Environmental injury

Environmental Outline
injury • Electrical and Lightning injury
• Burn
• Inhalation injury
• Heat illness
Emergency medicine, Uttaradit hospital • drowning

Electrical injury Electrical injury

แรงดันไฟฟ้ า
• High - voltage injury > 1,000 V
• Low - voltage injury < 1,000 V
(กระแสไฟฟ้ าบ้าน 220 V.)
Household : AC
Batteries, lightning :DC
CARDIAC ARREST
• Low-voltage AC : VF
• High-voltage AC ,DC : Asystole
Tissue damage
• Low-voltage : พบได้บา้ ง
• High-voltage : deep tissue destruction
Renal involvement
• Low-voltage AC : พบได้ในบางกรณี
• High-voltage AC : อาจพบ myoglobinuria, renal failure ได้
Clinical features
• Neuro : petechiae hemorrhage , cerebral
edema
– Altered mental status , coma , seizure , weakness ,
peripheral neuropathy ,headache or other
symptoms
– CT brain if abnormal mental status
Clinical features
• Cardiovascular : chest pain , palpitation ,
dysrhythmia , abnormal EKG (bundle branch
block , ST-T segment abnormality) cardiac
arrest (asystole , VF)
• Other injury : fracture , dislocation muscle
injury , rhabdomyolysis , compartment
syndrome or other injury

Emergency management Emergency management

• ATLS , ACLS with spinal immobilization
Cardiac monitoring
• ECG monitoring • High voltage
• vascular and neurologic examination of limbs • Loss of consciousness / amnesia
• Altered mental status
• Fluid resuscitation • Episode of seizure or tetany
– Isotonic crystalloid • Chest pain or other chest symptoms
– Parklands formula • Transthoracic current paths.
– Higher than estimates provided by thermal burn injury formula Special populations
>>> deep tissue damage Pregnancy patient GA > 20-24 weeks
• Mornitor and treatment : compartment syndrome, • Mornitor fetal heart rate
rhabdomyolysis , renal failure • Mornitor uterine activity
 Emergency management Emergency management
Disposition and follow up
Laboratory tests • Low voltage injury (<600V)
• BUN/Cr, electrolytes – Asymptomatic contact<240 V >>>D/C if normal
• CPK EKG and examination
• Serum and urine myoglobin • High voltage injury (or >600 V) >>> admitted
• CBC for observation
• EKG 12 leads
• Imaging studies : indicated for suggested injuries

Lightning injury Lightning injury

• ฟ้าผ่าเกิดขึน้ จากการสะสมประจุไฟฟ้าสถิตในก้อนเมฆ แล้วเกิดการ
ถ่ายเทประจุไฟฟ้าระหว่างเมฆกับพืน้ ดิน ดังนัน้ ฟ้าผ่าแตกต่างจาก
กระแสไฟฟ้าจากแหล่งกําเนิดปกติคือ ฟ้าผ่าจะเป็ นไฟฟ้ากระแสตรง
(Direct current : DC) เกิดขึน้ ในช่วงเวลาสัน้ ๆ
• Extremely high–voltage DC
CUTANEOUS : 6 manifestations
1.Lichtenberg figures : pathognomonic sign
(electron showering over skin, not true thermal
burns, disappear in 24 h.)

Ref: Tintinalli’sEMERGENCY MEDICINE , 7thEdition

 Lightning injury Lightning injury
CUTANEOUS : 6 manifestations
NEUROLOGIC
1.Lichtenberg figures
• The most lethal heat-induced coagulation :
2.Flash burns epidural, subdural hematoma, ICH
3.Punctate burns • Transient effects (resolve in 24 h) : loss of
consciousness, confusion, amnesia, and extremity
4.Contact burns paralysis.
5.Superficial erythema & blistering burns • Delayed/progressive disorders : seizures, spinal
muscular atrophy, progressive cerebellar ataxia,
6.Linear burns myelopathy with paraplegia or quadriplegia, and
chronic pain syndromes.

