Roberts, James R. MD
Learning Objectives: After reading this article, the physician should be able to:
1. Discuss the etiology and treatment of burns from car radiators.
2. Describe flash burns from flame injuries.
3. Recall the clinical issues surrounding eye burns.
The majority of minor burns do quite well with a modicum of common-sense therapy that includes appropriate debridement, a proper burn dressing, and good follow-up in a compliant patient. Although no self-respecting emergency physician would ever think of discharging a burn patient from the ED without the ritual smearing of silvadene or other topical concoction, this intervention is likely more placebo than true therapy. Fancy topicals do, however, get the patient to look at his burn, and daily dressing changes promote debridement.
The clinical approach to burns has not changed significantly in the past 20 years. But old-time burn therapy still goes a long way in promoting an overall good feeling about the ED visit, even though there's not much science involved. Protecting the burn with a simple non-adherent dry dressing is very acceptable therapy, albeit less fancy. Bacitracin ointment without a covering is the best way to treat a face burn.
In prior columns, I highlighted the potential for seemingly minor burns of the feet to take a turn for the worse very quickly, and even motivated patients have trouble following the regimen needed to ensure a good result with all but the most minor foot burns. A liberal admission policy for foot burns is advocated. Tar burns are another special situation that deserves mention. I noted that many tar burns are easily handled as an outpatient, and there is no need to remove all the tar completely on the first visit. Finally, I gave a no-nonsense approach to burn debridement, noting that it's difficult to do anything wrong when it comes to blisters: Almost any blister philosophy gives a good ultimate result.
Most physicians are familiar with the treatment of minor outpatient thermal burns, but unusual burns may be encountered occasionally. This discussion addresses issues involved with car radiator burns and flash thermal burns to the face. Although these are somewhat unusual injuries, they are seen in every ED, and there are a number of important issues involved in the emergency department approach to diagnosis and treatment of these entities.
Car Radiator Burns: A Report of 72 Cases Al-Baker A, et al Burns 1989;15(4):265
This is one of the few articles in the literature that specifically discusses burns from the hot fluid expelled from car radiators. Although this report came from the Middle East (Qatar), it contains information applicable to patients in the United States. The authors note that many new cars have sealed radiators with an overflow tank that allows one to fill a radiator without opening the actual radiator cap. This innovation still has not kept some inquisitive motorists from opening the cap of their hot car radiator to check the antifreeze level or to investigate an episode of overheating. The authors present a retrospective examination of 72 such patients admitted to their burn unit. They state that this was the first study ever conducted on this type of burn injury, and judging from the literature I was able to find on Medline, it's probably true.
Over a six-year period, 72 patients with scald burns from to car radiator fluid were treated. Minor injuries treated in the emergency department were not included, and all patients were admitted to the burn unit for the investigators' version of a significant (hospital worthy) thermal injury. The main reasons for admission were extensive involvement of the face, the extent of the surface area involved, or the depth of the burn. It's not stated how these parameters actually influenced the admission decision.
Interestingly, all patients were men, ranging from age 11 to 58. The majority of the patients (95%) had body surface area burns of less than 10 percent. Car drivers, passengers, and bystanders were included as victims. As one would suspect, most of the injuries were in the summer, when overheating of a car radiator was more common. Lighter clothing is also worn in summer, lessening the protective factor of clothes. Interestingly, there were no injuries between November and January.
Most burns included the upper body, arms, and face. Twelve patients had ear burns, and three had ophthalmologic injuries in the form of conjunctival burns. The hands and legs were generally spared. Only five of the 72 patients required skin grafting, and the majority of burns were superficial or secondary dermal burns.
Immediate cooling with cold water can limit the damage of a facial scald burn and relieve pain
These scald injuries comprised about eight percent of total admissions to the burn unit. The most common mechanism of injury was an overheated car coupled with an unthinking victim, trying to investigate a problem or cool the car engine by opening the radiator cap while the engine was still hot. The steam trapped in the radiator is under great pressure, pushing steam and hot water and antifreeze onto the victim when the radiator cap is removed.
In this Qatar series, no women suffered radiator burns. The authors note that few women drive in their country, and women tend to ask for assistance rather than try to fix the problem themselves, an interesting comment on the habits and common sense of men vs. women.
The authors believe that car radiator burns are preventable, mainly by relying on education and common sense. The incidence reflects the lack of basic knowledge about safety and the less than ideal common sense of the drivers. Fortunately, most radiator fluid burns healed without skin grafting, although the potential for injury to the eyes and the need for skin grafting were emphasized.
There are no similar studies I could find in the American literature, but all emergency physicians have seen patients who have tried to cool their cars by taking off the radiator cap. One would think that the steam and fluid bubbling from the sides of the radiator cap would be a warning sign. I could never understand the concept of removing the top from a boiling container, and there are usually written warning signs on the radiators, but this still happens.
Some of the newer cars have radiator caps that cannot be easily removed, saving drivers from their own stupidity. Most radiator fluid injuries are comprised of steam and hot radiator fluid, usually year-round antifreeze. Antifreeze is most often ethylene glycol or one of the newer variants. Although ethylene glycol antifreeze can be lethal if swallowed, there appears to be no systemic absorption of ethylene glycol from car radiator burns. Antifreeze does not make the liquid-induced injury more severe and the products are not caustic. Hot steam, of course, need be the only culprit if the fluid has already boiled away.
