World Health Organization Issues Guidelines on Hand Hygiene in Healthcare

May 6, 2009 — The World Health Organization (WHO) has issued Guidelines on Hand Hygiene in Health Care, offering a thorough review of evidence on hand hygiene in healthcare and specific recommendations to improve hygiene practices and reduce transmission of pathogenic microorganisms to patients and healthcare workers (HCWs).

The guidelines target hospital administrators and public health officials as well as HCWs, and they are designed to be used in any setting in which healthcare is delivered either to a patient or to a specific group, including all settings where healthcare is permanently or occasionally performed, such as home care by birth attendants. Individual adaptation of the recommendations is encouraged, based on local regulations, settings, needs, and resources.

Hand Hygiene Indications

Indications for hand hygiene are as follows:

• Wash hands with soap and water when visibly dirty, when soiled with blood or other body fluids, or after using the toilet.

• Handwashing with soap and water is preferred when exposure to potential spore-forming pathogens, such as Clostridium difficile, is strongly suspected or proven.

• In all other clinical situations, use an alcohol-based handrub as the preferred means for routine hand antisepsis, if hands are not visibly soiled. Wash hands with soap and water if alcohol-based handrub is not available.

• Hand hygiene is needed before and after touching the patient; before touching an invasive device used for patient care, whether gloves are used; after contact with body fluids or excretions, mucous membranes, nonintact skin, or wound dressings; if moving from a contaminated body site to another body site on the same patient; after touching inanimate surfaces and objects in the immediate vicinity; and after removing gloves.

• Hand hygiene is needed before handling medication or preparing food using an alcohol-based handrub or handwashing with water and either plain or antimicrobial soap.

• Soap and alcohol-based handrub should not be used together.

Hand Hygiene Techniques

Specific recommendations for hand hygiene technique are as follows:

• Rub a palmful of alcohol-based handrub over all hand surfaces until dry.

• When washing hands, wet hands with water and apply enough soap to cover all surfaces; rinse hands with water and dry thoroughly with a single-use towel. Whenever possible, use clean, running water. Avoid hot water, which may increase the risk for dermatitis.

• Use the towel to turn off the tap or faucet, and do not reuse the towel.

• Liquid, bar, leaf, or powdered soap is acceptable; bars should be small and placed in racks that allow drainage.

Surgical Hand Preparation

Specific recommendations for surgical hand preparation are as follows:

• Before beginning surgical hand preparation, remove jewelry. Artificial nails are prohibited.

• Sinks should be designed to reduce the risk for splashes.

• Visibly soiled hands should be washed with plain soap before surgical hand preparation, and a nail cleaner should be used to remove debris from underneath the fingernails, preferably under running water.

• Brushes are not recommended.

• Before donning sterile gloves, surgical hand antisepsis should be performed with a suitable antimicrobial soap or alcohol-based handrub, preferably one that ensures sustained activity. Alcohol-based handrub should be used when quality of water is not assured.

• When using an antimicrobial soap, scrub hands and forearms for the length of time recommended by the maker, usually 2 to 5 minutes.

• When using an alcohol-based surgical handrub, follow the maker's instructions; apply to dry hands only; do not combine with alcohol-based products sequentially; use enough product to keep hands and forearms wet throughout surgical hand preparation; and allow hands and forearms to dry thoroughly before donning sterile gloves.

Selecting Hand Hygiene Agents

Some specific recommendations for selection and handling of hand hygiene agents are as follows:

• Provide effective hand hygiene products with low potential to cause irritation.

• Ask for HCW input regarding skin tolerance, feel, and fragrance of any products being considered.

• Determine any known interaction between products used for cleaning hands, skin care products, and gloves used in the institution.

• Provide appropriate, accessible, well-functioning, clean dispensers at the point of care, and do not add soap or alcohol-based formulations to a partially empty dispenser.

Skin Care Recommendations

Some specific recommendations for skin care are as follows:

• Educate HCWs about hand-care practices designed to reduce the risk for irritant contact dermatitis and other skin damage.

• Provide alternative hand hygiene products for HCWs with confirmed allergies to standard products.

• Provide HCWs with hand lotions or creams to reduce the risk for irritant contact dermatitis.

• Use of antimicrobial soap is not recommended when alcohol-based handrub is available. Soap and alcohol-based handrub should not be used together.

