Multisystem Trauma in Children, Part Two: Massive Transfusion, Trauma Imaging, and Resuscitative Pearls

A 5-year-old boy was playing with his older brother in front of their home when he was struck by a car. He sustained a femur fracture, splenic laceration, and blunt head trauma – the so-called Waddell’s triad.

On arrival, he was in compensated shock, with tachycardia.

He decompensates and needs blood.

How do we manage his hemodynamics and when do we perform massive transfusion?

Pediatric Massive Transfusion

40 mL/kg of blood products given at any time within the first 24 hours.

Adolescents and Adult Massive Transfusion

6-8 units of packed red blood cells (PRBCs)

• Adults have about 5 L of circulating blood.
• Not including plasma, one could replace all circulating erythrocytes with about 10 units of PRBCS
• The best ratio of PRBCs:Plasma:Platelets is unknown, but consensus is 1:1:1.
• 1 unit of PRBCS is typically 300 mL of volume.

The typical initial transfusion of PRBCs in children is 10 mL/kg.

Massive transfusion in children is defined as 40 mL/kg of any blood product.

Once you start to give a child with major trauma the second 10 mL/kg dose of PRBCs – start thinking about other blood components, and ask yourself whether you should initiate your massive transfusion protocol.

The goal is to have the products ready to use in the case of the dynamic trauma patient.

The Thromboelastogram (TEG)

Direct measures the four components of clot formation. When there is endolethial damage and bleeding, the sequence that your body takes to address it is as follows:

1.  Platelets migrate and form a plug
2. Clotting factors aggregate and reinforce the platelets
3. Fibrin arrives an acts like glue
4. Other cells migrate and support the clot.

R time – reaction time – the initial line in the tracing that shows time to beginning of clot formation.

• Treated with platelets

K factor – kinetics of the clot –how much the clot allows the pin to move, or the amplitude.

• Treated with cryoprecipitate

Alpha angle – the slope between the R and K measurements – reflects how quickly the fibrin glue is working.

• Treated with cryoprecipitate

Ma – maximum amplitude – reflects the overall strength of the clot.

• Treated with platelets

LY30 – the clot lysis at 30 min – is the decrease in strength of the clot’s amplitude at 30 min.

• Treated with an antifibrinolytics (tranexamic acid)

Shape Recognition

Red wine glass: a normal tracing with a normal reaction time and a normal amplitude. That patient just needs support and monitoring.

Champagne glass: a coagulopathic TEG tracing – thinned out, with less amplitude. This patient needs specific blood products.

Puffer fish or blob: a hyperfibrinolytic tracing. That patient will needs clot-stablizer.

TEG – like the FAST – can be repeated as the clinical picture changes.

The Trauma Death Spiral

Lethal triad of hypothermia, acidosis, and coagulopathy.

Keep the patient perfused and warm.

Each unit of PRBCs contains 3 g citrate, which binds ionized calcium, causing hypotension. In massive transfusion, give 20 mg/kg of calcium chloride, up to 2 g, over 15 minutes. Calcium chloride is preferred, as it is ionically readily available – just use a larger-bore IV and watch for infiltration. Calcium gluconate could be used, but it requires metabolism into a bioavailable source of calcium.

Prothrombin complex concentrate (PCC)

Prothrombin complex concentrate (PCC) is derived from pooled human plasma and contains 25-30 times the concentration of clotting factors as FFP. Four-factor PCCs contain factors II, VII, IX and X, while 3-factor PCCs contain little or no factor VII.

The typical dose of PCC is 20-50 units/kg

In the severely hemorrhaging patient – you don’t have time to wait for the other blood products to thaw – PCC is a powder that is reconstituted instantly at the bedside.

Tranexamic acid (TXA)

Tranexamic acid (TXA), is an anti-fibrinolytic agent that functions by stopping the activation of plasminogen to plasmin, and the degradation of fibrin. The Clinical Randomisation of an Antifibrinolytic in Significant Hemorrhage (CRASH-2) investigators revealed a significant decrease in death secondary to bleeding when TXA was administered early following trauma.

Based on the adult literature, one guideline is to give 15 mg/kg loading dose of TXA with a max 1 g over 10 minutes followed by 2 mg/kg/h for at least 8 h or until bleeding stops.

