Good morning. First, I want to thank the Trauma Center Association of America for allowing me to be part of such an esteemed group to talk about burn patients. And this is a title slide, I guess, and let me just tell you my assignment actually was really to talk about less common burns, so not thermal and not pediatrics and those kinds of things. And so I'm going to talk about the less common types of burn injuries as well as burn injuries that might damage things other than just the skin. I do have two disclosures. I speak for Medline, which makes some dressings for burns, and Xerco that makes equipment for burn operations, but none of those products will be discussed in this talk this morning. Just to tell you a little bit about our burn center, the star is Lubbock, Texas. Our catchment area is 220,000 square miles. Unfortunately, New Mexico does not have a burn center, and we also get patients from southeastern Colorado and about a western third of Oklahoma besides 40% of Texas, so a fairly large surface or geographic area. And just a little bit about our burn center, it's called the TJH Regional Burn Center for Timothy J. Harner, the first medical director. Dr. Harner was actually the first official burn fellow at the University of Washington under David Heimbach and then was recruited down to Tech. And he had Wilson's disease and passed away early in his career, and then I was recruited back in 1992. Dr. Fagin is right, the American Burn Association started verifying burn centers in 1995. Prior to that, interestingly, the Verification Committee of the COT verified both trauma centers and burn centers, and so we were in that early group that was verified by the COT. I promise you that number for 2022 is not made up. We really did admit 1,111 burn patients last year. 40% of them are children because we're approved for both adults and children, and so about 430 of those patients were children. We also admit a lot of other non-burn type wounds, it's like necrotizing soft tissue infections, avulsion wounds, diabetic wounds with sepsis, and those kinds of things. And then we have a very active surgical and laser recon program, just like Dr. Fagin mentioned. Okay, so as I mentioned, we're going to talk about some of the less common burns. So I'll present a couple of patients with electrical injuries, and then a couple patients with chemical injuries, and then towards the end, just a patient or two that had combined burn and trauma, just to make some comments about those trauma patients who might need operations through burned tissue. Okay, so the first patient is this patient, a 13-year-old male. He was riding his bike near some cotton irrigation fields near his house, and he came across a downed line, electrical line. He didn't at the time know that it had power or how strong the power was. It was 7,000 volts, and so he attempted to lift the line up to get it out of his path so he could continue bike riding, grabbed it with his right hand, and he's right hand dominant. No other past medical history. There was positive loss of consciousness at the scene. He arrived to our burn center about four hours after the injury, and his right hand was titanically contracted. There were no pulses at the wrist and cyanotic from mid-forearm down to the fingertips. He also had contact points on his medial thigh and medial right calf. He was taken to the OR immediately for fasciotomy and muscle compartment evaluation, and I've got some pictures here. I hope I'm a better surgeon than I'm a photographer, but anyway, you can see this right hand, how titanically contracted. So when these patients come in, if they have significant muscle damage where those compartments are destroyed, you cannot open that hand. It's just like cemented in a fist shape, and so that's, and then you can see the cyanosis there in that picture, and here's a dorsum picture here. These are after he was taken to the operating room for the fasciotomies. And then pictures of his calf and thigh burns. These are very deep, full thickness, leathery burns that are typical for these high-voltage electrical patients. His troponins were negative on arrival, and there was no conduction abnormality on the monitor during transport. His CKA was 37,000, and his myoglobin was 6,800. His estimated fluid needs, based on the fluid resuscitation categories that you've already seen this morning, for electrical burns it's 4 cc, so the kind of the old-fashioned Parkland formula, and he had 10% body surface area, so 4 times his weight in kilograms, which is 72, times 10, and that gave him a total resuscitation estimation of 2,800 cc's. He actually received 4,500 cc's in addition some albumin, and that was to maintain his urine output to 2 cc's per kilo per hour. And I'll talk a little bit about the algorithm for resuscitating electrical burn patients with these kind of deep tissues in a sec. The right forearm had to have a guillotine amputation on post-injury day 3. The arm was revised and closed on post-injury day 11. The electrical burns to his legs were excised and grafted on post-injury day 12, and fortunately he was able to be discharged to inpatient rehab on post-injury day 22. Then