Recommendations for Glove Use

Some specific recommendations for use of gloves are as follows:

• Glove use does not replace the need for hand hygiene.

• Gloves are recommended in situations in which contact with blood or other potentially infectious materials is likely.

• Remove gloves after caring for a patient, and do not reuse.

• Change or remove gloves if moving from a contaminated body site to either another body site within the same patient or the environment.

"In hand hygiene promotion programmes for HCWs, focus specifically on factors currently found to have a significant influence on behaviour, and not solely on the type of hand hygiene products," the guidelines authors write. "The strategy should be multifaceted and multimodal and include education and senior executive support for implementation. Educate HCWs about the type of patient-care activities that can result in hand contamination and about the advantages and disadvantages of various methods used to clean their hands."

Four of the guidelines authors have disclosed various financial relationships with GOJO, Clorox, and GlaxoSmithKline, and other companies and institutions. A complete description of their disclosures is available in the original article. The other guidelines authors have disclosed no relevant financial relationships.

WHO Guidelines on Hand Hygiene in Health Care. May 2009.

Clinical Context

In 2004, WHO convened a group of international experts in infection control to prepare guidelines for hand hygiene in healthcare. In 2002, the Centers for Disease Control and Prevention Guideline for Hand Hygiene in Health-Care Settings was adopted. Following a systematic review of the literature and task force meetings, the Advanced Draft of the WHO Guidelines on Hand Hygiene in Health Care was published in 2006. An Executive Summary of the Advanced Draft of the Guidelines is available separately (http://www.who.int/gpsc/tools/en/). Pilot testing of the advanced draft occurred, with subsequent updating and finalization of the guidelines.

The WHO Guidelines on Hand Hygiene in Health Care includes a review of scientific data, consensus recommendations, process and outcome measurements, proposals for large scale promotion of hand hygiene, patient participation in promotion of hand hygiene, and a review of national and subnational guidelines. The recommendations are expected to be valid until 2011 and will be updated every 2 to 3 years.

Study Highlights

• Indications for washing hands with soap and water include visibly dirty hands, hands visibly soiled with body fluids, or after using the toilet.
• Handwashing with soap and water is preferred after exposure to potential spore-forming pathogens, including Clostridium difficile outbreaks.
• Alcohol-based handrub is preferred in the following situations if hands are not visibly soiled: before and after touching a patient; before handling an invasive device for patient care; after contact with body fluids or excretions, mucous membranes, nonintact skin, or wound dressings; between contact with a contaminated body site to another site on the same patient; after contact with inanimate surfaces and objects; and after removing sterile or nonsterile gloves.
• Handwashing with soap and water is recommended when alcohol-based handrub is unavailable.
• Alcohol-based handrub or soap and water can be used before handling medication or preparing food.
• Concomitant alcohol-based handrub and soap use is not recommended.
• Soap and water hand-washing technique includes using a towel to turn off the faucet, thorough drying of hands, and single towel use.
• Acceptable forms of soap are liquid, bar, leaf, or powdered.
• Bar soap racks should allow drainage to ensure that the soap dries.
• Alcohol-based handrub technique includes applying palmful amount of handrub, covering all surfaces, and rubbing hands until dry.
• Surgical hand hygiene recommendations include removal of jewelry, no brushes, and use of either antimicrobial soap or alcohol-based handrub according to the maker's recommendations.
• Selection of hand hygiene agents should consider input from HCWs, interaction with other products or gloves, risk for contamination, accessibility and proper functioning of dispensers, approval of dispensers for flammable materials, and cost comparisons.
• Soap or alcohol-based handrub should not be added to partially empty soap dispensers.
• Skin care irritation in HCWs can be avoided by providing educational programs, alternative hand hygiene products for those with allergies or adverse reactions to standard products, and hand moisturizers to reduce irritant contact dermatitis.
• Glove use does not replace the need for handrub or handwashing.
• Gloves should be used if contact with potentially infectious body fluids, mucous membranes, or nonintact skin is anticipated.
• Gloves should be removed or changed after each patient or after contact with a contaminated body site.
• Artificial nails or extenders should not be used, and the length of natural nail tips should be less than 0.5 cm.
• Educational and motivational programs for HCWs should focus on behavior; be multimodal; include senior executive support; educate about the advantages and disadvantages of various hand hygiene methods; monitor adherence and provide performance feedback; and encourage partnership between patients, families, and HCWs.
• Healthcare administrators should provide and monitor safe, continuous water supply; provide alcohol-based handrub at the point of patient care; prioritize compliance; provide leadership, administrative support, and financial resources; ensure training; implement a multidisciplinary, multifaceted, and multimodal program to improve adherence; and adhere to national safety guidelines and local legal requirements.
• National governments should prioritize adherence; consider funded, coordinated implementation and monitoring; support strengthening of infection control in healthcare settings; promote community hand hygiene; and encourage use of hand hygiene as a quality indicator in healthcare settings.