Resuscitative Pearls

Our goal here is damage control. Apply pressure whenever possible. Otherwise, resuscitate, identify the bleeding source, and slow or stop the bleeding with blood products or surgery.

How Children are Different in Trauma

In adults, we speak of “permissive hypotension” (also called “balanced resuscitation” or “damage control resuscitation”). The idea is that if we bring the adult patient’s blood pressure up to normal, we may be promoting clot rupture. To avoid this, we target a MAP of 65 and look for clinical signs of sufficient perfusion. Adults tolerate hypotension relatively well, and is sufficient until we send them to the OR or interventional radiology suite.

In children, this is simply not the case. Hypotension in children is a sign of pre-arrest. Remember, they compensate with an increased systemic vascular resistance and tachycardia to maintain blood pressure.

We should not allow children to become hypotensive – severe tachycardia alone should prompt us to resuscitate.

In other words, permissive hypotension is not permissible for children.

FAST is not sensitive enough to rule-out abdominal trauma.

Fox et al in Academic Emergency Medicine found a sensitivity of 52%; with a 95% confidence interval [CI] = 31% to 73%.

Often children even with high-grade splenic and liver lacerations can be managed non-operatively. If they are supported adequately, they are observed in the ICU and can avoid surgery in many cases. Unfortunately, a negative FAST cannot help with detecting or grading the laceration for non-operative management. In other words, feel free to use ultrasound – especially for things that we in the ED will react to and intervene on – but CT may help to manage the traumatized child non-operatively.

General Guideline for Imaging in Pediatric Trauma

CT Head and Neck, non-contrast: in concerning mechanisms of injury, patients that are difficult to assess (especially those under 3 months), those with a GCS of 13 or lower.

CT Chest, IV contrast: for suspicion of vascular injury that needs exploration, especially in penetrating trauma. Otherwise, chest xray will tell you everything you need to know in children – especially in blunt trauma. Hemo or pneumothoraces are readily picked up by US or CXR. Rib fractures on CXR predict pulmonary contusions. If you are concerned about great vessel injury, then CT Chest may be helpful; otherwise consider omitting it.

CT Abdomen and Pelvis, IV contrast: helpful in grading splenic and liver lacerations with goal to manage non-operatively. Abdominal tenderness to palpation, significant bruising, or a seat belt sign are concerning and would generally warrant a CT. Also, consider in liver function test abnormalities, or hematuria.

Extremity injuries: in general can be evaluated with physical exam and plain films. However, some injuries in high-risk anatomically complex areas such as the hand and wrist, tibial plateau, and midfoot may be missed by plain films, and CT may be helpful here.

Remember: you can help to mitigate post-traumatic stress and risk for adult healthcare aversion.

Summary

1. Massive transfusion in children is at 40 mL/kg of total blood products. Think about it if you are giving your second transfusion to the traumatized child.
2. Do everything you can to support perfusion and avoid the death spiral of hypothermia, coagulopathy, and acidosis. Keep the child perfused with blood as needed, correct coagulopathy, avoid too much crystalloid, and make sure to use the least high-tech of all of these interventions – keep him dry and covered with warm blankets.
3. Do a careful physical exam, and use CT selectively with an end-point in mind – the default is not the pan-scan – evaluate possible injuries depending on your suspicions from history, physical, and lab tests.
4. Become familiar with the relatively new modalities in trauma such as TXA, cryoprecipitate and the emerging technology of thromboelestogram – red wine is good for you, champagne is weak, and a puffer fish is trouble.

Selected References

Dehmer JJ, Adamson WT. Massive transfusion and blood product use in the pediatric trauma patient. Semin Pediatr Surg. 2010 Nov;19(4):286-91. doi: 10.1053/j.sempedsurg.2010.07.002.

Fox JC, Boysen M, Gharahbaghian L, Cusick S, Ahmed SS, Anderson CL, Lekawa M, Langdorf MI. Test characteristics of focused assessment of sonography for trauma for clinically significant abdominal free fluid in pediatric blunt abdominal trauma. Acad Emerg Med. 2011 May;18(5):477-82.