I have some follow-up photos. We actually have a very extensive recon program, and this this is when he was coming back to the burn center for one of his laser treatments, but you can see the forearm amputation and the fasciotomy incisions there. Fortunately he has great range of motion of the remaining part of his limb, and the next picture is of him for one of the burns on his legs, grafted also back at this time for another CO2 laser ablation therapy. The second patient I want to show, and then we'll get into the particulars about electrical injury. This is a 46-year-old power company employee, and he was working on a high-voltage power line. He thought the power was off, but obviously it was not, and he grabbed the line with his right hand, again right hand dominant. He took two hours to get to us from the scene, and on arrival he had stable vital signs, but again a titanically contracted fist with cyanotic right upper extremity, no pulses at the wrist, and then he other had other contact electrical contact areas on his left lower extremity. The estimated TBSA was 15.5 percent, and he was again taken immediately to the operating room for right upper extremity fasciotomy and muscle compartment exploration, and here you can see the example of the injury. This is of his arm, and you can see how deep the burn looks, and actually those compartments, muscle compartments are destroyed all the way up into the proximal biceps, so unfortunately his injury was deep tissue involving nerves all the way up to the shoulder joint. The leg injury up there on the thigh is the contact injury, so electrical injuries when they first meet the body, and I'm going to talk about this in a sec, meet resistance and turn into heat and injury. That heat injury is very high, and it'll actually catch clothing on fire, so actually the thigh is more of an electrical component, but the burn that you can see farther down on the leg that goes below the knee is a flash burn or a heat or typical thermal burn from his clothing catching on fire from the electrical current that turned into high temperature. He had elevated troponins, 159, but they trended down over the next 48 hours. His CK was 6,800, but his myoglobin was 27,000, so you can see that there's a dichotomy between these two patients, between CK and myoglobin, and we'll talk about that in a bit. His estimated calculation, again, is 4 cc's times his weight, which was 90 kilograms, and his TBSA 15.5, so his estimated resuscitation needs were 5,500, but he actually took 7,000 cc's with an additional albumin and FFP to keep his urine output 2 cc's per kilogram per hour, and we'll talk about that and why that's so important. We also used CRRT, so continuous renal replacement therapy, to help for just hemofiltration to help remove the myoglobin, and myoglobin can be filtered out with CRRT to speed up its disappearance from the circulation. He underwent, unfortunately, had to undergo a right shoulder disarticulation on post-injury day 4. The amputation site was revised on post-injury day 12, and then excision and split thickness skin grafting to the left lower extremity on post-injury day 14, and he was discharged to inpatient rehab on post-injury day 19, and here you can just see a couple of areas, the split thickness skin graft on the right and the closure of the shoulder disarticulation there, or on the left and the shoulder disarticulation on the right of the slide. Okay, so let's talk a little bit about electrical burns. First of all, we divide them into high and low voltage, and that cutoff is a thousand volts, so anything that's less than a thousand volts, we consider low voltage. Everything above a thousand volts, we consider high voltage. So these two patients both had high voltage electrical injuries, so as you can tell, very devastating tissue injury, and the tissue, the tissue damage begins because the electricity, as it contacts our body and as the current begins to move through the body, meets resistance, and so when it meets resistance, it is converted from electrical energy to thermal energy. Now, our skin has the most resistance of all the tissues in our body, but usually we have moisture, perspiration, oils on our skin, and so that lowers the resistance some. So the second most resistant tissue in our body is bone, and that's why these muscle damage areas were so severe, because as the electricity passes through the extremity, if that's the contact point at the bone, the temperature can be very high, and the muscle can be damaged when the skin doesn't look injured at all. So we call these kind of the tip of the iceberg injury, and you have to be very concerned and suspicious that in these high voltage injury patients, they have dead muscle, even though the skin on the surface doesn't look damaged, and that's definitely true in these two patients, and you can see there that the, in cadaver studies, at the temperature at the bone level is well over 500 degrees as it converts from electrical energy to thermal energy. So the heat that those muscle compartments are being exposed to is really quite high and very difficult for any of the muscle to survive at that kind of temperature. So