Lightning injury Lightning injury

Treatment
• Pre-hospital
• Cardiac effect : hypertension , tachycardia , – Verify scene safe
EKG may be ST-T segment abnormality , QT – ATLS ( A B C D E)
prolongation • In Hospital
– ATLS ( A B C D E)
• Ocular injury – Admit
• Musculoskeletal injury – Monitor EKG , V/S
– CBC, Serum electrolyte, Calcium, Magnesium, BUN,
• Cutaneous injury Creatinine, Cardiac enzyme, Urine analysis, Urine
myoglobin level
– Chest x-ray, Cervical spine film related with clinical
Ref: Tintinalli’sEMERGENCY MEDICINE , 7thEdition
ชาย 50 ปี ถูกไฟฟ้ าดูด ตกจากทีส่ ู ง 3 เมตร ไม่ ร้ ูสึกตัว Burn
Burn : injury to tissue caused by contact with
• Dry heat (Fire)
• Moist heat (steam or hot liquid)
• Chemical (corrosive substance)
• Electricity (Current or lightning)
• Friction ( แรงเสียดทาน)
• Radiant energy
จงให้การ management • Electromagnetic energy

Factors associated severity Burn size

• Cause of burn Rule of nines ( % of TBSA)
• Each upper extremity 9 %
• Time to contact • Each lower extremity 18 %
• Age • the anterior and posterior trunk 18 %
• The head and neck 9 %
• Underlying disease • The perineum 1 %
• Associated injury • Technique of the patient’s hand
= 1% TBSA (for small area)
 Burn depth

rule of nines (Figure

210-2).

Tintinalli’s Emergency
Medicine 7th edition Ref.Peter C. Neligan. Plastic Surgery third edition.Sabiston Textbook of Surgery, 18th edition

Burn 2nd degree burn

1st degree Burn
• Epidermis lesion
• Dry ,Redness, no blister
• Sun burn
• Painful
• Recovery in 2-3 days
2nd degree burn • Deep 2nd burn
• Superficial 2nd burn – Less skin appendage
– Skin appendage – Deep partial thickness burn
– 1/3 upper dermis
– Scald, flame, chemical burn
– Blister
– painfull – Dry, less pain
– Spontaneous healing with in – Bleb and blister
5-14 days – Scar contracture
– TX. Topical antibiotic and burn
wound dressing
– Red or white/pink/yellow
– Recovery within 14-21 days
Bleb, Pink, Moist, Pain – Early excision and skin graft
 3rd degree burn 4th degree burn
• Involve all dermis
• Unconscious patient
• Flame, scald, concentrate
chemical burn, Electrical burn
• Deep to muscle , tendon or bony part
• Inelastic, dry ,grill
• Pallor or black, superficial
vessel thrombosis
• Painless
• Early excision and skin graft
within 7-10day after admit

Burn management : ABCDE

ED management
A : Airway maintenance with cervical spine
Prehospital protection
• stop burning process • Supraglottic tissue swelling can obstruct the
airway rapidly (12 hours)
• maintain airway
• fluid resuscitation • Inhalation injury signs include : hoarseness,
• burn wound care stridor , facial burns, singed facial hair,
• transfer to hospital expectoration of carbonaceous sputum, presence
of carbon in the oropharynx
• Intubation if indicated
 Burn management
B : Breathing and ventilation
• Effort to breath, depth of respiration, and
auscultation of breath sounds must be detect
early
• Support Oxygen and mornitoring
Burn management
D : Disability or neurological status
• Evaluate consciousness and responsiveness
• Level of consciousness
• Pupillary light reflex
• Response to pain
Burn management
C : Circulation and hemorrhage control
• Large-bore peripheral line for fluid
resuscitation(unburn skin)
• Burn injury causes a combination of
hypovolemic and distributive shock by the
inflammatory mediators, dynamic fluid shifts,
evaporative water loss from the burn injury
Burn management
E : Environment or exposure
• Remove all clothing
• Irrigate injuries with water or saline to remove
harmful residues
• Remove jewelry (particularly rings) to prevent
injury resulting from increasing tissue edema
 Emergency management Parkland Formula for Fluid Resuscitation

