1. Burn 2 DR. AXIEL YC SIU REVISED BY DR. CHAN MING YIN JULY, 2013 HKCEM College Tutorial

2. Ambulance information ▪ A 45 year old man was found unconscious while working with electric drill

3. 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.

4. What are the possible differential diagnoses?

5. Differential diagnosis ▪ CVS ▪ Cardiac arrhythmia ▪ Ischaemic heart disease ▪ CNS ▪ Syncope ▪ Epilepsy ▪ Endocrine ▪ Hypoglycaemia ▪ Electrolyte disturbance ▪ Addison’s disease ▪ Others ▪ Electrocution ▪ Drug effect ▪ Substance abuse

6. Vital Signs Alert (GCS:15/15) BP: 140/89 mmHg Pulse: 84/min (Regular) SpO 2 : 100% (Room Air)

7. 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.

8. 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

9. WHAT IS YOUR MANAGEMENT PRIORITY? What is the most likely diagnosis?

10. WHAT IS YOUR MANAGEMENT PRIORITY? Electrical Injury

11. Management Priority ▪ Airway with cervical protection ▪ Breathing ▪ Circulation ▪ Deficit and Disability ▪ Exposure ▪ Fluid Management and Foley ▪ Gastric tube (if indicated)

12. What Investigations will you order? Baseline Investigations ▪ Chest X-ray ▪ Electrocardiogram ▪ CBP, electrolytes, CPK, troponin I

13. 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

14. How is the electrical burn wound different from other burn wound?

15. 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

16. 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

17. 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

18. Wound Management ▪ Promote wound healing ▪ Keep clean ▪ Prevent infection ▪ Keep dry but not too dry ▪ Minimize pain ( each time of change dressing)

19. 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

20. Dressing materials

21. ▪ 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

22. 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

23. Thank you