Chapter 9

Emergency Medicine

1 What are the three causes of burns? How should all burns be managed initially?

Burns may be thermal, chemical, or electrical. Initial management of all burns includes lots of intravenous fluids (first choice: lactated Ringer solution; backup choice: normal saline), removal of all clothes and other smoldering items on the body, copious irrigation of chemical burns, and, of course, the ABCs (airway, breathing, circulation). You should have a low threshold for intubation. In the setting of burns related to a fire, give 100% oxygen until significant carboxyhemoglobin in the blood from carbon monoxide inhalation is ruled out.

2 What are the important sequelae of electrical burns?

Because most of the tissue destruction caused by electrical burns is internal, sequelae include muscle necrosis, myoglobinuria, acidosis, and renal failure. Use large amounts of intravenous hydration to prevent renal shutdown. The immediate life-threatening risk associated with electrical shock and burn (e.g., from lightning or household outlets) is cardiac arrhythmia; obtain an electrocardiogram (ECG).

3 How are chemical burns managed? Which is worse, acid or alkali burns?

All chemical burns should be treated with copious irrigation from the nearest source (e.g., tap water) because the sooner you dilute the chemical, the less damage will be done. Alkali burns are worse than acidic burns because alkaline substances penetrate more deeply.

4 What is burned skin prone to develop?

Burned skin is much more prone to infection, usually by Staphylococcus aureus or Pseudomonas aeruginosa. With pseudomonal infection, look for a fruity smell and/or blue-green appearance. Prophylactic antibiotics are given topically only. Give a tetanus booster to all burn patients unless they have recently received one (within the past 5 years).

5 How is burn severity classified? Describe the management of each class

Burn depth terminology no longer includes the use of first-, second-, and third-degree burns. Burn severity is now classified as superficial, superficial partial thickness, deep partial thickness, and full thickness burns.

Superficial burns are erythematous without blister formation, involve only the epidermis, and pain is localized.

Superficial partial thickness burns are painful, warm, and moist with blister formation and involve the epidermis and superficial papillary dermis.

Deep partial thickness burns reveal skin that is mottled, waxy, and white in appearance with ruptured blisters. Pain sensation is absent, but pressure sensation is intact.

Full thickness burns involve both the epidermis and dermis, have a white to gray leathery appearance, and do not blanch with pressure.

6 Define hypothermia. How is it managed? What are the complications?

Hypothermia is defined as a body temperature <95°F (35°C), usually accompanied by mental status changes and generalized neurologic deficits. If the patient is conscious, you can rewarm the patient slowly with blankets. If the patient is unconscious, consider gastric and bladder lavage with warm water as well as warm intravenous fluids.

Monitor the ECG for arrhythmias, which are common in hypothermic patients. You may see the classic J wave—a small, positive deflection following the QRS complex (Fig. 9-1). Also monitor electrolytes, renal function, and acid-base status.

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