Harvey V, Perrone J, Kim P. Does the use of tranexamic acid improve trauma mortality? Ann Emerg Med. 2014 Apr;63(4):460-2.

Holscher CM, Faulk LW, Moore EE, Cothren Burlew C, Moore HB, Stewart CL, Pieracci FM, Barnett CC, Bensard DD. Chest computed tomography imaging for blunt pediatric trauma: not worth the radiation risk. J Surg Res. 2013 Sep;184(1):352-7.

Nosanov L, Inaba K, Okoye O, Resnick S, Upperman J, Shulman I, Rhee P, Demetriades D. The impact of blood product ratios in massively transfused pediatric trauma patients. Am J Surg. 2013 Nov;206(5):655-60.

Ryan ML, Van Haren RM, Thorson CM, Andrews DM, Perez EA, Neville HL, Sola JE, Proctor KG. Trauma induced hypercoagulablity in pediatric patients. J Pediatr Surg. 2014 Aug;49(8):1295-9.

Scaife ER, Rollins MD, Barnhart DC, Downey EC, Black RE, Meyers RL, Stevens MH, Gordon S, Prince JS, Battaglia D, Fenton SJ, Plumb J, Metzger RR. The role of focused abdominal sonography for trauma (FAST) in pediatric trauma evaluation. J Pediatr Surg. 2013 Jun;48(6):1377-83.

This post and podcast are dedicated to Larry Mellick, MS, MD, FAAP, FACEP. Thank you for your dedication to medical education, and sharing your warm bedside manner, extensive knowledge and talents, and your patient interactions with the world.

Powered by #FOAMed — Tim Horeczko, MD, MSCR, FACEP, FAAP

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Multisystem Trauma in Children, Part One: Airway, Chest Tubes, and Resuscitative Thoracotomy

Traumatized children need your full attention.

Protocols work well for adults, but trauma in children requires that we exercise our clinical muscles just a bit more.

 

Two main reasons:

1.  Children have specific injury patterns

2.  Their physiologic response to trauma is unique.

 

Crash course in pediatric anatomy and physiology in trauma

When you think of trauma in children, think of Charlie Brown. Large head, no neck, his chest and abdomen form an underdeveloped, amorphous shape.

Alternatively, think of children as apples – they are rounder than they are tall, with a large increased surface area. Apples don’t have a hard shell or thick rind to protect them. If you drop them, you may not see any evidence of damage to the outside, but there can be considerable bruising just under the surface.

• A child has thin skin, less subcutaneous deposits than an adult, and a non-calcified, pliable thorax that deforms more than it protects or shields.
• The child’s abdominal muscles are not yet developed. There is less peritoneal fat to cushion a blow, and so traumatic forces transmit readily into internal organs, often without external bruising.
• The child’s large surface area also causes him to dissipate heat more quickly. He may be wet from urine or blood, and in a major trauma, this faster cool-down predisposes him to coagulopathy.

Case

A 5-year-old boy who was playing with his older brother in front of their home when the ball rolled into the street. He ran after it, and was struck by a sedan going approximately 30 mph.

This is the so-called Wadell’s triad that occurs in a collision of auto versus pedestrian or auto versus bicycle. The initial impact is the greatest, and will vary depending on the child’s height and what part of his body reaches up to the bumper of the car. Depending on the height of the child and the height of the car, the initial impact will cause a femur fracture, a pelvic fracture, or direct abdominal trauma. The second impact happens as the child is flung onto the grill or the hood of the car, causing usually thoracic trauma. The third impact can be the coup de grace – to add insult to major injury, the child is then propelled forward, worsening the two previous impacts’ injuries and adding a third – severe blunt head trauma.

Intubation Pearl #1:

If your patient has any subtle change in mental status, intubate early. In pediatric trauma, we need to be proactive. Hypoxia is our enemy.

Intubation Pearl #2:

Thankfully cervical spine injuries in children are uncommon, and when they do occur, they typically occur at the child’s fulcrum, which is at C2. Compare this with an adult’s injury pattern with our fulcrum at C7. Be careful and minimize manipulation of the cervical spine, but do what you must to visualize the chords and place the tube. Keep the neck midline, and realize that the child’s usual decrease respiratory reserve is even more affected by trauma. Preoxygenate and pass that tube quickly.