Clinical Implications

• The WHO guidelines recommend handwashing with soap and water for visibly dirty hands, hands visibly soiled with body fluids, after toilet use, exposure to potential spore-forming pathogens, and if alcohol-based handrub is not available in other situations.
• The WHO guidelines recommend alcohol-based handrub before and after touching patients; before handling invasive devices; after contact with body fluids or excretions, mucous membranes, nonintact skin, or wound dressings; between touching contaminated body site and another body site; after contact with inanimate surfaces and objects; and after removing gloves.

Source : http://cme.medscape.com/viewarticle/702403?src=cmenews

Call for Routine Cardiac Screening in Emergency-Department Patients with Cocaine Intoxication, Addiction

May 21, 2009 (San Francisco, California) — Despite the fact that cocaine abuse accounts for approximately 25% of nonfatal myocardial infarctions (MIs) in young people, most addicted individuals presenting to the psychiatric emergency department are not routinely screened for this potentially lethal complication, new research suggests.

A retrospective study presented here at the American Psychiatric Association 162nd Annual Meeting showed that, of 122 cocaine-addicted patients, only 42% received an electrocardiogram (ECG) upon presentation to the emergency department. However, of these individuals, more than 90% had abnormal ECG results — including significant patterns of peak T waves. Further, 4 patients (8.2%) had ST elevations indicative of significant cardiac ischemia.

Valerie D'Aurora and John Charooonbara

"Many cocaine-addicted patients present to the psychiatric emergency department vs a medical emergency department. So this is potentially the only opportunity to screen for cardiac complications. Yet our research suggests psychiatrists are not being vigilant enough with respect to this," Valerie D'Aurora, from St. George's University School of Medicine, in Grenada, the West Indies, told Medscape Psychiatry.

Baseline ECG Should Be Standard Practice

To determine current management of cocaine-addicted patients presenting to the psychiatric emergency department and examine cardiac risk factors in this patient population, the researchers conducted a chart review of 122 patients with a diagnosis of cocaine dependence.

Of these individuals, 52 (42.6%) received an ECG and 4 (3.3%) had measurement of cardiac bioenzymes, including troponin and creatine kinase (CK)-MB. Among subjects who did receive an ECG, the most common findings were:

• Nonspecific ST-T wave changes in 15 (31.2%) patients.
• Peaked T waves in 23 (47.9%) patients.
• Early afterdepolarizations in 19 (39.6%) patients.
• ST elevations in 2 or more contiguous leads in 4 (8.3%) patients. However, the investigators note there were no baseline ECGs available for comparison to determine the acuity of changes.

The researchers also note ECGs were conducted, on average, 2 days after patients presented to the emergency department, with follow-up in only 2 (1.6%) patients. This, in spite of the fact that research shows the greatest risk for MI is 1 hour after cocaine use and is independent of dose, frequency, or routine. They also note that even trace amounts of cocaine in urine indicate the need to implement acute coronary syndrome (ACS) protocol.

"We're lucky if these patients get to the emergency department an hour after use, so they need to get an ECG immediately upon presentation," said Ms. D'Aurora.

Few Patients Assessed for Cardiac Risk Factors

Concomitant alcohol dependence was identified in 40 (32.8%) patients, and 81 (66.4%) individuals were nicotine dependent. In addition, 63 (51.6%) were also dependent on opioids and 26 (21%) on benzodiazepines.

When researchers analyzed data on additional cardiac risk factors, they found that this information, including family history of heart disease, hypertension, obesity, diabetes, and abdominal aortic aneurysm, were documented in only 21.3% of study subjects.