The initial treatment of facial scald burns would be similar to any other thermal injury. If available, immediate cooling with cold water would be advised to limit the extent of the damage and to relieve pain. Under most circumstances, however, this likely would not be available. Facial burns tend to blister and swell, so a liberal admission policy is suggested for pain control and wound care. Most cases, however, can probably be handled as outpatients. The patient should be warned that blisters may develop and that swelling is to be expected. A 24-hour recheck would be prudent.
Eye injuries in patients with facial burns are extremely rare, but always check these patients with a flourescein eye exam
A facial burn is one area of the body where an occlusive dressing is generally not used. The head and neck tend to become macerated when occlusive dressings are applied so gauze dressings are usually eschewed for burns of these areas. Most patients also do not appreciate looking like a mummy. The topical concoction of choice for facial burns seems to be plain bacitracin ointment.
Silvadene is generally not used on the face, and the neomycin component of the triple antibiotic ointment may cause contact dermatitis. I commented on the use of silvadene cream previously. Upon reading the current PDR, I noted that silvadene is indicated as an adjunct for the “prevention and treatment of wound sepsis in patients with second- and third-degree burns.” It says nothing about minor or superficial outpatient burns.
Most patients with wounds that would never have a chance of becoming infected are treated with silvadene in the ED, and this has evolved as standard practice without any evidence. Because it is a sulfa derivative, silvadene has a theoretical potential to cause a reaction in patients allergic to sulfa preparations, but I could not find any reference to this in the literature.
I also could not document the common contention that silvadene on the face is contraindicated. It does not irritate the eyes, and it does not cause depigmentation, according to the manufacturer. Despite the lack of evidence, I often see this caution in review articles. Maybe it's seeing the white cream on the face that annoys the burn specialists. It would certainly be difficult to separate any temporary or permanent skin changes from the burn vs. the cream. Nonetheless, it seems reasonable to use plain bacitracin ointment without an occlusive dressing on thermal burns of the face and neck.
Figure. Patients wit...Image Tools
There is nothing fancy about the bacitracin ointment regimen. It is merely applied once or twice a day after the prior layer is gently washed away with soap and water. The washing technique tends to help debride dead skin. If the patient has blisters indicating a deeper burn, it's probably more reasonable to admit him to the hospital for the first few days. It's also a good bet that pain control would be problematic with these blistered patients if they were discharged from the ED.
Table. Characteristi...Image Tools
A related type of burn occurs when individuals attempt to light charcoal grills, gas stoves, or campfires, often with the help of gasoline or lighter fluid. The result is a flash flame burn to the face. This usually results in a superficial or partial second-degree burn that singes the eyebrows and facial hair. If a scalding liquid is included in the explosion, deeper burns will result. As with car radiator burns, minor flash thermal burns are usually treated on an outpatient basis unless there is significant blistering or soft tissue swelling, or pain control becomes an issue.
These burns also probably would be best treated with bacitracin ointment, eschewing an occlusive dressing. For some odd reason, I find many house staff sending blood for ABG and carboxyhemoglobin levels following momentary flash facial burns. Injuries to the respiratory track would be almost impossible, and it makes no sense that carboxyhemoglobin would be an issue.
Ophthalmic Thermal Injuries Lipshy K, et al Amer Surg 1996;62(6):481
The authors note that reflex lid closure usually protects the eye in a situation causing a thermal facial burn, and corneal injuries in facial burns are not common. Ocular injury usually occurs with chemical burns, contact with metal or ashes, or electrical burns. As with burns from car radiator mishaps, burn injuries to the eye are poorly addressed in the medical literature. Although the eye itself may be spared, injuries to the eyelids can be particularly problematic and disfiguring.
The authors performed a two-year retrospective study of thermal injuries with associated ocular involvement. Of the 44 patients with facial burns, 16 (36%) had ophthalmic injuries. These were significantly traumatized burn victims, and all had significant thermal exposure and inhalation injury. All of the ophthalmic injuries in patients who survived burns from other body areas had resolution of their ophthalmic injuries without surgical treatment. In general, facial burns severe enough to cause eye injury were associated with very severe or lethal injuries. The specific eye injuries that were identified included corneal burns, conjunctival burns, and corneal abrasions.
The authors make an interesting observation that reflex closure of the lid is so fast that it is almost impossible for the globe to be burned. Essentially, the light from the burn reaches the retina before the heat, and the reflex immediately triggers lid closure. It is suggested that flourescein examination with a slit lamp is mandatory in facial burns. Tonometry also may be helpful in severe burns. A variety of plastic surgery techniques can be performed if there is severe scarring or burning around the eyes and eyelids.
This article concludes that ophthalmic injuries generally occur only in critically burned patients who require intensive resuscitation measures and sophisticated burn care. I have seen many patients with facial burns, but I have never seen an eye injury in patients exposed to flash thermal burns or car radiator fluid. I would agree, however, that it's a good idea always to check such patients with a flourescein eye exam. If an injury to the cornea is identified, referral to an ophthalmologist is mandatory. Also, if the eyelids are significantly involved, the patient will likely be admitted, and a plastic surgeon or ophthalmologist should be involved early on.
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