Chest Tube Pearl #1:

Chest tube sizing in pediatrics is straightforward if we remember that the traditional chest tube size is 4 x the ETT size.

Chest Tube Pearl #2:

Try using a pigtail catheter.

Safety Triangle

• Lateral edge of the pectoral muscle
• Lateral edge of the latisimus dorsi
• Line along the fifth intercostal space at the level of the nipple.

It’s roughly where you would put on a generous dose of deodorant. Insertion here minimizes the risk of damage to nerves, vessels and organs.

Resuscitative Thoracotomy in Children

In a 40-year review of ED thoracotomy, Moore et al. analyzed 1,691 patients who received ED thoracotomy. Overall all-cause adult survival was 6.1%. In children ? 15 years of age, overall all-cause survival was considerably less, at 3.4%.

In a large case series and review of the literature for pediatric ED thoracotomy, Allen et al. found a survival rate in penetrating trauma of 10.2%, with a much lower survival rate in blunt pediatric arrest, at 1.6%. Adolescents had more penetrating injuries, and younger children had more blunt trauma.

To synthesize, the rarity of ED thoracotomy in children is due to the fact that:

1. Traumatic full arrest in children is uncommon.
2. It is most often blunt trauma.
3. Blunt traumatic arrest in children is mostly non-survivable.

REBOA

If you have access to resuscitative endovascular balloon occlusion of the aorta or REBOA, this may be an option to temporize the child to get him to the relative control of the operating room. REBOA involves accessing the common femoral artery, passing a vascular sheath, floating a balloon catheter to the appropriate section of the aorta, and inflating the balloon to occlude blood flow.

Brenner et al. described a case series of 6 patients from two Level I trauma centers. They used REBOA for refractory hemorrhagic shock due to either blunt or penetrating injury. After balloon occlusion, blood pressure improved sufficiently to take the patient either to interventional radiology or to the OR. Four patients lived, two died. The AORTA trial is underway to investigate its use in trauma.

Summary:

1. Children are like Charlie Brown – large head, no neck, amorphous, underdeveloped and unprotected thorax and abdomen. Or, if you like, they’re like, apples – they have a large surface area and are easily internally bruised, often without overt signs of external bruising.
2. Chest tubes for children are very similar to the adult procedure – the traditional chest tube size is 4 x the child’s ETT size. Try to use smaller pigtail catheters, available in commercial kits, whenever possible. They’re easy, safe, and effective.
3. Resuscitative thoracotomy is for penetrating trauma with signs of life wthin 10-15 minutes of arrival. Find the correctable surgical cause of the arrest. Resuscitative thoracotomy for blunt trauma has a dismal prognosis in children.

Selected References

Allen CJ, Valle EJ, Thorson CM, Hogan AR, Perez EA, Namias N, Zakrison TL, Neville HL, Sola JE. Pediatric emergency department thoracotomy: a large case series and systematic review. J Pediatr Surg. 2015 Jan;50(1):177-81.

American College of Surgeons Committee on Trauma; American College of Emergency Physicians Pediatric Emergency Medicine Committee; National Association of Ems Physicians; American Academy of Pediatrics Committee on Pediatric Emergency Medicine, Fallat ME. Withholding or termination of resuscitation in pediatric out-of-hospital traumatic cardiopulmonary arrest. Pediatrics. 2014 Apr;133(4):e1104-16.

Holscher CM, Faulk LW, Moore EE, Cothren Burlew C, Moore HB, Stewart CL, Pieracci FM, Barnett CC, Bensard DD. Chest computed tomography imaging for blunt pediatric trauma: not worth the radiation risk. J Surg Res. 2013 Sep;184(1):352-7.

Moore HB, Moore EE, Bensard DD. Pediatric emergency department thoracotomy: A 40-year review. J Pediatr Surg. 2015 Oct 19.

Scaife ER, Rollins MD, Barnhart DC, Downey EC, Black RE, Meyers RL, Stevens MH, Gordon S, Prince JS, Battaglia D, Fenton SJ, Plumb J, Metzger RR. The role of focused abdominal sonography for trauma (FAST) in pediatric trauma evaluation. J Pediatr Surg. 2013 Jun;48(6):1377-83.