In light of these findings, Ms. D'Aurora and colleagues have developed an algorithm for individuals presenting to the psychiatric emergency department with a high suspicion of cocaine abuse to optimize patient care that includes a baseline ECG within 1 hour of presentation to the emergency department.

"What was really surprising about this study is what is not being done. When these patients have positive ECGs, they are not being referred to cardiologists per the ACS guidelines."

Regardless of whether they present to a medical emergency department or psychiatric emergency, they should be assessed for potential cardiac complications, said Ms. D'Aurora.

"With all of the other things that go on in a psychiatric emergency department, I think the importance of this is probably underrated. But even if it just means taking out your stethoscope and listening to the heart or taking a pulse, cardiac assessment in these patients needs to become part of the standard management in the psychiatric department," she said.

High Index of Suspicion

Asked by Medscape Psychiatry to comment on the study, Mark Willenbring, MD, director of the division of treatment and recovery research at the National Institute on Alcohol Abuse and Alcoholism, said the findings highlight the need to have a higher index of suspicion for cardiac complications in cocaine addiction and intoxication.

"We've known for a long time that this patient group is at particular risk of cardiac complications. This study suggests that there are significant cardiac abnormalities that are being missed in patients who are triaged to a psychiatric service, and I suspect that's quite likely," said Dr. Willenbring.

"That said, I'm not a cardiologist, and so I don't know if providing a routine ECG in all of these patients is necessary or cost-effective, but I do think one should always have a very high index of suspicion and investigate for the possible presence of cardiac abnormalities with a lower threshold in these patients than you would with others," he added.

Source : http://www.medscape.com/viewarticle/703149?sssdmh=dm1.474949&src=nldne

Pediatrics, Fever

Introduction

Background

Pediatric patients presenting in the ED with fever are sometimes the more challenging patients emergency physicians face. Patients with fever can be present in a wide variety of clinical presentations ranging from mild clinical conditions to the most serious of bacterial illnesses. Fever is both a high-impact and a high-frequency chief complaint. The clinician should be knowledgeable about febrile conditions that occur in pediatric patients. Although clinical guidelines have been reported and scrutinized in major journals in the past few years, definitive conclusions are sometimes elusive.¹

Fever phobia is well described as existing with both caregivers as well as medical providers.²

Inconsistent treatment approaches exist even in the most experienced pediatric EDs.³

For related information, see Medscape's Pediatrics Resource Center.

Pathophysiology

A child's core temperature may normally vary by as much as 1-1.5°F throughout the day. This variation occurs with or without pathology being present. An elevated temperature above the normal range is defined as a fever. The standard definition of fever is a rectal temperature of 100.4°F (38.0°C) or higher.

In the face of pathology, pyrogens release prostaglandin E1 and D2. Pyrogens are low-molecular-weight proteins produced by leukocytes.

Prostaglandins mediate the set point for heat regulation in the human body. Their effects act on the hypothalamus and affect the body's response to heat by altering vascular constriction and other heat production and/or release mechanisms.

Frequency

United States

In the general emergency department setting, the chief complaint of fever accounts for approximately 20-25% of the presenting concerns of pediatric patients, with another 10-15% of children having a fever as an associated sign on presentation.

International

International studies both in Europe and Asia show rates of fever similar to US rates in acute care settings.

Mortality/Morbidity

The incidence of serious bacterial illness (SBI) occurs in approximately 1% of children presenting to an acute care setting with fever.

• Serious bacterial infection includes infections causing meningitis, bacteremia or sepsis, enteritis, pneumonia, pericarditis, osteomyelitis, septic arthritis, or cellulitis.^4,5
• Febrile patients may present with other more common bacterial illnesses, such as otitis media, pharyngitis, sinusitis, urinary tract infections, enteritis, and appendicitis, or with viral illnesses, such as upper respiratory infections, bronchiolitis, enteroviral exanthems, gastroenteritis, and flulike illnesses.

Race

No race-based differences are appreciable in the occurrence of fever.

Sex

No sex-based differences are appreciable in the occurrence of fever.

Age

Fevers may occur in any age group. Neonates (<28 d) and young infants (28-60 d) have been traditionally discussed as subsets of pediatric febrile patients. Their presentation and evaluation and management will be the focus of this discussion. Children younger than 24 months of age were traditionally another subset of febrile patients.

