action is delayed for 4 to 6 hours. However, they inhibit or lessen biphasic and protracted anaphylactic reactions, including bronchospasm with their anti-inflammatory properties, and should be given in the ED. All patients with moderate to severe reactions requiring resuscitation must be hospitalized and observed for 24 to 48 hours, even in the absence of persistent symptoms.
Patients with milder reactions can be sent home after 6 to 8 hours of observation. Antihistamines and steroids should be prescribed to these patients orally for the next 72 hours. Upon discharge, patients can be referred to an allergist for desensitization immunotherapy. Patient and/or parent education regarding possible future recurrences is important. They must be prepared for severe reactions because a mild reaction at this hospital visit does not guarantee that future episodes will not be life-threatening. Patient with severe reactions should wear a MedicAlert bracelet that indicates precipitating agents if known. Insect exposure should be avoided and patients should be instructed to avoid wearing things that attract insects such as perfumes or bright-colored clothing. Latex-free gloves and catheters should be used with patients allergic to latex. Parents and older children should be provided with a prescription and educated about self-administering epinephrine (eg, EpiPen, EpiPen JR).
Anaphylaxis is a potentially life-threatening manifestation of an IgE-mediated hypersensitivity reaction involving 2 or more organ systems.
Life-threatening features include upper airway obstruction (laryngeal, pharyngeal, and lingual edema) and hypotensive shock due to profound vasodilation and increased vascular permeability.
IV fluids and epinephrine are the mainstay of therapy for anaphylaxis regardless of the cause.
Figure 18.14 ▪ Acute Allergic Reaction.
Acute onset of intensely pruritic, erythematous maculopapular rash, bilateral periorbital edema, and swelling of the left ear were the presenting complaints of this child. The etiology of this acute allergic reaction was unclear. (Photo contributor: Binita R. Shah, MD.)
The brown recluse spider (violin or fiddle back spider; Loxosceles reclusa) is a small orange to reddish brown spider measuring 6 to 12 mm in length that is found in the midwestern and southeastern United States. It can be identified by the classic brown, violin-shaped mark on its dorsal surface. These spiders are not usually aggressive and bite only when threatened.
Initially, bites are red and may be pain-free. Most become firm and heal with little scarring over days or weeks. However, severe and/or systemic envenomations occasionally occur. In these patients, there is localized pain and tissue destruction with systemic symptoms. Depending on the amount of venom delivered, bites may progress over days to weeks to large necrotic defects that may require reconstructive cosmetic surgery to repair. Systemic signs and symptoms include fever and chills, nausea, morbilliform rash formation, arthralgias, and myalgias. Renal failure, hemolysis, thrombocytopenia, disseminated intravascular coagulopathy, and seizures may all occasionally be seen and very rarely may progress to coma or death in small children. The constellation of symptoms classically known as loxoscelism includes necrosis at the bite site, nausea, malaise, fever, hemolysis, and thrombocytopenia.
ED care can vary from local wound care to intensive care unit (ICU) hospitalization. There are no specific tests to diagnose brown recluse spider envenomation, so definitive diagnosis depends upon identifying the offending arachnid. Patients with systemic symptoms should receive a CBC including platelet count, coagulation profile, serum electrolytes, creatinine, BUN, and urinalysis. A local poison center may be helpful in identifying the species of spider when available.
Brown recluse spider bites typically require local wound cleansing, splinting (for immobilization), tetanus prophylaxis, and pain management. Long-term cosmetic reconstruction may be necessary because the toxin in recluse venom can cause massive local tissue destruction. Some advocate early use of dapsone (leukocyte inhibitor) for these bites but no scientific study has ever proven its efficacy. Patients with systemic manifestations or evidence of a rapidly expanding necrotic lesion should be admitted for observation. If hemolysis is present, maintenance of urine output, urine alkalinization with intravenous (IV) sodium bicarbonate to keep the urine pH >7, and close monitoring of renal function and hematocrit are required. Heat can accelerate tissue destruction and should not be applied. Steroid creams usually do not help and overcutting to extract the venom with a suction device should never be attempted. High-voltage electrotherapy from stun guns has been reported but never shown to be effective in scientific studies. Other home remedies have not been proven useful.
Figure 18.16 ▪ Brown Recluse Spider Bite.
This patient stated that she was bitten by a 1-inch-long brown spider with a dark brown marking on its back that “looked violin-shaped.” The bite rapidly progressed to form this lesion only 2 days after the event, making the brown recluse spider the likely culprit although the offending arachnid was never captured or definitively identified. (Photo contributor: Mark Silverberg, MD.)
Monitor patients for evidence of hemolysis, renal failure, or coagulopathy. Smaller children are more likely to develop these systemic manifestations.