Stannard A, Eliason JL, Rasmussen TE. Resuscitative endovascular balloon occlusion of the aorta (REBOA) as an adjunct for hemorrhagic shock. J Trauma. 2011 Dec;71(6):1869-72.

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Pediatric Trauma on WikEM

 

This post and podcast are dedicated to Dr Al Sacchetti, MD, FACEP. Thank you for promoting the emergency care of children and for spreading the message that you don’t need subspecialty training to take good care of acutely ill and injured children.

Powered by #FOAMed — Tim Horeczko, MD, MSCR, FACEP, FAAP

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Vomiting in the Young Child: Nothing or Nightmare

In the young child, vomiting is the great imitator:

Gastrointestinal, Neurologic, Metabolic, Respiratory, Renal, Infectious, Endocrine, Toxin-related, even Behavioral.

To help us organize, below is a review of can't-miss diagnoses by age.

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The Neonate: Malrotation with Volvulus

In children with malrotation, 50% present within the first month of life, with the majority occurring in the first week after birth. 90% of children with malrotation with volvulus will present by one year of age.   This is a pre-verbal child’s disease – which makes it even more of a challenge to recognize quickly.

The sequence of events usually is fussiness, irritability, and forceful vomiting.  The vomit quickly turns bilious.

Green vomit is a surgical emergency.

Babies may also present unwell, with bloating and abdominal tenderness to palpation.  Be aware that later stages of malrotation may present as shock – they present in hypovolemic shock due to third-spacing from necrotic bowel and/or septic shock from translocation or perforation.   In the undifferentiated sick neonate, always consider a surgical emergency such as malrotation with volvulus.

In the stable patient, get an upper GI contrast study.

Rapid-fire word association for other vomiting emergencies in a neonate:

• Fever, irritability and vomiting?  Think meningitis, UTI, or sepsis.
• Premature, unwell, and vomiting?  Think necrotizing enterocolitis.  Remember, 10% of cases of NEC can be full-term. Look for pneumatosis intestinalis.
• Systemically ill, afebrile, and vomiting for no other reason?  Think inborn error of metabolism.  Screen with a glucose, ammonia, lactate, and urine ketones.
• Others include congenital intestinal atresia or webs, meconium ileus, or severe GERD

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The Infant: Non-Accidental Trauma

All that vomits is not necessarily from the gut.

Abusive head injury is the most common cause of death from child abuse.   Infants especially present with non-specific complaints like fussiness or vomiting.   Up to 30% of infants with abusive head injury may be misdiagnosed on initial presentation.

Louwers et al. in Child Abuse and Neglect developed and validated a six-question screening tool for use the in ED.  The power of this tool was that it was validated for any chief complaint – it is not an injury evaluation checklist – it is a screen for potential abuse in the undifferentiated child:

1. Is the history consistent?
2. Was seeking medical help unnecessarily delayed?
3. Does the onset of injury fit with the developmental level of the child?
4. Is the behavior of the child and his interaction with his care-givers appropriate?
5. Do the findings of the head-to-toe examination match the history?
6. Are there any other red flags or signals that make you doubt the safety of the child or other family members?

On multivariable analysis, if at least one of the questions was positive, there was an OR of 189 for abuse (CI 97 – 300).  In other words, if any of those six questions are problematic, get your child protective team involved.

Other important diagnoses in the infant: intussusception and pyloric stenosis (rapid review in audio).

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The Toddler: Diabetic Ketoacidosis (DKA)

The important diagnosis not to miss in the vomiting toddler or early school age child is the initial presentation of diabetic ketoacidosis.  Children under 5 (especially those under 2) and those from lower socioeconomic groups have a higher risk of DKA as their initial presentation of diabetes.

This is true for any child that isn’t quite acting right – check a finger stick blood sugar as a screen.

The International Society for Pediatric and Adolescent Diabetes (ISPAD) criteria for DKA:

1. Hyperglycemia, with a blood glucose of >200 mg/dL (11 mmol/L)
   AND
2. Evidence of metabolic acidosis, with a venous pH of less than 7.3 or a bicarbonate level of < 15 mEq/L
   AND
3. Ketosis, found either in the urine or if directly checked in the blood.

