Airway compromise in children with anterior neck burns: Beware the scalded child.

AIM: The aim of the study was to describe characteristics of children with anterior neck burns admitted to our Paediatric Intensive Care Unit (PICU) and to highlight potential airway complications associated with these injuries, especially in children with scalds. METHODS: Retrospective review of children with anterior neck burns requiring admission to PICU January 2004-December 2013. RESULTS: Fifty-two children with anterior neck burns were admitted; average age 6.6 years. Thirty sustained flame/explosion injuries; 22 scalds. Seventy-nine per cent were male. Mean total body surface area (TBSA) burn 21%. Forty-seven were intubated. Some primary reasons for intubation included unconsciousness, inhalational/ingestion/direct airway injury and large TBSA. Majority, however, required intubation for airway complications secondary to subcutaneous/soft tissue anterior neck oedema not associated with airway injury/ingestion/inhalational burns. The scalds subgroup mean age was 2.3 years. Eighty-two per cent were male. Mean TBSA 18%. There were no inhalational/ingestion/airway injuries. Nineteen children were intubated; average 9.3 h post-injury. Majority (63%) were intubated post-arrival in the Burn Unit, compared with flame/explosion group (32%). Primary reasons for intubation included large burns, although majority (74%) required intubation for airway complications secondary to subcutaneous and soft tissue anterior neck oedema. For the flame/explosion group this was the case in only 46%, with other primary reasons such as unconsciousness or inhalational injury being the immediate precedent. CONCLUSION: These results demonstrate that subcutaneous and soft tissue oedema secondary to anterior neck burns may contribute to airway narrowing and compromise requiring intubation. When assessing children's airways, evolving oedema should be recognised and higher observation or early intubation considered regardless of the mechanism of injury.

Steam inhalation: More harm than good? Perspective from a UK burns centre.

INTRODUCTION: Steam inhalation is common practice in UK households for coryzal symptoms in adults and children. Steam inhalation has the potential to and has caused significant scald injuries, predominantly due to unintentional contact with the hot water used. METHODS: The authors used electronic health records to retrospectively identify all patients admitted with scald injuries secondary to steam inhalation over a 2-year period from January 2018-December 2019 at Chelsea and Westminster Hospital, a regional burns centre. Data collected included patient demographics, mechanism of burn, as well as burn size, depth, treatment and any associated complications. An International Burns Injury Database enquiry assessed the national prevalence steam inhalation scalds over the same time period. RESULTS: 19 adult and paediatric patients were identified in our centre over a 2-year period, with an age range of 2 weeks to 91 years old. The majority (16/19, 84%) of patients received burns to their lower body, with three patients receiving burns to their chest and/or upper limbs. Six patients underwent surgery, 98 clinic appointments were utilised and the total length of hospital stay was 83 days. The estimated total cost of treating these 19 patients was over £31,872. Nationally, 201 cases were identified between Jan 2018-Dec 2019. CONCLUSIONS: Scald injuries secondary to steam inhalation have a significant impact both in terms of hospital stay and cost. Since this study captured only patients admitted to hospital, the true negative impact of steam inhalation is likely to be much higher than calculated. Better public awareness on the risks of steam inhalation and primary prevention policies could reduce the frequency of such injuries.

Trauma mechanisms, patterns of injury, and outcomes in a retrospective study of 71 burns from civil gas explosions.

BACKGROUND: Although explosion injuries caused by terror attacks or in war are evaluated in many studies, limited information about civil explosion injuries can be found in the literature. METHODS: In a retrospective study of 71 civil gas explosion injuries treated in a single burn center during a 16-year period, we evaluated trauma mechanisms, patterns of injury, and clinical outcome. RESULTS: More than 50% of all gas explosions injuries occurred in private households. The mortality correlated significantly with higher burned total body surface area (TBSA), higher abbreviated burn severity index (ABSI) score, accompanying inhalation injuries, and lung contusions. Although mean ABSI score and burned TBSA were similar in men and women (6 vs. 7 and 22% vs. 21%), the female mortality from gas explosions was noticeably higher, albeit not statistically significant due to small patient numbers (32% vs. 17%). Although mean burned TBSA, ABSI scores, and intensive care unit lengths of stay in patients with burns from gas explosions were comparable and not significantly different compared with all burn patients treated in our burn center (TBSA: 22% vs. 17%; ABSI: 6 vs. 6; and intensive care unit lengths of stay: 12 vs. 11 days), the mortality from gas explosions was significantly higher (21% vs. 12%, p = 0.04). CONCLUSIONS: The mortality from gas explosion-related burns correlated significantly with burned TBSA, ABSI score, accompanying inhalation injuries, and lung contusions. Despite comparable ABSI scores, the mortality from gas explosion-related burns was significantly higher than the mortality for all burn victims.