the initial injury from electrical contact is a thermal, is a heat injury. However, it's also complicated by a second problem that the electricity itself causes, and we call that electroporation or electroporosity. So if you can envision the electricity moving through the tissue, and if it, some of the electrical energy stays as electricity, as it passes through the tissues, what it does is actually drills holes in the cell wall of the cells of the tissue that it's passing through. Now for the sake of discussion, you might say that, well, a hole with four holes might be able to seal itself, but a cell with 20 holes is going to slowly die as its cytoplasm leaks out, and that's exactly what happens in electrical injury. And so the reason this is so important to realize is that it was kind of a no-brainer that those, where the skin was damaged, those are deep burns that are going to need some kind of surgical debridement and some kind of skin closure. But the electroporosity or electroporation can take several weeks to sometimes several months to define itself, and so these are very difficult burn injuries, and we tend to be a little less aggressive with getting them closed than our straightforward thermal injury patients because we're still waiting for the tissue to declare itself and tell us if it's alive or dead. And I actually have one patient who had a deep electrical injury to the foot, grafted them at about three weeks, thing looked great at two months, and three months later it was dead because the base of the tissue that we thought looked healthy went on to die. So that's pretty much of an outlier. Usually it's in a couple of weeks that we can tell what these, what the tissue health or not so and get these covered. So electroporosity or electroporation is another unique part of the electrical injury for these patients. Okay, so if the skin contact involves muscle compartments, the thing is mostly being concerned about those those muscle compartments specifically. So we talked about the rigid joint contraction and the hands that we couldn't open up, tense compartments, so when you feel their compartments you don't have to measure compartment pressures. I mean these are tense, there's no ability to indentate, they're not supple, evidence of reduced blood flow which these patients showed, and then they need emergent operation one to release the compartments to hopefully save some of the muscle that isn't totally destroyed and to examine how much muscle has actually been destroyed so that you know the extent of the injury. And we keep those fasciotomies open so that we can see them daily because the muscle is going to change, unfortunately oftentimes for the worse, and so we need to keep monitoring that muscle so we know at what level the damage will stop. Okay, in our first audience participation slide, the best test to assess potential risk of pigment release and possible acute kidney injury is So it's actually serum myoglobin level. CK is a good sensitive marker to decide if there's been some muscle damage, but it doesn't really tell you the degree of muscle damage and how at risk the kidneys are. So serum myoglobin is really the critical component in these types of injuries. I will also tell you that actually big burns with no muscle damage will have elevated CK levels. So it really is not as sensitive as we need it to be in the burn environment as it is for the trauma patient. So serum myoglobin has to be measured in these patients, and we'll talk a little bit about that. The myoglobin release is what is the problem for nephrotoxicity. As the myoglobin passes through the glomerulocyte, it actually is turned into ferric hematin or hematin and then precipitates into the cytoplasm. And it's that hematin that is actually cytotoxic, and that's where the acute kidney injury evolves or resolves or begins, is by the myoglobin changing its steric form and destroying the cells. And ferric hematin is a positively charged chemical, and this is where some people talk about alkalinizing the urine. Because if you can change the cell membrane to a negatively charged environment, it may stabilize the myoglobin. But really, the most important thing when you have tons of myoglobin in the circulation is to flush it through the kidneys. If you get it through before it can precipitate and start damaging the cells, that's your best chance. And so we really aggressively resuscitate these patients. And I've got some numbers here. If you have a myoglobin of less than 1,000 and it doesn't rise above 1,000, most of those patients will not develop acute kidney injury. The patient's kidneys can tolerate that. But if it gets up to 1,500 without any kind of renal protective strategy, about 80% of those patients will develop an AKI that may go on to end stage renal disease and needing dialysis. So what do we do at our place? For every patient that has a myoglobin of 1,000 or greater, we start renal protective therapy. And that really is just two main categories. You've got to get their urine output up very high, and it's very important to avoid any kind of metabolic acidosis. So if you can keep their pH normal and flush the myoglobin