Grand Rounds Recap 1.11.23

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R1 Clinical diagnostics: caustic skin injuries WITH Dr. wolski

  • Severity of caustic skin injuries depends on physical state of substance, concentration, strength, amount, skin characteristics, time of exposure

  • Algorithm to manage most caustic skin injuries

    • Safety: scene safety, PPE

    • Strip: remove clothing

    • Shower: 45-60 minutes of irrigation time

    • Size: attempt to estimate the burn size and depth 

    • Sedate: adequate pain control 

    • Stabilize

      • Chemicals can be associated with systemic toxicity so monitor electrolytes and telemetry

      • Do not neutralize substances due to possible exothermic reaction

  • Cement

    • Typically delayed presentation. Several hours after exposure, patients will develop burning pain, erythema, and vesicles. 24-48 hours after exposure, wounds will ulcerate and develop black necrosis

    • Treatment: extensive irrigation, debridement, and hydrocolloid dressing

  • Hydrofluoric Acid

    • Glass etching/cleaning, ceramic manufacturing, rust removal, automobile wheel cleaners, air conditioner cleaners, germicides, insecticides, tile cleaning, laundry powders, semiconductor production, plastic production

    • Distinct characteristics

      • Pain out of proportion to burn appearance

      • Progressive tissue destruction, with maceration, erythema, edema, ulcers, necrosis, eventually whitish/silvery-gray discoloration 

      • Delay in presentation depending on HF concentration

    • Systemic effects

      • Acidemia, hypocalcemia, hypomagnesemia, hyponatremia, hyperkalemia, hyperphosphatemia → cardiac arrhythmias

      • Tenosynovitis and osteolysis can occur due to depth of HF penetration. Patients may also have nausea, abdominal pain, muscle fasciculations

      • Pulmonary edema, bronchopneumonia, and tracheobronchial hemorrhage also possible

    • Treatment

      • Copious irrigation followed by administration of calcium

        • All cases: topical calcium gluconate gel

        • Deep wounds: above plus subeschar calcium gluconate injection

        • Digital burns: topical treatment + arterial infusion after identifying arterial supply to injury

        • IV calcium for hypocalcemia

  • Phenol

    • Found in soaps, sprays, ointments, as well as industrial production of explosives, fertilizers, rubber

    • Distinct characteristics: sweet odor, numbness over burns due to anesthetic properties of phenol, dark-colored burns

    • Systemic effects

      • Direct damage to renal tubules and glomeruli leading to renal failure

      • CNS stimulation (hyperreflexia, convulsions) or CNS depression (lethargy, respiratory arrest)

      • PNS demyelination

      • Cardiovascular toxicity

      • Erythrocyte lysis

      • Central lobar hepatic necrosis

    • Treatment

      • DO NOT RINSE. Irrigation with inadequate amounts of water increases risk of absorption by exposing more body surface area to the phenol. Instead, you should wipe phenol off with polyethylene glycol. Alternative solvents include soap and vegetable oil

  • White Phosphorus

    • Most frequently used in military, fireworks, insecticides, fertilization as well as illicit methamphetamine production

    • Combined thermal and chemical burn

    • Distinct characteristics: yellow flame with white smoke, burn appears yellowish, waxy, and necrotic

    • Systemic effects

      • Hypocalcemia, hyperphosphatemia → bradycardia, QT prolongation, ST/T wave changes

      • Erythrocyte hemolysis

      • Renal damage

      • Hepatic necrosis

    • Treatment

      • Extensive irrigation, particle removal, and dressing with saline-soaked pads. 

      • Beware

        • Dry dressings can ignite

        • Removed particles should be placed in cold water to prevent combustion

        • Examine debrided wounds twice daily for smoking and missed particles

      • Of note, you can use a Wood’s lamp for particle visualization

R2 CPC WITH Dr. Shaw and Dr. Hughes

Case: Middle aged female with recent history of molar pregnancy with chief complaint of abdominal pain, vaginal bleeding. Found to have a temperature of 101.2 and tachycardia. 

Diagnosis: Gestational trophoblastic disease with secondary hyperthyroidism

Test of Choice: Thyroid Studies

  • Premalignant: hydatidiform mole (partial, complete)

  • Malignant: Gestational trophoblastic neoplasia

  • Gestational Trophoblastic disease: abnormal proliferation of trophoblastic cells

    • Trophoblasts provide nutrients to the embryo and develop into a large part of the placenta

    • Secrets hCG early in pregnancy

  • Clinical signs and symptoms

    • Hyperemesis

    • Elevated BP

    • Enlarged uterus

    • Vaginal bleeding

  • Diagnostics

    • Ultrasound

    • Laboratory testing

  • Thyrotoxicosis

    • Can be complication of GTD

    • Treatment

      • Beta-blockers

      • Glucocorticoids- prevent conversion of T4 to T3

      • Definitive management: Dilation and curettage

      • Post-operatively: methimazole, birth control

pediatric simulation

  • Consider congenital cardiac etiology in a newborn with poor feeding, vomiting, cyanosis, or mottling.

  • Coarctation typically presents with sudden symptoms of heart failure and shock due to closure of the PDA that has been bypassing the coarc for systemic circulation, so they are often pale, mottled, irritable with hepatomegaly and diminished or absent femoral pulses. Four extremity BPs demonstrate hypotension in bilateral LEs +/- LUE depending on the location of the coarc

  • In addition to other supportive measures, prostaglandins are administered to keep the PDA open to allow for systemic circulation. The starting dose is 0.05 mcg/kg/min but can be titrated up to 0.1 mcg/kg/min

  • Risks of prostaglandins include apnea and hypotension, which increase with increasing doses. Be prepared to secure the airway and provide resuscitation as needed. This is a patient you would want to talk to peds cardiac ICU very early in the process to coordinate transfer and care