• When presenting with fever, neonates and infants are considered at risk for sepsis until proven otherwise. The neonate has been traditionally described as being at greater risk than older children for 2 reasons. First, their bacterial pathogens may be different from those in older children. Their immune systems may be less capable than those of older children to opsonize and compartmentalize infection.
• Note: Not all septic neonates present with fever. Septic neonates may present to the ED with a lower than normal temperature.
• Careful attention to the rectal temperature is suggested in all neonates and young infants presenting in the ED.

Clinical

History

The evaluation of any child in the emergency department should include documentation of the presence or absence of temperature changes.

Thermometer use varies between oral, rectal, or axillary. Ear-probe thermometers may not be as accurate as rectal thermometers in the neonate. Some study results suggest that operator error is the main reason. A rectal-probe thermometer is probably most likely to result in an accurate assessment of a neonate's temperature.

Temperature elevation may not be the only sign of sepsis in neonates and infants. Other potential signs and symptoms of sepsis unique to infancy should also be assessed.

• For the neonate, the history is explored for possible evidence of poor feeding, vomiting, poor social interaction, changes in the quality of crying, and possible apneic episodes. Any of these findings are reasons to consider serious bacterial infection and may warrant laboratory evaluation.
• The birth history is explored to ascertain risk factors for underlying pathology, such as prematurity, maternal infections, and congenital or chronic disease states. Neonates at risk for congenital herpes are those born to mothers with recent genital infection, high-risk sexual activity, and rupture of membranes >6 hours, and scalp electrode. Neonates who present with irritability, seizures, respiratory distress, jaundice, or a characteristic vesicular rash should be considered at risk for neonatal herpes. Note that 10-50% will not develop skin lesions during the course of their illness.
• The history is also explored for previous diagnostic studies and their results.
• For the older child, the following questions might be helpful.
  • What is the timing of the current illness?
  • When did the fever start?
  • How long has the fever been present? Are there any related symptoms?
  • What has been done at home to help control the fever?
  • Has the correct dose of antipyretic been given at home?
  • What is the patients' medical history? The past history may not be applicable in all cases, but it must be explored to reveal potential high risk or complicating factors.
  • Has the child's activity significantly changed during the illness?
  • Is the child tolerating fluids at home? Has there been less interest in eating?
  • What is the patient's immunization status? Which recent immunizations have been administered? Some children may not be fully immunized secondary to compliance, finances, or perceived health risks.⁶
    • See also Complications of routine administration of childhood vaccinations below.
    • In particular, what recent vaccinations might have caused an elevation in the patient's temperature? How many doses of pneumococcal conjugate (PCV-7) vaccine have been administered? How many doses of Haemophilus influenzae type B (HIB) vaccine have been administered?
  • Have the stool patterns changed in consistency or frequency?
  • Has there been recent antibiotic use?
  • Has there been exposure to illness through babysitters, daycare contacts, or other caregivers? Are others at home sick?
  • Have the sleep patterns changed? Has the patient been snoring more at night than usual?
  • Has there been any recent travel that might have exposed the child to illnesses?
• Some pediatric patients may have had a subjective determination of an elevated temperature by their caregivers before coming to the hospital but are afebrile when they present to the ED. Parents may report a temperature elevation in their child without having actually recorded the temperature with a thermometer.
• Parental reporting of fever on the basis of subjective information (eg, touching the child's torso or extremities or feeling his or her forehead) is a reliable indicator of a fever having been present. Studies have shown that the parental assessment of fever in this situation is usually accurate.⁷
• Inquire about the use of antipyretics at home. At times, the clinician finds that the dose of medication used at home is not sufficient. Over-the-counter medications do not always list the correct weight-based dose for children younger than 2 years. Some boxes simply state "call physician" or "seek medical care." Parents should be educated that the ever-changing weight of their child will result in a need to periodically calculate or update the correct dose of medication.^8,9

Physical

The physical examination of the febrile child is directed at locating a source of the temperature elevation, with specific attention to potential serious bacterial illnesses. Hypothermia may be a presenting vital-sign abnormality in septic neonates.

