7.3 Burns, Electrical Injury, and Hanging/Strangulation
Key Takeaways
- For adults with burns ≥20% TBSA, ABA 2024 recommends starting about 2 mL/kg/%TBSA of balanced crystalloid and titrating to urine output near 0.5 mL/kg/hour; blind Parkland 4 mL dosing drives fluid creep.
- Intubate early for soot, facial burns, hoarseness, or stridor. Closed-space fires need 100% oxygen for carbon monoxide and hydroxocobalamin when cyanide is suspected.
- High-voltage electrical injury is a deep muscle disease: rhabdomyolysis, compartment syndrome, and arrhythmia matter more than the small entry and exit wounds.
- Hanging and strangulation combine hypoxic-ischemic brain injury, blunt cerebrovascular dissection or thrombosis, and possible cervical or laryngeal injury; CTA of the neck is the practical vascular screen.
- Delayed cerebral edema after hanging often peaks over 24–72 hours; do not declare brain death on the first early CT, and after cardiac arrest use AHA 2023 temperature control of 32–37.5 °C for at least 24 hours with fever prevention.
Burns, high-voltage electricity, and hanging look like surgical or psychiatric problems until the airway closes, the compartments die, or delayed cerebral edema declares itself. The neuro ICU inherits the airway, the toxin, the rhabdomyolysis, and the anoxic brain. Treat the immediately lethal problems first, then plan for the delayed wave that this exam loves to write into a day-2 vignette.
Burn Resuscitation Without Over-Resuscitation
Adults with burns of 20% total body surface area (TBSA) or more need formal intravenous resuscitation. Historical Parkland dosing is 4 mL/kg/%TBSA of lactated Ringer’s over 24 hours, with half in the first 8 hours counted from the time of injury—not from the time of arrival. That starting number is too wet for many modern burn units. The American Burn Association (ABA) 2024 burn-shock guideline recommends initiating at 2 mL/kg/%TBSA over 24 hours and titrating to urine output of about 0.5 mL/kg/hour (roughly 30–50 mL/hour in adults), using lactated Ringer’s or an equivalent balanced crystalloid. Consider albumin, especially in larger burns, to lower total volume. Formulas estimate; urine output and the bedside decide.
Worked example: an 80 kg adult with 40% partial- and full-thickness burn. Parkland 4 mL/kg/%TBSA is 12,800 mL in 24 hours (6,400 mL in the first 8 hours). An ABA-style 2 mL start is 6,400 mL in 24 hours, then up or down so urine stays near 40 mL/hour. If urine is 90 mL/hour for two hours, decrease the rate; if it is 10 mL/hour, increase it. Do not bolus huge crystalloid loads that recreate shock-lung and abdominal hypertension.
Over-resuscitation (“fluid creep”) causes pulmonary edema, extremity and abdominal compartment syndromes, and orbital hypertension. Measure bladder pressure in large burns. Circumferential torso eschar that blocks ventilation needs escharotomy, not more fluid. Use the rule of nines or a Lund-Browder chart; do not count simple first-degree erythema in the formula. Children and high-voltage electrical injuries are not “just a Parkland percentage of visible skin.”
| Starting formula | 24-hour estimate | How to use it |
|---|---|---|
| Parkland 4 mL/kg/%TBSA | Historical; half in first 8 hours from injury | Know it, do not infuse it blindly |
| ABA 2024 / modified Brooke-type 2 mL/kg/%TBSA | Lower starting volume | Preferred adult start for ≥20% TBSA |
| Titration target | Urine ~0.5 mL/kg/h (about 30–50 mL/h) | The actual prescription |
| Adjunct | Albumin in larger burns | Lower total volume |
| Danger sign | IAP >20 mm Hg, tense abdomen, rising airway pressures | Stop the fluid creep; consider decompression |
Airway Edema
Soot in the airway, facial burns, singed nasal hair, hoarseness, stridor, or a closed-space fire are warnings that edema will progress over hours. Intubate early, before the anatomy disappears. A delayed “wait and see” on a hoarse patient is a classic failed airway. After intubation, expect a difficult tube change; do not be casual about cuff leaks. Circumferential neck eschar can also obstruct venous drainage and raise ICP—escharotomy is a neck as well as a chest procedure when indicated.