If you have access to checking a serum beta-hydroxybutryrate – the unsung ketone – it can help in diagnosis in unclear cases.

Cerebral Edema Criteria:

• Minor criteria: headache, vomiting, irritability or lethargy; hypertension in the face of hypovolemia.
• Major criteria: change in mental status, including agitation or delirium; incontinence (especially if inappropriate for the child’s age); sluggish pupils and cranial nerve palsies; relative bradycardia (Cushing’s triad).

Cerebral Edema Action Items:

• Immediately give mannitol, 1 g/kg over 15-20 minutes.  May repeat it in 2 hours if needed.  Hypertonic saline (3% NaCl) is second-line therapy.
• Put the head of the bed up 30 degrees.
• Alert your colleagues and counsel your parents.  Make sure everyone knows what to watch out for.

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As you can see, vomiting in the young child can be really anything!  Keep your differential broad, and think by age and by system.

Differential Diagnosis of Vomiting in Children

The general approach to the child with chiefly vomiting starts with the decision: sick or not sick.  If ill appearing, establish rapid IV access, or if needed IO.  Rapid blood sugar and if available a point of care pH and electrolytes.  Be the detective in your history and doggedly go after any red flags as you go methodically by organ system.

• Do a careful physical exam. The general assessment is always helpful – is the child irritable, listless, agitated?
• What is his work of breathing?  Effortless tachypnea may be a sign of acidosis or sepsis.
• Is the abdomen soft or is it tender or distended.  Always look in the diaper area – is there a hernia, is there a high-riding, tender, discolored scrotum without cremasteric reflex?  Ovarian torsion has been reported in infants as young as 7 months.
• Any skin signs?  Look for petechiae, urticaria, purpura.

In other words, use your best judgement, have the dangerous differentials in the back of your mind, and pull the trigger when red flags mount up.  Otherwise, a good history and a good exam will get you where you need to be.

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Take home points for the young child with vomiting:

1. Neonates are allowed to regurgitate (effortless reflux of stomach contents -- the happy spitter-upper).  They are not allowed to vomit (forceful, unpleasant contraction of abdominal muscles).  Consider surgical causes of forceful vomiting, especially if the child does not look anything other than well.
2. Bilious is bad – green vomit is always a surgical emergency – do not pass go – get the surgeons involved early
3. Not all vomiting is GI related – if it is not obviously benign, think methodically by organ system and adjust your targeted history and physical to pick up any leads.
4. Match the tempo of your treatment to the tempo of the disease.

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References

Applegate KE, Anderson JM, Klatte EC. Intestinal malrotation in children: a problem-solving approach to the upper gastrointestinal series. Radiographics. 2006; 26(5):1485-500.

Glaser NS, Wootton-Gorges SL, Buonocore MH et al. Frequency of sub-clinical cerebral edema in children with diabetic ketoacidosis. Pediatr Diabetes. 2006 Apr;7(2):75-80.

Louwers ECFM, Korfage IJ, Affourtit MJ et al. Accuracy of a screening instrument to identify potential child abuse in emergency departments. Child Abuse & Neglect. 2014; (38): 1275–1281.

Lee HC, Pickard SS, Sridhar S et al. Intestinal Malrotation and Catastrophic Volvulus in Infancy. J Emerg Med. 2012; 43(1): e49–e51.

Marcin JP, Glaser N, Barnett P et al. Factors associated with adverse outcomes in children with diabetic ketoacidosis-related cerebral edema. J Pediatr. 2002; 141(6):793-7.

Parashette KR, Croffie J. Intestinal Malrotation in Children: A Problem-solving Approach to the Upper Gastrointestinal. Pediatrics in Review. 2013; (34)7: 307-321.

Wolfsdorf JI, Allgrove J, Craig ME et al. ISPAD Clinical Practice Consensus Guidelines 2014. Diabetic ketoacidosis and hyperglycemic hyperosmolar state. Pediatr Diabetes. 2014 Sep;15 Suppl 20:154-79.

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This post and podcast are dedicated to Damian Roland, BMedSci (Hons), MB BS, MRCPCH, for his fervor in the care of children and his dedication to quality medical education.

