Pediatric emergency medicine trisk 492

Young children are vulnerable to orofacial burns, especially of the lips ( Fig.
90.9 ). These full-thickness burns of the upper and lower lips and oral
commissure usually involve mucosa, submucosa, muscles, nerves, and blood
vessels. The lesion usually has a pale, painless, well-demarcated, depressed center
with surrounding pale gray tissue and erythematous border. After a few hours, the
wound margin extends and marked edema occurs. Drooling is common. The
eschar separates in 2 to 3 weeks and bleeding may occur at this time; granulation
tissue gradually fills the wound. Scarring may produce lip eversion, microstomia,
and loss of function. Damage to facial or even carotid arteries may result in
delayed hemorrhage. Devitalization of deciduous and secondary teeth may occur.

FIGURE 90.9 Patient with electrical burns to the corner of the mouth after biting on an
electrical cord. (Courtesy of Evaline Alessandrini, MD.)

Inadequately debrided burned or gangrenous tissue provides a medium for
infection. Staphylococcal, pseudomonal, and clostridial species are common
pathogens in the extremities. Streptococci and oral anaerobic organisms may
infect mouth wounds.

Management and Diagnostic Studies
The first step in emergency management ( Table 90.9 ) is to separate the victim
from the current source. The rescuer must be well insulated to avoid becoming an
additional casualty. If the current cannot be shut off, wires can be cut with a
wood-handled ax or appropriately insulated wire cutters. In cases of lightning,
contact with the victim does not pose any threat to the rescuer, and treatment may
be started immediately.
Any victim in cardiopulmonary arrest should be resuscitated promptly
following the guidelines discussed in Chapters 7 A General Approach to the Ill or
Injured Child , 8 Airway , and 9 Cardiopulmonary Resuscitation . Prolonged

efforts to restore adequate cardiopulmonary and cerebral function, especially in
the lightning victim, may be appropriate in the context of bizarre neurologic
phenomena that inhibit ventilatory efforts, consciousness, or pupillary function.
The patient who fails to respond to resuscitative efforts over hours to days and
meets standard brain death criteria should be pronounced dead.
Any patient who sustains electrical injury needs a comprehensive physical
examination. Bleeding or edema from orofacial burns may compromise the upper
airway. The head, particularly eyes, and neck should be examined carefully for
evidence of trauma. The skin should be examined carefully for burns and bruises.
Limbs should be evaluated for pulses, perfusion, and motor and sensory function,
as well as for soft tissue swelling or evidence of fractures. Burns and deep tissue
injury may progress over hours to days, so repeated examination and monitoring
are important.
Neurologic evaluation is especially important in all but the most minor,
localized peripheral injuries. Level of consciousness and mental status should be
assessed and cranial nerve, cerebellar, motor, and sensory function should be
evaluated.
Children who have sustained minor household electrical injuries and are
asymptomatic usually do not require laboratory evaluation, cardiac evaluation, or
hospitalization. In cases of a high-tension injury or lightning strike, evaluation
should include ECG, CBC, CPK, troponin, BUN, creatinine, and urinalysis,
including urine myoglobin. Physical examination that reveals evidence of bruises,
bony tenderness, or distorted long bones should prompt appropriate radiographic
studies.
Most children who sustain burns of the oral commissure (usually after biting an
electrical cord) do not require extensive evaluation or admission. In cases of
severe orofacial burns, use of an artificial airway should be considered before
progressive edema leads to catastrophe. Mechanical ventilation may be necessary
to overcome CNS depression or primary lung involvement.
Patients with coma and loss of protective airway reflexes should be intubated

to avoid aspiration. Good oxygenation and ventilation adequate to maintain a
normal pH and PaCO 2 must be ensured. Seizure activity should be treated (see
Chapter 72 Seizures ).
The neck and back should be immobilized if the patient was thrown from the
site of injury. If the mechanism of injury was severe, a cervical collar should be
maintained in place despite normal cervical spine radiographs until more
definitive evaluation can be accomplished. If a child fails to regain consciousness


within a short time or shows signs of neurologic deterioration, a computed
tomography scan will help exclude intracranial hemorrhage.
Cardiopulmonary support is nonspecific. Most patients resume circulatory
stability unless severe hypoxia and ischemia have weakened the myocardium.
Arrhythmias should be treated along usual lines (see Chapter 86 Cardiac
Emergencies ).
Patients struck by lightning require only maintenance fluids. Patients with
ordinary thermal burns should be treated according to standard recommendations
(see Chapter 104 Burns ), although body surface area calculations may seriously
underestimate fluid requirements. It has been noted that burns caused by lightning
do not usually require special care. Extensive vascular and deep tissue destruction
may lead to extensive fluid sequestration. Isotonic fluid should be given in
amounts to maintain normal pulse and BP. In all cases, fluids should be given
with attention to possible CNS complications.


TABLE 90.9
MANAGEMENT OF ELECTRICAL INJURIES