Carbon Monoxide and Cyanide
Closed-space fires deliver carbon monoxide (CO) and often cyanide. Measure CO-oximetry; ordinary pulse oximetry is falsely reassuring. Treat CO with 100% oxygen. Consider hyperbaric oxygen for significant neurologic injury, very high CO-hemoglobin, or pregnancy according to local capability. Cyanide presents as unexplained lactic acidosis, cardiovascular instability, soot, and coma. Treat empirically with hydroxocobalamin, which turns secretions red and interferes with some laboratory assays. Do not delay toxin treatment for a perfect confirmatory test. If both CO and cyanide are plausible, hydroxocobalamin is preferred over nitrite-based kits that further impair oxygen carrying.
Electrical Injury
High-voltage injury is often defined as greater than 1,000 volts. It is a deep thermal and electroporation injury that skin wounds underestimate. Current follows vessels and muscle. Priorities:
- Rhabdomyolysis: dark urine, rising creatine kinase, myoglobinuric acute kidney injury. Give generous isotonic fluids titrated to urine output—this is not a Parkland burn of the visible TBSA. Avoid potassium-containing fluids if the patient is already hyperkalemic. Watch potassium, phosphate, and calcium as muscle dies.
- Compartment syndrome: tense compartments, pain out of proportion, rising creatine kinase, neurologic deficit in a nerve’s territory. The threshold for fasciotomy is low. Escharotomy releases burned skin; fasciotomy releases muscle compartments—know which operation you are asking for.
- Cardiac arrhythmia: ventricular fibrillation or asystole at the scene; obtain an electrocardiogram and telemetry after high-voltage exposure or any loss of consciousness. Delayed unstable rhythms are less common than immediate arrest but still justify monitoring.
- Hidden visceral, spinal, and traumatic injury if the patient was thrown. Treat as blunt trauma with C-spine protection until imaged.
Lightning can cause keraunoparalysis (transient limb paralysis) and cardiac arrest. Resuscitate the arrest first; the neurologic deficit may recover. Small entry and exit burns never “clear” the patient for discharge when the creatine kinase is climbing or a forearm is tense.
Hanging and Strangulation
Survivors of hanging or ligature strangulation carry a triad this exam returns to: hypoxic-ischemic brain injury, blunt cerebrovascular injury (dissection or thrombosis), and cervical spine or airway injury. Judicial drop hangings fracture the spine. Typical suicidal hangings more often spare bony injury but still warrant immobilization until imaged. Ligature marks do not grade the vascular injury. Incomplete hanging with feet on the ground can still be lethal through venous obstruction and hypoxia.
Imaging: noncontrast CT head, CT of the cervical spine, and CT angiography of the neck from the aortic arch through the intracranial vessels. Expanded Denver-type screens include near-hanging with anoxic brain injury as an indication to look for blunt cerebrovascular injury (BCVI). Clinical examination cannot exclude dissection. Stroke may appear after a lucid interval as a carotid or vertebral artery thromboses—often within the first 72 hours.
Pulmonary complications include negative-pressure pulmonary edema and aspiration. Airway complications include hyoid and laryngeal fractures and delayed edema; observe or intubate based on voice, swelling, and trajectory rather than on a single reassuring early look.
Neurologic course: the initial CT may be unimpressive. Delayed cerebral edema often peaks over 24–72 hours as cytotoxic injury matures—exactly the window when families ask for a brain-death examination too early. If hanging caused cardiac arrest, temperature control after return of spontaneous circulation follows the American Heart Association 2023 focused update: select and maintain a constant temperature of 32–37.5 °C for at least 24 hours and prevent fever. Do not teach that every patient must be cooled to 33 °C. Seizures and myoclonus need electroencephalography. Antithrombotic therapy for proven BCVI is a hemorrhage-risk decision (coexisting TBI, solid-organ injury) made with neurosurgery and trauma—not a heparin drip before images exist. Prognosticate late, after the delayed edema wave, confounders, and the temperature protocol.
An 80 kg adult has a 40% TBSA partial- and full-thickness burn. Which initial 24-hour fluid plan best matches current adult burn-shock teaching?
A patient from a house fire has facial soot and a hoarse voice but no stridor. What is the most appropriate airway plan?
After high-voltage contact, a patient has small entry and exit burns, a tense forearm, dark urine, and creatine kinase 45,000 U/L. What is the priority?
A near-hanging survivor has GCS 6 after return of spontaneous circulation. Noncontrast head CT at 2 hours shows no herniation. Which statement is most accurate?