Resuscitation Adults
• Oxygen • LR 2 mL x weight (kg) x % TBSA over initial 24 hr
– 100% oxygen high-humidity facemask • Half over the first 8 h from the time of burn
• Intravenous access • Other half over the subsequent 16 h
Fluid Resuscitation Children
• Excess of maintenance fluids is administered to • LR 3 mL x weight (kg) x % TBSA over initial 24 hr
all patients with burns > 20% BSA • Half over the first 8 h from the time of burn
• Parkland formula • Other half over the subsequent 16 h
Lactated Ringer's (Crystalloid) solution
volume (24 hr) = 2 mL × %TBSA × BW(kg)

**Electrical injury adjusted fluid rates = 4 mL × %TBSA × BW(kg)

Fluid Resuscitation Laboratory examination

• Maintain adequate tissue perfusion as measured by • CBC
rate of urine output • Type and cross-match
• Electrolytes, BUN Cr
• For children (<30 kg or less ) : D5LR at a maintenance
• Arterial carboxyhemoglobin
Foley catheter • ABG
• monitor urine output (index of adequate tissue • Urinalysis
perfusion ) • Toxicology screen and an alcohol level
• A minimum urine production rate of 1 mL/kg/hour in • ▪when suggested by history or mental status
children (weighing ≤30 kg) and 0.5 mL/kg/hour in examination.
adults • Chest x-ray
Pain control
Complication
• IV morphine
• small doses to guard against hypotension, over
sedation, and respiratory depression. • Compartment syndrome
Early irrigation and debridement  sign & symptom indicate poor perfusion of
• Topical antimicrobial agents and sterile dressings
• Tetanus prophylaxis
distal extremity ; cyanosis,deep tissue pain
• No indication for antibiotic prophylaxis in early period progressive paresthesia , progressive decrease or
of burn absent pulse , sensation of cold extremities
• Silver sulphadiazine : Common used
– broad spectum topical antibiotic but not recoment in
graft area • Pneumonia

Inhalation injury Carbon monoxide (CO) poisoning

• Carbon monoxide : colorless ,odorless

• CO + Hb >>> COHb
• Carbon monoxide poisoning • LEFT shift of oxy-Hb curve
• Cyanide posoning • binding affinity : CO > oxygen
• Relative anemia and hypoxia
• Thermal airway injury
• Sign and symptoms : headache ,vomiting ,Visual
disturbances , seizure , confusion ,syncope , retinal
hemorrhage , cherry-red lips, cyanosis , increased
HR,RR
 Carbon monoxide (CO) poisoning cyanide poisoning
CO toxicity diagnosis • Binds cytochrome oxidase
• Pulse oximetry false high SpO2 • Sign : peripheral redness, desaturation, conscious
• ABG : measurement of COHb change
• CT/MRI : abnormal lesion of globus pallidus
• Treatment • BP RR , no central cyanosis
• Oxygen , hyperbaric oxygen therapy ( improve tissue • Smell of Bitter almonds
hypoxia and decreased half-life of CO)
• Hydrogen Cyanide : lactic acidosis or ST elevated of
ECG
• Antidote : Sodium thiosulfate , sodium nitrite
• Oxygen , IV fluid

Thermal airway injury

Heat Illness
• Heat stream damage is limited to upper
airway and proximal trachea
• Oropharynx & nasopharynx heat exchange
• Vocal cord closure reflex
• Manifests as erythema, edema, hemorrhage
ulceration of upper airway
• Lead to upper airway obstruction
Physiologic response to heat stress HEAT ILLNESS
1. Dilatation of blood vessels Heat cramp
– Especially skin  cutaneous vasodilatation Heat edema
Heat tetany
2. Sweat production Heat Syncope
Prickly Heat
3. Decreased Heat Production
Heat Exhaustion
Heat stroke >>>> major heat injury
4. Behavioral Control