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Nausea and Vomiting | Non-Accidental Trauma | DKA

 

Powered by #FOAMed -- Tim Horeczko, MD, MSCR, FACEP, FAAP

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Electrical Injuries: Hertz So Bad

Victims of electrical injuries present either in extremis or as the seeming well patient with insidious, developing disease.

A targeted history usually gets you the information you need.

 

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Four main things to find out:

1. Household or Industrial electricity?

Household electricity uses alternating current, or AC.  Voltages across the world range anywhere from 100 to 240 V.  Here in North America, most outlets and appliances use 120 volts, which is the measure of electrical tension, or the potential difference in electrical charge.

Cut-off between low voltage and high voltage is 1000 V.

Industrial energy may be AC or direct current, DC.  DC current propels the victim -- think of this as a blast injury.  The same voltage in AC is three times as damaging as that voltage at DC, because AC causes muscle tetany, and prolonged contact time.

2. What was the likely pathway that current took?

Did the current pass through the thorax?  -- Think dysrhythmias.  Through the head or neck?  -- Think damage to the CNS and risk for later central respiratory arrest; acoustic nerve damage; cataract formation.  Did the current pass along an extremity? -- Think compartment syndrome and rhabdomyolysis.

3. What was the contact time?

The electrical charge meets resistance and converts to thermal energy, which causes tissue necrosis, increasing with the contact time.  Was your patient extricated?  Was there tetany?  Was he found in a pool of water or liquid?  Longer contact time correlates with extensive injuries that may only be apparent hours later.

4. Are there any associated injuries?

Think of electrical injury as a trauma – major trauma rarely occurs in isolation.   Was the patient flung after contact?  Did he have a syncopal episode? -- Think precipitated dysrhythmia and fall.   Was there any chest pain?   -- Consider stress-induced ischemia.

 

Pearl: Patients may be confused initially or unable to localize symptoms because of CNS disruption.  Get collateral information, re-interview, and re-examine as needed.

 

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 Case 1: Toddler with an oral commissure burn

An electrical burn to the angle of the mouth cauterizes superficial bleeding vessels, and hours later the wound becomes covered with a white layer of fibrin, surrounded by erythema.  Edema and thrombosis will continue, and at 24 hours there is typically a significant margin of tissue necrosis.  Most patients do well, and the burn heals by secondary intention.  The eschar will slough off in 1 to 2 weeks.  The labial artery is just deep to the burn, and as the eschar sloughs off, it can be exposed.  It’s a high-flow artery to the face, and if disrupted, the child may have significant bleeding and possibly hemorrhagic shock.

These children need close wound care follow-up, and potentially outpatient coordination with Head and Neck Surgery and/or Plastic Surgery consultants.

Precautionary advice:  take the moment to talk to parents about the risk, and show them how to apply pressure to the wound, pinching the inner and outer cheek together with the thumb and index finger until the child arrives to the hospital.

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Case 2: School-age child with knife versus electrical outlet

A a “kissing burn” occurs when the electrical charge creates an arc and jumps to a more proximal portion of the extremity.

The kissing burn typically occurs at flexor creases such as the wrist or the antecubital fossa.  There is often extensive underlying tissue damage even under the skin where it doesn’t appear to be involved.  Compartment syndrome and subsequent rhabdomyolysis and renal failure are the highest-risk complications.

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Case 3: Adolescent after a taser exposure

Nitrogen capsules propel two barbs into the dermis, which deliver short bursts of energy; most patients have no harm from the electricity delivered.

How to remove a dart:  The darts are typically 9 mm long, but the small barb is typically not buried very deep in the skin.  Hold the skin taught, use a hemostat to grasp the end as close to the skin as possible, align the dart perpendicularly to the skin, and pull quickly and firmly.

If the patient can’t tolerate this or the barb appears particularly embedded, inject with local lidocaine and make a small superficial incision with an 11-blade scalpel just large enough to allow passage.   Ultrasound can be used to troubleshoot when needed.

Taser dispo:  People who have been tased do remarkably well and complications are rare.   In a review of tasers used by law enforcement, Vilke et al. found that there was no need for routine laboratory testing or observation, as there was ‘no evidence of dangerous laboratory abnormalities, physiologic changes, or immediate or delayed cardiac ischemia or dysrhythmias after exposure to electrical discharges of up to 15 s.”  Subsequent studies with minors less than 16 years of age found similar results.