[Endotracheal tube fire during laryngeal surgery: analysis of the root cause of a sentinel event]. / Ignición del tubo endotraqueal durante cirugía laríngea. análisis causa-raíz de un suceso centinela.

Endotracheal tube fire during laryngeal surgery is a rare complication but one that has serious consequences. Surgeons, anesthesiologists and others involved with this type of surgery should become familiar with how to manage this difficult situation, which should be considered a sentinel event requiring prompt analysis of the root cause and surrounding circumstances. Measures to improve management should be implemented and training provided in order to prevent the recurrence of a similar unfortunate event. We report a case in which a patient's airway caught fire during use of an electrocautery device. The patient died as a result of the lesions sustained. We report the results of the investigation and the protocols for prevention and response implemented in our surgical department, in the hope that the experience will be of interest to others working in similar settings.

Airway management in inhalation injury: a case series.

Inhalation injury is a serious consequence of a fire or an explosion, with potential airway compromise and respiratory complications. We present a case series of five patients with inhalational burns who presented to Singapore General Hospital and discuss our approach to their early management, including early evaluation and planning for the upper and lower airway, coexisting cutaneous burns, and monitoring their ICU (intensive care unit) severity of illness, sepsis and acute respiratory distress syndrome. All five patients suffered various grades of inhalation injury. The patients were initially assessed by nasolaryngoscopy, and three patients were prophylactically intubated before being sent to the emergency operating theatre for definitive airway and burns management with fibreoptic bronchoscopy. All patients were successfully extubated and discharged stable. Various complications can arise as a result of an inhalation injury. Based on our cases and literature review, we propose a standardised workflow for patients with inhalation injury.

Application of calcium nebulization for mass exposure to an accidental hydrofluoric acid spill.

PURPOSE: To determine the long-term prevalence and characteristics of acute hydrofluoric acid (HF) exposure in 2223 patients during the first 30 months after a mass-casualty exposure, and to confirm the antidotal effect of nebulized calcium on inhalation burns caused by HF. METHODS: This observational cohort study included patients after an HF spill in the Republic of Korea on September 27, 2012; registered patients were followed until April 2015. We assessed toxic effects, distance from spill, degree of acute poisoning, and the effect of nebulized calcium in HF-exposed individuals. RESULTS: Overall, 2223 patients received emergency management or antidote therapy for 20 days. Seventy-four of 134 patients with dermal toxicity received calcium-lidocaine gel, and 368 individuals with bronchial irritation signs received calcium gluconate via nebulizer nCG. A total 377 ampoules 786 g of calcium gluconate were used in the nCG formulation. Calcium administration did not cause adverse reactions during the observation period. Long-term cohort observation showed that 120 patients (120/2233, 5.4%) returned to medical facilities for management of HF-related symptoms within 1 month; 18 persons (18/1660, 1.1%) returned 1-3 months later with chronic cough and respiratory symptoms; and 3 patients (3/1660, 0.2%) underwent medical treatment due to upper-airway toxic symptoms more than 2 years after HF exposure. CONCLUSION: Respiratory toxicity after mass exposure to an HF spill was successfully treated by calcium nebulizer. Based on our experience, detoxification processes and the amounts of antidote stocked are important when planning for future chemical disasters at the community level.

[Forensic medical evaluation of a burn injury from combustion of flammable fluids on the human body based on morphological changes in internal organs].

The author describes morphological features of splanchnic organs in the patients that suffered an injury from combustion of flammable fluids at the body surface. The burn injury is a specific form of trauma originating from a combination of several injurious factors including thermoinhalation and intoxication with combustion products in the absence of oxygen in the centre of the hot spot. A rather specific combination of morphological changes in internal organs along with results of laboratory studies provides the most reliable criterion for forensic medical diagnosis of burn injuries from combustion of flammable fluids on the human body.

E-cigarette burn injuries: Comprehensive review and management guidelines proposal.