through the kidneys, you are usually successful. Now, in my training, when I first started, I was trained that, well, we want 0.5 cc's per kilo per hour for the adults with thermal burns, but we want it to be 1 cc double for the patients with electrical burn. Well, we now know that it needs to be more. And you saw on Dr. Fagan's slide, the 2 cc per kilo per hour. So we're really pushing these patients up. And you can see that we use a lot of colloid with our crystalloid to get there, so we don't have to just drown these patients in the lactated ringers. And for us, if we can get a 2 cc per kilo per hour filtration of kidney output or urine output, then we completely avoid any acute kidney injury. And also CRRT. We use CRRT when the myoglobin gets above 7,000 because we worry that we're not going to be able to filter quick enough to protect the kidneys. And CRRT, as a hemofiltration technique, works great to help precipitously drop that myoglobin and create a safe environment for the patients. So I mentioned that we have two types of electric injury. High voltage, the pictures I showed, and then low voltage. Low voltage injuries, these are usually far less complicated than the patients I showed you. And they really are oftentimes just skin injuries. And so when somebody gets a low voltage injury, they'll have some charring or some punctate little black injuries where they came in contact with the injury. And so most of the time, they will have no cardiac abnormality. And the cardiac abnormalities, if they haven't had any problems with telemetry during transport or any monitoring abnormalities, when you're assessing them in your emergency center, actually, many of those patients can go home the same day and just be followed in the clinic. So the low voltage injuries are a lot less intense than the high voltage injuries. So just remember the 1,000 volt cutoff. Oh, one other question. OK. What city in the US has the highest concentration of lightning strikes that put you at risk for being struck by lightning? Well, it's actually Four Corners, Florida, and they, look at that, 474 lightning strikes per square kilometer per year. So don't go to Four Corners, Florida, at least don't go out and play golf there, which probably it's near Orlando, so, you know, but, so it could be pretty risky from as far as lightning strikes. But, I mean, that beat everything else by 20, 30-fold, so they get a lot of lightning strikes. Okay. Now let me move on to chemical burns. So we've talked about the devastation of electricity, I think a lot of people have a lot of fear about chemical burns as well, and I'm going to talk about two patients. One is an 18-month-old female, and she and her three-year-old brother were in the bathroom with the door closed, and mom found them in there when the 18-month-old started screaming. And what had happened is they got into some very highly concentrated hydrochloric acid, and it got spilled or splashed onto the 18-month-old. And the injuries are from the right face, bilateral upper extremities, lower extremities in the back. I'll show you some photos in a sec. And they were taken immediately to their local hospital where they got very appropriate decon or dilution or irrigation. So the solution to a chemical burn is dilution, irrigate and irrigate, and then more irrigation, tap water, saline, LR, whatever you want to use. But the more you can dilute that chemical quickly, the better off the patient's going to do. And they were very concerned about the right eye, so they were actually flushing that right eye as well. Transport time to us was 45 minutes. The total body surface area was 10%, and there was actually, on arrival, fortunately, no internal injuries. It didn't look like the child ingested any, and the eye was safe. It was not damaged, so that was really good news. Remembering kids, the modified formula now is 3 cc times the weight in kilograms times their body surface area. And so for this child, that turned out to be 300 cc for 24 hours. Just like Dr. Fagan said, we actually, it's less than 20%. Oftentimes in kids, we'll be aggressive on the front end, but within 12 hours, the baby was taking plenty of PO, fluid intake, and had great urine output. So we were able to stop the resuscitation early at 12 hours. And here you can see the damage, the injury. This is in our EC. So just right when the baby came in, you can see, and you can see why the hospital, referring hospital was worried about that eye, because that upper lid was involved. And here's just some other close-ups once we got him over to the burn center. Okay. So the child was placed in topical ointments, dressed daily at the burn center, and fortunately, 50% of the wound was closed in four days, and the baby was able to go home with just a few minimally involved dressings on post-injury day five, and then we followed them in the outpatient clinic. And this is the child, actually before she goes home, you can see that there's two little patches on her back, but really, the burn responded very nicely just to topical therapy, and we were able to get the patient healed, the baby healed, without any surgery. Here she is back for laser recon for