Burns, Electrical Injury & Hanging

Recognize Injury Beyond the Visible Lesion

Burns, electrical injury, and hanging or strangulation are named in the NCC outline because their neurologic consequences often depend on systemic resuscitation. A skin lesion can underestimate deep tissue damage; an apparently normal head CT can coexist with hypoxic injury; a normal oxygen saturation can coexist with carbon monoxide poisoning. Begin with mechanism, airway, breathing, circulation, temperature, and a documented neurologic baseline. Consult trauma, burn, toxicology, and relevant surgical services early for major exposure.

In a sedated patient, absence of a pain complaint is not reassurance. Record the circumstances of injury, duration if known, associated fall or blast, enclosed-space exposure, loss of consciousness, and any resuscitation. These details help separate primary CNS injury from toxic exposure, hypoxemia, and post-arrest physiology.

Thermal Injury and Inhalation

Inhalation injury can involve upper-airway edema, lower-airway inflammation, and systemic toxic exposure. Facial burns, soot, hoarseness, stridor, progressive swelling, and an enclosed-space fire increase concern. Early controlled intubation may be necessary when the airway is threatened because edema can make delayed intubation difficult. Facial burns alone do not mandate intubation in every patient, and absence of visible oral burns does not exclude lower-airway injury.

Standard pulse oximetry cannot distinguish oxyhemoglobin from carboxyhemoglobin reliably. Give high-concentration oxygen when carbon monoxide exposure is suspected and obtain co-oximetry. Carboxyhemoglobin concentration depends on elapsed time and preceding oxygen therapy, so interpret it with symptoms and exposure history. Severe neurologic or cardiac manifestations warrant discussion of hyperbaric oxygen with the appropriate center; there is no single laboratory number that substitutes for the full assessment.

Cyanide exposure can accompany smoke inhalation, particularly with severe cardiovascular collapse or marked lactic acidosis. Consider the entire exposure and competing causes of lactate elevation. Emergency antidotal treatment is guided by toxicology and resuscitation protocols rather than delayed confirmatory testing when suspicion is high. Hydroxocobalamin can discolor body fluids and interfere with some laboratory and dialysis-device measurements, which matters during later ICU assessment.

Fluid, Temperature, and Limb Assessment

Extensive burns create capillary leak and substantial fluid needs. Burn formulas estimate an initial rate; they are not fixed prescriptions independent of urine output, perfusion, pulmonary status, and evolving examination. Under-resuscitation causes ischemia, while excessive fluid contributes to edema and compartment syndromes. In combined TBI and burns, preserve cerebral perfusion and select fluids with the treating teams rather than applying one service's routine protocol without modification.

Prevent hypothermia while exposing wounds. Reassess distal perfusion under circumferential burns; vascular compromise or ventilatory restriction can require urgent escharotomy by the burn team. Tetanus review, wound management, and appropriate nutrition are part of treatment. Routine systemic antibiotics solely to prevent infection in an uninfected burn are not equivalent to treating a documented invasive infection.

Electrical Injury

Electrical current can injure myocardium, peripheral nerves, spinal cord, and deep muscle. The visible entry or exit wound does not define total injury. Obtain an ECG and assess for loss of consciousness, arrhythmia, chest pain, significant voltage exposure, and associated trauma. Monitoring needs depend on these findings and the exposure; prolonged admission is not mandated for every minor low-voltage contact with a normal assessment.

Deep muscle necrosis can cause rhabdomyolysis, hyperkalemia, acute kidney injury, and compartment syndrome. Follow potassium, creatinine, creatine kinase trends, urine findings, limb swelling, and perfusion. Manage hyperkalemia immediately when indicated and titrate fluids to the total clinical situation. A weak or unresponsive patient may have central, peripheral nerve, or muscle injury; localization and serial examinations prevent attributing every deficit to the skin burn.

Hanging and Strangulation

Neurologic injury may arise from interrupted arterial inflow, venous obstruction, airway compromise, or cardiac arrest. Assess airway swelling and laryngeal injury, cervical spine trauma based on mechanism, and carotid or vertebral arterial injury when clinical or institutional screening criteria are met. CT angiography can be needed even when noncontrast head CT shows no hemorrhage. Persistent voice change, dysphagia, focal deficits, or evolving neck swelling deserve further evaluation.

Treat pulmonary edema, aspiration, and seizures when present. For post-arrest patients, use deliberate temperature control and appropriately delayed multimodal prognostication. An early poor motor response or initially normal CT cannot establish an irreversible outcome. After stabilization, address the circumstances of intentional injury through appropriate psychiatric and safeguarding care.

Sources checked October 17, 2026: American Burn Association referral guidance, CDC carbon monoxide clinical guidance, and ACS trauma guidance.