The shorter the time to the onset of symptoms following a spider bite, the more severe the envenomation is.
Figure 18.17 ▪ Brown Recluse Spider Bites.
(A) Extremities are the most commonly affected sites. Ulceration and surrounding erythema on the forearm at the bite site are seen. (B) Local intense erythema, induration, bullous lesion followed eschar and a deep ulcer on the hand of a different child following a spider bite. (Photo contributor: Binita R. Shah, MD.)
Widow spiders (hourglass spiders; Latrodectus mactans) range in size from 2.5 to 3.5 cm and have large fangs and a distinct red hourglass-shaped mark on their ventral surface. Envenomations tend to cause local erythema and pain but considerably more systemic effects. Cramping of the back, abdomen, and chest are classic and may become severe enough to require narcotic analgesics. Hemodynamic instability and coagulopathy are also common. Systemic symptoms include nausea and vomiting, hypertension, tachycardia, and diaphoresis. Classic “facies latrodectismica” is characterized by sweating, contortion, and grimacing.
ED care can range from simple local wound care to hospitalization and antivenom administration. There are no specific tests to diagnose Lactrodectus envenomation, so definitive diagnosis requires identification of the spider. A local poison center may be helpful in identifying the arachnid and locating the appropriate antivenom.
CBC including platelet count, coagulation profile, serum electrolytes, creatinine, BUN, and urinalysis should be obtained. Pain control with nonsteroidal anti-inflammatory drugs (NSAIDs) or even opioids is important because cramping can be severe. Calcium has been used to reduce cramping but has not proven more effective than placebo. Antivenin is indicated in small children for severe envenomations with systemic symptoms and is available as a hyperimmune horse serum, which can be given intramuscularly (IM) or IV. Indications for antivenin include life-threatening hypertension, tachycardia, and respiratory difficulty. Antivenom usually relieves symptoms rapidly though may precipitate anaphylaxis or serum sickness. Hospitalization is recommended for all Latrodectus envenomated pediatric patients.
Scorpions, like spiders, are members of the class Arachnida. Of the approximately 1500 venomous species of scorpion found throughout the world, 50 are potentially dangerous to humans, with only one species, Centruroides exilicauda (the bark scorpion), residing in the North America. All scorpions have hard exoskeletons with flat and elongated bodies armed with claws in the front and a whip-like tail in the back. Their tail ends in a bulbous segment known as the telson that contains 2 venom glands and the stinger. Scorpion venom is usually a heterogeneous mixture containing multiple proteins, many of which are neurotoxins that typically activate ion channels such as fast sodium channels. Humans are often stung on the hands or feet as they try to pick up or step on a scorpion. Children frequently manifest worse toxicity because of their small size. Envenomated individuals immediately complain of severe pain at the sting site progressing to local erythema and edema. Systemic symptoms are rare but include nausea, vomiting, hypersalivation, sweating, hyperthermia, anxiety, autonomic instability, myoclonus, and cardiac dysrhythmias. Symptoms typically last 24 to 48 hours although when fatal, death is usually due to cardiogenic shock or pulmonary edema. Pancreatitis is seen in up to 80% of victims of Tityus trinitatis scorpion stings.
Figure 18.19 ▪ Emperor Scorpion (Pandinus imperator).
Because of their impressive size and the relatively low toxicity of their venom, emperor scorpions are often kept as pets. Found in the wild only in Africa, they can grow to 8 inches in length. (Photo taken at the San Diego Zoo. Photo contributor: Mark Silverberg, MD.)
It is important to get a thorough history surrounding the sting and a description of the scorpion if no specimen is available. Initial first aid involves cleaning the wound with soap and water and applying ice to the sting site. ED care is supportive with analgesics plus benzodiazepines for myoclonus and muscle spasms. Tetanus prophylaxis should be checked and updated when indicated. Atropine is typically not needed for excessive oral secretions although it can be used if necessary. Nitroprusside and prazosin have been used to control malignant hypertension. Narcotics and barbiturates should be avoided as they may potentially increase the toxic effects of the venom by an unknown mechanism. Administration of antivenin is recommended in all cases of severe envenomation when available. Observation for 24 hours is prudent for closer monitoring for all envenomated children.
Dog bites in children occur disproportionately to the head and face, which is typically closer to a dog’s mouth than adults; male children are twice as likely to suffer dog bites. Most occur from an animal owned by the family or a neighbor. Approximately 5% of dog bites become significantly infected and these are usually polymicrobial in nature. Larger wounds can be easily cleansed and débrided and are paradoxically less likely to become infected than are minor lacerations or puncture wounds, which quickly close over the bacterial inoculum.
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