Heat edema Heat Cramps Heat tetany

• Painful- involuntary • Consists of typical
• Self limited in several Treatment
spasmodic contractions of hyperventilation
days – Respiratory alkalosis
•Resolves after several days skeletal muscle
• Cause by cutaneous • Sweat loss  replace fluid – Paresthesia of limbs
vasodilatation and •Simple leg elevation – Circumoral paresthesia
with hypotonic solution
orthostatic pooling – Carpopedal spasm
•Adequate acclimatization, – hyponatremia
return to home climate – hypochloremia • Paresthesias are prominent,
• DDx less pain or cramping
thrombophlebitis, • Self limited
•Diuretic therapy are not • Treatment
lympedema, CHF recommended • Treatment :
– Remove patient from heat
– fluid and salt replacement
– Decrease respiratory rate
– rest
 Heat Exhaustion
Heat Syncope
• Temperature not above 40c
• Postural hypotension • Water depletion
– Relative volume depletion • Sodium depletion
– Peripheral vasodilatation • Symptoms : non specific
• Treatment – Headache, nausea, vomiting, malaise, dizziness,
– Rehydration cramps
– Sign of dehydration
– Rest
• Treatment
– Fluid replacement
– Supportive treatment

Heat Stroke Heat Stroke

• Life-threatening , high mortality rates
• Exposure to heat stress, endogenous or
exogenous
• Cardinal features
– Hyperthermia > 40c ( core temperature)
– Altered mental status
• +/- Anhidrosis
Differential diagnosis of heat stroke
• Sepsis
• Infection: Meningitis, Encephalitis
• Toxin, drug: amphetamine, anticholinergics
• Neuroleptic malignant syndrome (NMS)
• Malignant hyperthermia
• Thyroid strom
• Seizure
 Heat Stroke Treatment
Investigation • Goal : Immediate cooling and Support of
• CBC, Electrolyte, LFT BUN/Cr, CPK organ system function
• Coagulogram • Pre-hospital
– Remove from source of injury
• ABG
– Remove clothing
• Urinalysis, Urinary myoglobin
– ABC + IV fluid
• EKG, CXR – Initial cooling method ( tepid water, fan , ice pack)
• +/- CT scan , LP – Antipyretic drug : no benefit

Treatment Treatment
Emergency department care • Cooling Techniques
• Initial resuscitation Preferred : Evaporative cooling with fans
– ABC : airway , O2 • Not recommend : Cold IV , cooling blanket ,cold
– Average fluid requirement : 1200 ml in first 4 hrs water gastric lavage
– IV 250 ml/h NS (cautiously : elderly)
• Antipyretic drug are ineffective
– Monitor core temperature : 0.2 C /min >>>39
C(102.2°F)
– Cardiac monitoring
– Pulse oximetry
– Retain foley’s cath to record urine output
 Drowning
Drowning Prehospital Care
• Removal of the victim from the water
Definition • Begin resuscitation (BLS)
• Supplement oxygenation
submersion in a liquid medium resulting in •Breathing: high-flow oxygen by facemask
respiratory difficulty or arrest •No breathing: positive-pressure bag-valve mask
ventilation
• CPR as indicated
• Protection of the c-spine (history or signs of injury)
• Prevent hypothermia

Drowning Drowning
CPR 2015 AHA
At ER
• Removed from water
• ABCD management
• A-B-C approach
• Maintain airway, suction
• A &B: open the airway, check for breathing
• Provide oxygen
– 2 rescue breaths
Assist ventilation : BMV, ETT
• C: No pulse >>> BLS CPR & AED
• Warmed isotonic IV fluids
• Treatment hypothermia and associated injuries
note : Procedures to drain fluid from the lung
• Investigation : EKG CXR Lab
-Heimlich maneuver; Ineffective and dangerous
-Delay CPR
 Drowning
Disposition
• Symptomatic patients must be admitted
• Asymptomatic , normal O2sat,CXR,ABG
Observe 4-6 hr
Serial monitoring of vital signs & physical
examination