INTRODUCTION: Electronic cigarettes (EC) have been reported to be associated with burns secondary to explosions of the device or battery, or contact from overheating, resulting in flame, contact or chemical burns. In addition to this, there have also been reported cases of soft tissue and bony trauma with or without associated burns. Using collective evidence, this review aims to summarise all reported burns associated with ECs, and its implications on immediate management with a particular focus on surgical treatment. METHODS: A search was conducted on PubMed, EMBASE and Medline for all case reports, case series and letters to editors published since 2014, using terms "electronic cigarette", "e-cigarette", "vaping" and "burn". The search was repeated by the co-author to avoid bias and a review of the bibliographies of each paper was conducted to ensure all relevant cases were included. The mechanisms, type and severity of burn injury, and management and treatment outcomes of the patients were recorded. Exclusion criteria included non-English articles, explosions with no associated burn and publications with insufficient information. RESULTS: 90 patients from 19 case series or case reports were included. With the exception of one study, gender was recorded with a male predominance (95.6%). Mean age is 30.1years (range 18-59). The most common type of burn was flame. However, there were reports of chemical burns associated with ECs. The mean total body surface area (TBSA) affected was 4.9% (range 1-27.25%) with the majority of burns being mixed partial and full thickness. 22 patients underwent excision and autologous skin grafting within range of three to 21days. One patient had a full thickness contact burn excised and closed, one patient received a xenograft following debridement and one had biosynthetic skin dressing. 42 patients were managed conservatively with dressings or ointments. DISCUSSION: In this review over a three-year period (2015-2017), 90 cases of EC related burn injuries were reported, however, this is likely an underestimation of the problem. The suggested mechanism for EC related injuries is battery malfunction. ECs are powered by Lithium ion batteries which are susceptible to "thermal runaway" reactions, which result in device overheating with potential for subsequent explosion. We explain hypothesized triggers for these reactions and mechanisms of other injuries associated with ECs such as chemical burns and blast injury. CONCLUSION: EC-associated burn injury results in combined thermal and chemical burns, which should be managed in tandem. Explosion injuries sustained whilst using the device may result in both facial trauma or inhalation injury and therefore should be reviewed with a high index of clinical suspicion. It is noted that there is no agreed standard for management for such burns by specialist bodies in the UK. We suggested a treatment algorithm to provide guidance for the burn injuries associated with ECs.

Acute anhydrous ammonia injury from accidents during illicit methamphetamine production.

BACKGROUND: Anhydrous ammonia (AA), a chemical commonly used in agriculture, is a key component in illicit methamphetamine production. Although injuries associated with AA exposure are well studied, AA injuries associated with incidents during illicit methamphetamine production have not been adequately described in the literature. OBJECTIVE: This study better characterizes AA injuries occurring in an agricultural region where illicit methamphetamine production is common. METHODS: We performed a cross-sectional study based on a chart review of 49 patients who were admitted to a tertiary hospital in Illinois with known or suspected exposures to chemical agents. Indices of morbidity were compared between injuries resulting from exposure to AA and injuries from other chemicals, and between AA injuries from incidents during illicit methamphetamine production and AA injuries from other causes. RESULTS: AA was the most common cause of chemical injury (41%; n=20/49). Incidents during illicit methamphetamine production were the most common cause of AA injury (75%; n=15/20). AA injury was associated with significantly greater morbidity compared to non-AA chemical injury. In addition, methamphetamine-related AA injury was associated with significantly greater morbidity compared to non-methamphetamine-related AA injury. CONCLUSION: Chemical burns during illicit methamphetamine production were the most common cause of both chemical and AA-related injury in our agricultural population and these injuries were associated with greater morbidity during hospitalization.

Respiratory management of inhalation injury.

Advances in the care of patients with major burns have led to a reduction in mortality and a change in the cause of their death. Burn shock, which accounted for almost 20 percent of burn deaths in the 1930s and 1940s, is now treated with early, vigorous fluid resuscitation and is only rarely a cause of death. Burn wound sepsis, which emerged as the primary cause of mortality once burn shock decreased in importance, has been brought under control with the use of topical antibiotics and aggressive surgical debridement. Inhalation injury has now become the most frequent cause of death in burn patients. Although mortality from smoke inhalation alone is low (0-11 percent), smoke inhalation in combination with cutaneous burns is fatal in 30 to 90 percent of patients. It has been recently reported that the presence of inhalation injury increases burn mortality by 20 percent and that inhalation injury predisposes to pneumonia. Pneumonia has been shown to independently increase burn mortality by 40 percent, and the combination of inhalation injury and pneumonia leads to a 60 percent increase in deaths. Children and the elderly are especially prone to pneumonia due to a limited physiologic reserve. It is imperative that a well organized, protocol driven approach to respiratory care of inhalation injury be utilized so that improvements can be made and the morbidity and mortality associated with inhalation injury be reduced.