Special note on the patient with agitated delirium or stimulant intoxication: treat these patients carefully, as the organic problem that got them tased in the first place still needs to be addressed, and substances such as PCP, cocaine, and methamphetamines are all cardiac irritants and may predispose them to dysrythmias.

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Case 4: Adolescent in full arrest after lightening strike

Patients who are struck by direct current like lightening should be treated aggressively, because the reason for their cardiac arrest is often reversible if treated quickly.  Either the current sent the victim into a dysrhythmia, or it caused a temporary paralysis of the thoracic muscles, resulting in a primary respiratory arrest.

For victims of a lightning strike, classically we use reverse triage – normally, those in full arrest are triaged as black, deceases.  In high-voltage and lightening injuries, we tend to those in full arrest first, because you might quickly reverse them, and can move on to the next patient triaged red, or immediate.

High-voltage injuries are a multi-trauma – other sequelae include pulmonary edema, paralysis, ileus, and cataracts, in addition to the more immediate cardiac, musculoskeletal, neurologic, and renal considerations.

Regardless of the exposure, obtain an ECG and look for bundle branch block, heart block, and dysrhythmias, since those will change disposition.  In those who are injured, consider a basic metabolic panel, looking for potassium, calcium, and creatinine.  A creatine phosphokinase or total CK will screen for rhabdomyolysis.  Troponin is not predictive of the extent of direct myocardial damage, but get it if you think there might be a stress-induced, or type II MI.  Radiography as needed depending on the presenting associated trauma.

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Take Home Points

1. Injury from electrical burns can be subtle.   Think of patients as having occult multi-trauma.   Be thorough in history and examination.  Plan to re-examine either during observation in the ED, or in close outpatient follow-up.

2. Discharge patients with low-voltage injury, no symptoms, and a normal ECG.  Counsel outpatients and provide close follow-up as appropriate.

3. Admit patients with low-voltage injury with signs or symptoms such as loss of consciousness, ECG changes, or evidence of end-organ damage on laboratory screening.  Admit all patients with high-voltage injury, even if asymptomatic and a normal laboratory screen.

4. Transfer patients with high-voltage injury or significant burns to a regional burn center or trauma center.

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References

Celik A, Ergün O, Ozok G. Pediatric electrical injuries: a review of 38 consecutive patients. J Pediatr Surg. 2004;39(8):1233-1237.

Ericsson KA. Deliberate Practice and Acquisition of Expert Performance: A General Overview. Acad Emerg Med. 2008; 15:988-994.

Fish RM. Electric injury, part I: treatment priorities, subtle diagnostic factors, and burns. J Emerg Med. 1999;17(6):977-983. doi:10.1016/S0736-4679(99)00127-4.

Fish RM. Electric injury, part II: Specific injuries. J Emerg Med. 2000;18(1):27-34. doi:10.1016/S0736-4679(99)00158-4.

Fish RM. Electric injury, part III: cardiac monitoring indications, the pregnant patient, and lightning. J Emerg Med. 2000;18(2):181-187. doi:10.1016/S0736-4679(99)00190-0.

Horeczko T. “Electrical Injuries: Shocking or Subtle?” In Avoiding Common Errors in the Emergency Department, 2nd Edition. Mattu M, Swadron SP (eds). Lippincott, Williams & Wilkins. Phiadelphia. 2016. (In Press).

Rai J, Jeschke MG, Barrow RE, Herndon DN. Electrical Injuries: A 30-Year Review. J Trauma Acute Care Surg. 1999;46(5):933-936.

Vilke GM, Bozeman WP, Chan TC. Emergency department evaluation after conducted energy weapon use: review of the literature for the clinician. J Emerg Med. 2011; 40(5):598-604.

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This post and podcast are dedicated to Joelle Donofrio, MD, FAAP for her tireless care of children, in the ED and in the field.  A special thank you and dedication to Cliff Reid, BM, FRCP(Glasg), FRCSEd(A&E), FRCEM, FACEM, FFICM, FCCP, EDIC, DCH, DipIMC, RCSEd, DipRTM, RCSEd, CCPU, CFEU for his transformative intelligence and educational verve.

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