Hot lips

aka Trauma Tribulation 010

Your next patient is a 2 year-old girl who has sustained a burn. This is what the injury looks like:


Questions

Q1. What is shown and what is the likely mechanism?

Answer and interpretation

An oral commissure burn.

These injuries typically result from biting on an electrical cord (no, not from smoking a cigarette and letting it burn all the way down…). This is one of the most common mechanisms of electrical injury in toddlers, who tend to explore their environment by putting things in their mouths.


Q2. What key complication must be considered?

Answer and interpretation

Delayed lingual artery hemorrhage

These burns are often full thickness and are subject to the usual complications of burns. They may be disfiguring and result in microstomia. They are often underestimated. A particularly important complication is the potential for lingual artery hemorrhage. This occurs in about 10% of cases, typically about 5 to 21 days after the injury when separation of the maturing eschar occurs.


Q3. Why is a top-to-toe examination of this child important?

Answer and interpretation

Consider the possibility of systemic electrical injury.

  • look for an ‘exit’ wound. This may suggest the likely path of current through the body.
  • a baseline ECG and cardiac monitoring should be considered if current may have passed through the heart.
  • musculoskeletal injuries can result from tetanic contractions (e.g. rhabdomyolysis or fractures)
  • assess for neurological injury, deep tissues burns and other organ injuries.

Q4. What is the appropriate disposition of this patient?

Answer and interpretation

Referral to a plastics/ burns surgeon, patients are usually discharged with outpatient follow up.

In the past children were often admitted for observation to ensure that a delayed lingual artery bleed would be detected and treated. However, in modern times, the pressure on bed numbers is such that this is infeasible. Parents should be instructed on how to apply bidirectional direct pressure to the floor of the mouth in the event of lingual artery hemorrhage. If this occurs urgent plastics/ ENT/ maxillo-facial surgery assessment and management is essential.

Admission may be required for analgesia, nutrition (e.g. nasogastric feeding) or for assessment of possible non-accidental injury or neglect. Definitive treatment options include conservative management with an oral commissure split, early reconstruction or delayed excision of the burn site.


References

Trauma Tribulation back

CLINICAL CASES

Trauma Tribulation

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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