Butane Hash Oil Burns: A 7-Year Perspective on a Growing Problem.

With the legalization of marijuana in four states, and decriminalization in many others, marijuana is becoming easier to obtain. The authors have experienced an increase in burn injuries related to the production of butane hash oil (BHO; a concentrated tetrahydrocannabinol product produced by the distillation of marijuana plant products with pressurized butane). This article updates our experience and highlights the increasing public health problem associated with these burns. Charts of patients who presented to the burn center with suspicion of BHO-related injuries between January 2007 and December 2014 were examined. Data collected included demographics, injury characteristics, treatment utilized, and outcomes. Charts of 101 patients were identified as having BHO-related burn injury. The mean age of these patients was 30.5 ± 10.6 years (mean ± standard deviation, range: 2-55 years) and 93.1% were male. Patients sustained a mean of 26.8 ± 24.1% TBSA burn with 14.3 ± 25.1% third degree burns. Three patients died as the result of their injuries. Patients required a mean of 12 ± 48.4 ventilator days, and 27.1 ± 59.4 days in the hospital. The number of patients presenting with these burns increased over the past 7 years. BHO burns occur most commonly in February (12 patients), on Wednesday (19 patients), and between 18:00 and 06:00 (58 patients). There has been a sharp increase in the number of patients presenting with burn-associated BHO production in the region over the past 7 years. The authors as burn care providers need to increase public awareness of this issue and aid in the development of legislation to help prevent these burns before it becomes a public health crisis.

Laryngeal Trauma Following an Inhalation Injury: A Review and Case Report.

The primary concern when managing a patient with inhalation injury is security of the airway. Airflow may be impeded by both edema of the upper airway and reduction of oxygen delivery to the lower respiratory tract. Although there has been much discussion regarding management of the latter, the focus of this article is the management of the former. This review aimed to determine the optimum management in burn victims with upper airway inhalation injury as an attempt to prevent laryngeal trauma leading to long-term voice disorders and upper airway dyspnea. We describe the case of a 57-year-old woman with significant inhalation injury and discuss the natural progression of her injuries and the laryngeal controversies surrounding her care. We conclude with advice on the optimal management of this condition based on our experience, combined with current best evidence.

A three decade analysis of factors affecting burn mortality in the elderly.

This study's objective was to identify variables that affect the mortality of elderly burn patients and to assess their changes over time. A retrospective review was conducted on all patients 75 or older (n=201) admitted to a university-based burn center between 1972 and 2000. Variables examined were age, sex, TBSA, ABSI, inhalation injury, timing from burn to operative intervention, the number of surgical procedures, the number of pre-morbid conditions, and mortality. There were 95 fatalities. TBSA strongly correlated with mortality (p<0.0001). Adjusting for TBSA and inhalation injury, mortality significantly decreased (p=0.04, odds ratio=0.58). Mortality significantly increased with inhalation injury (p<0.01). Fatality risk increased by 400% with inhalation injury. Absence of inhalation injury was not significant with respect to mortality in the 1970s, however there was a significant decrease (p=0.02) in mortality without an inhalation injury in the 1980s and 1990s. ABSI was strongly predictive of mortality (p<0.0001). On average there was a 200% increase in mortality per unit increase of ABSI. The elderly are 58% less likely to die from burns now as compared to the 1970s. Although mortality rose with increasing TBSA equally in each decade, the absolute risk of mortality decreased over time. This data suggests major strides have been made in burn care, however similar success has not been achieved with inhalation injuries.

Burn epidemiology in the Brisbane and Queensland area.

AIM: The aim was to evaluate changes in patterns of injury and whether mortality rates have decreased. METHOD: The database over 20 years from 1982 to 2002 and the 6 years 1997 to 2003 was studied. RESULTS: 4523 admissions. 73.7% males, 26.3% females. Monthly and seasonal admissions showed little fluctuation. 52.8% in the 21-40 years age group, 19.7% under 20 years, 19.4% in the 41-60 years group and 8.1% over 60 years. TBSA: 80.4% under 20%, 12.6-21% to 40%, 3.3-41% to 60% and 3.4% were over 61%. Causes: flame 56%, scalds 26%, contact 9%, chemical 5%, electrical 2%, friction 1% flash burns 1%. Fifty five percent at home, 20% work, 13% motor vehicles and 11% leisure. Fifteen percent had significant inhalation injuries and 81% required intubation. Mortality rate for 6 years was 2.1%. In 1972-1996 of 4096 burns was 3.6% and 3.4% in 1993-1996. CONCLUSION: Little change in patterns of injury. Burns less than 20% predominate. The majority were under 40 years. Inhalation injury, large burns and elderly were major causes of morbidity and mortality. Mortality rate is falling.