the face. Okay. Another chemical burn. It's a 33-year-old gentleman who was involved in an altercation, and he had concentrated sodium hydroxide poured on him. So the first one is an acid, this is a base, or an alkali, and he immediately jumped in the shower and began washing off the burn, and then he was relatively local, so we came by private vehicle to our burn center, took about 20 minutes, and he had about 8% TBSA burn involved, and he was able to be resuscitated just by oral intake, and had adequate urine output so we didn't have to do any involved IV or parenteral resuscitation. And these pictures, doesn't look too innocuous there, this is on the front, and then you can see there on the inside, or the medial side of the upper right arm, and then here's some on his back, had some tattoos that we covered up with patches, so you can see that it doesn't look too bad, but unfortunately by hospital day 3, a number of those areas converted to deep second to third degree burns, and he actually needed to be operated on, so he underwent excision and grafting, and then was discharged on post-injury day 6, and you can see some of the grafts there on his back, and there on his arm, this was before he was discharged. Okay, so let's talk a little bit about chemical burns. So the obvious two categories are acid and alkali. The severity of chemical burns are related to a couple things. The concentration of the chemical, is it a very concentrated or a dilute acid or base? The other thing is how long it's in contact with the skin, so the quicker you can get it off, dilute it, and remove the chemical or dilute the chemical, the better off for the patient, and then it also depends on skin thickness. So we don't actually gain our adult skin thickness until we're about 10 years of age, and then unfortunately at the age of about 42 to 45, we begin to lose our skin thickness, so that by the time you're 60 to 65, your skin thickness is the same as a toddler. So those of us, unfortunately, in that age group, the older age group or the young children, they're going to have a deeper injury or a worse injury just because they have thinner skin and less skin to protect them. Now it also depends on whether you have an acid or a base, and that's why I showed these two patients, because the acid burn patient did not need grafting, yet the alkali, but it looked pretty bad on the surface, but the alkali or the base, the sodium hydroxide patient didn't look too bad, but ended up needing grafting, and it's because acid burns cause a caseation necrosis, and that caseation necrosis thickens the tissue and almost makes a barrier to the chemical burning deeper, and so it actually creates an environment where it can't necessarily destroy all the skin, and so it's somewhat protective in that aspect, where an alkali burn causes a liquefaction necrosis. It just continues to dissolve the tissue, and if you don't get that diluted or the patient out away from the chemical, that chemical will cause a deep burn that oftentimes needs excision and grafting, as you can see in that second example. So copious irrigation is the treatment. If you have powdered chemicals, please brush the powder away or pull the patient away from the powdered chemical, because sometimes the chemical in powdered form mixed with water will have a heat reaction, and that heat reaction can actually burn the patients as well. Ingested chemicals, and so one of my assignments was to talk about injury inside the body, I guess, or deeper, or in addition to the skin, and I think we all are worried that especially in these kids that get into chemical burns or chemicals that they may swallow the chemical and cause damage to the upper aerodigestive part of their airway or into the esophagus, stomach, et cetera, and so any burn, any child or any burn, any patient with a burn that looks like it goes past the lips really should be considered for upper endoscopy to assess what their back of the throat looks like and their esophagus and stomach to make sure that they're, whether there's injury or not. Now I will tell you that we looked back at, we had 42 patients over the last seven years, children, who had head and neck chemical burns, and only two of those had burns that went past the lips. One had no injury other than inside a little bit on the oral mucosa, and the other one had very mild redness of the esophagus and just had to be monitored, didn't need any kind of excessive surgery or procedures to protect that esophagus. And so my takeaway from that is that I think in these kids it burns so badly when it comes to the lips that they fortunately don't swallow it, they usually spit it out, and so that becomes fairly protective. Still, if the lips are burned or certainly any oral mucosa, you've got to consider esophagogastro-duodenoscopy, EGD, to assess their upper digestive tract to see if there are any deeper injuries. So let me just finish up, hopefully I'm going to be okay on time. The next, I wanted to say a couple of things about the burns plus internal injuries, and so I've got a patient just to show you. This is a 44-year-old male with significant psychiatric history, and he decides to shoot at one of the local police stations, not a good idea, and then flees in an automobile and the police run out and start chasing him. He's driving about 100 miles an hour and then he runs into a cement pylon. So it was a several minute extrication. He was conscious at the scene but had a lot of soot in his mouth and they were concerned about smoke inhalation, so they intubated the patient. And then he was brought to the emergency room and it took about 40 minutes to get to us. He was hypotensive, had a very distended abdomen, and a 27% burn. Just as Dr. Fagan and Dr. Christmas mentioned so far, remember the burn skin injury is not immediately life-threatening. So this patient obviously has something going on in his belly, it's not the burned skin on his belly that's causing him to be distended and be hypotensive. So don't let the burn skin take your focus. You really should look past the burn skin and focus on does the patient have other injuries for all burn patients because they're a trauma patient too. And he actually had a grade 5 splenic laceration and ended up having to have a splenectomy. The reason I bring this up is that here you can see the burn, so pretty bad burn there on his left arm, flank and chest, and you can see he's got burns on his belly and then some on his back. In my experience, every single patient that gets an incision on their abdomen that goes through a burn, no matter what it's for, that skin and soft tissue does not heal, does not close normally, when they're primarily closed in the operating room. So we recommend leaving those wounds open, certainly close the fascia, but leaving the skin and subcutaneous tissue open because they're just either going to not heal when you take the staples or sutures out, they just pop open anyway, or they're going to get a secondary infection depending upon how bad the burn is. So we recommend leaving those open. I think I've got just a little bit more about that here. Now, we can let them heal secondarily. Sometimes we can delay primary closure with steri-strips if they'll stick, but usually the burns are weepy and it doesn't stick. If you can get negative pressure wound therapy, vacuum dressing on it, that works great too, but you obviously got to get a seal. So some of these patients we just have to let them heal secondarily. Other patients, some patients will need ostomies for GI tract injuries. If you can put the ostomy through unburned skin, so think about that, that is very beneficial because it's just an absolute mess trying to deal with an ostomy where the ostomy bag won't stick to the skin because it's so goopy and soupy. Or at least try to get it far away from the incision because since we're going to have a trouble getting the ostomy appliance to work, keep it from dripping into the incision, wherever their incision was used. And then finally I'm going to just finish up with one other comment. I mentioned Tim Harner. Dr. Harner was a phenomenal surgeon, but he actually is famous for something, and this is going back to the electrical burns. He wrote an article in 1985 called The Killer Rabbits of West Texas, and it got a lot of attention not just in the medical environment, but also in the lay communities, and this is what was happening. So we got a lot of cotton in West Texas and in New Mexico in that time, 1985-ish. Most of the irrigation pipes were aluminum. They're now I think mostly PVC. But what would happen is when the kids that lived on these cotton farms weren't busy helping parents and going to school, they would chase rabbits with their .22s or BB guns. And what would happen is as they're chasing them through the field, the rabbits would go hide in the pipes. Well, in order to have those irrigation motors work, they have to be tied into an electrical line, and oftentimes what will happen is there will be a high-voltage electrical line nearby that's actually very low so that they can plug in and get power to their irrigation motors. So what will happen is two kids are chasing these rabbits. One of them gets the pipe and lifts it up to shake the rabbit out, while his buddy is at the other end to get the rabbit. Unfortunately, they would come in contact with the high-voltage electrical lines and have devastating injuries. Many of these kids had horrible anoxic injury because of cardiac arrest and no oxygen and blood flow to their brain, and had devastating neurologic injuries as well as the soft tissue injuries. Well, that actually went, well, I'm not sure viral was a thing then, but it went viral, and it was picked up by Saturday Evening Post, New York Times, and there's now a federal law that says that power companies in the spring need to do some type of prevention education by advertisement to prevent or try to keep people from getting injured with high-voltage electrical injuries, and the signs or the billboards or whatever that you might see, Look Up and Live, that's where it came from, was that killer rabbits of West Texas. Well, thank you very much. It's been an honor to visit with you, and I appreciate your attention.

burn injuries

electrical burns

chemical burns

prompt treatment

adequate treatment

acid burns

alkali burns