Epidemiological and outcome characteristics of major burns in Tokyo.

The Tokyo Burn Unit Association (TBUA) was established in 1983 funded by the Tokyo Metropolitan Government, and is organized by 13 burn units in Tokyo. TBUA covers more than 90% of severe burn patients occurring in Tokyo, and all of the cases are registered according to the burn injury registration format. The purpose of this study is to analyze the registered data and to elucidate epidemiological and outcome characteristics of major burn injuries in Tokyo. The total of 6988 hospitalized patients had data for epidemiological analysis, and 6401 patients had complete data for outcome analysis as well, and were included in this study. The characteristic profiles for the analysis included age, sex, cause of burns, inhalation injury, %BSA, burn index (BI), length of burn unit stay, and outcome, and were analyzed by age groups. The mean age of the patients was 40.4 years, and 63% of them were male. It was noteworthy that 25% of the total patients were elderly patients over 60 years of age. Flame was the most common cause making up 45.6% followed by scalding (32.0%). The overall mortality rate was 15.4%. Inhalation injury was accompanied in 27.3% of burn patients. The mortality rate was 34.6% with inhalation injury, and 8.2% without inhalation injury. Causes of death showed that multiple organ failure made up 36.9% of total mortality, followed by sepsis 25.2 and shock 19.0%. The burn size (%BSA and BI) and inhalation injury were the factors for high mortality rate in all age groups whereas age was a predictor for high mortality in the patients older than 16 years of age. Gender was not a factor for high mortality in any age group. The mortality rate showed mildly decreasing tendency since 1995 for which implementation of skin bank was thought to be responsible.

Case with bromine exposure leading to respiratory insufficiency.

A 21-year-old male had a chemical burn on the right forearm when he inadvertently spilled bromine during an experiment. Since he inhaled vaporized bromine and had dyspnea and pharyngalgia, he arrived at our hospital in an ambulance as an emergency patient. On arrival, he kept a clear consciousness with a pulse rate of 98, body temperature of 36.8 degrees C, blood pressure of 132/80 mmHg, respiratory rate of 25, and oxygen saturation of 100%. (10 L/min of oxygen were administered.) He had marked dry coughs. His clothes had a foreign odor with mucosal irritation. Arterial blood gas analysis and blood biochemistry were normal. Based on these findings, he was diagnosed with chemical airway damage and bulbar conjunctiva from the exposure to bromine and a chemical burn on the right forearm. His respiratory condition became worse after admission, resulting in pulmonary edema. He was endotracheally intubated and controlled with an artificial ventilator on Day 3 after his injury. He was continuously treated with steroids and sivelestat sodium hydrate, which gradually improved his respiration. He was released from the artificial ventilator and extubated on Day 7. Although dyspnea associated with body movement and hoarseness persisted after extubation, the symptoms decreased and he was discharged on Day 41. This rare case is worth attention because serious respiratory insufficiency requiring artificial ventilation due to pulmonary edema from bromine exposure has not been reported in Japan.

Occupational-Related Chemical Injuries: A Review of the Literature.

Although few occupational chemical injuries are reported each year, the severity of these injuries increases their importance to occupational health nurses who intervene to prevent these injuries by understanding their nature and etiology. This article is a review of the literature detailing specific occupational chemical injuries as well as a review of common occupational chemical injuries in the United States focusing on pulmonary, ocular, and burn injuries.

Injuries following a serious hydrofluoric acid leak: First aid and lessons.

Hydrofluoric acid is a dangerous inorganic acid that can cause local corrosion and systemic effects by ongoing absorption via the skin, mucosae, respiratory tract and digestive system. Recently, a serious toxic leak of low-concentration hydrofluoric acid solution occurred in the Pujiang area of Zhejiang Province, China. This accident resulted in 253 cases of chemical injury due to hydrofluoric acid exposure. Despite an immediate response by the local and provincial health-care system, as well as the local government, three people died due to acute poisoning and related complications. This article describes the events that took place leading to casualties as well as presenting the first-aid experience and the lessons learnt from this kind of mass injury.