• Observation of the infant or child's interactions with the parent or caregiver is easily done while the history is obtained.
  • What is the quality of the cry? Is it abnormal, high pitched, or weak in effort?
  • Does the child appear fearful of the examiner? Beyond infancy, healthy young children should fear strangers. The child who lies on the examination table without much interaction or who is not disturbed by an examination may be more likely to have a more serious illness.
  • What is the skin color? Are there areas of cyanosis or jaundice? Are there any rashes present?
  • What is the degree of hydration? Are there tears present during crying? Is there moisture on the oral mucosa/lips or tongue? For the neonate, a gentle palpation of the anterior fontanelle may give a general indication to the fluid status. A sunken fontanelle indicates possible hypovolemia/dehydration.
  • What is the response to social overtures? Does the baby smile at the examiner? Does the baby smile or appear interested in a small toy or other shiny object? Social smile remains one of the best predictors of well babies.¹⁰
  • Lethargy is defined as a decrease in the level of consciousness, some examples of which may include the following:
    • Failure of the child to recognize parents or caregivers
    • Absent eye contact with the examiner
    • Failure to interact with the environment at an age-appropriate level
    Toxicity is defined as a clinical syndrome with the following:
    • Lethargy (see the bullet point above), with,
    • Poor perfusion as evidenced by delayed capillary refill, or,
    • Cyanosis or other signs of respiratory distress
• Physical examination findings suggestive of serious illness (eg, serious bacterial infection) include the following:
  • Presence of dyspnea, tachypnea, grunting, flaring, and retractions should be noted. These findings are abnormal and require further exploration (eg, pulse oximetry, chest radiography).
  • Hydration status should be documented. Specific signs of dehydration might include dry mucous membranes, sunken fontanelle, absence of tears when crying, and/or a lack of urine output (by history).
  • Persistent irritability despite feeding or inability of parents to console the child is concerning. True irritability and lethargy are physical signs traditionally associated with an ill child.
  • The presence or absence of meningeal signs should be documented in older children.
  • Caution: In some infants and younger children (perhaps younger than 12-15 months) who develop meningitis, specific meningeal signs, such as the Kernig or Brudzinski sign, may not be present.
  • A hemorrhagic rash is classically described as resulting from overwhelming systemic bacterial infection due to meningococcemia but may be due to other (usually serious) infections. The presence of petechiae or purpura in febrile children indicates the need for prompt evaluation and therapy.
• Clinical observation scales have been developed to aid in the determination of the degree of illness.¹¹
  • Clinical observation by house staff and seasoned clinicians has produced inconsistent results over the reliability and consistency of clinical observational scales.
  • Regardless of the clinical scale used, one predictor of overall wellness of a child is the presence of a smile.
• A physical finding of an isolated bacterial illness, such as otitis media or pneumonia, should not preclude the clinician from possibly pursuing a more extensive workup to exclude sepsis in the neonate.
• Note: The capillary refill time is generally thought to be the quickest early assessment of hypoperfusion. Faster to obtain than a blood-pressure measurement, the capillary refill time is particularly helpful in a loud or busy ED. Triage nurses should be trained in the rapid assessment of hypoperfusion.
• A delay in the capillary refill time (>2 seconds) indicates hypoperfusion of the skin. Shunting of blood from the capillary beds in the skin is an indication of increased systematic vascular resistance (SVR).
  • An increase in SVR is generally thought to occur early in the face of pediatric hypovolemia. Hypovolemia can result from obvious conditions, such as blood loss and vomiting and diarrhea, or from more subtle reasons, such as tachypnea and sweating.

Causes

Causes of elevated temperature include the following:¹²

• Infectious etiologies (SBI is the concern in the evaluation of the child with fever)
  • Meningitis, or encephalitis
  • Upper respiratory tract infection (URI)
  • Bacterial or viral pneumonia
  • Otitis media
  • Local skin infections, such as cellulitis
  • Oral infections, including pharyngitis due to Streptococcus pyogenes (group A Streptococcus species) and viral herpetic gingivostomatitis
  • Urinary tract infection (UTI)
  • Generalized viral illness
• Parents may be overly concerned about possible outcomes of prolonged high temperature, or they may believe that every fever requires antibiotic therapy.¹³
• The emergency physician may spend time educating parents on these subjects. In fact, not all temperature elevations are caused by bacterial infections. Temperature elevations may occur without infectious etiology.
  • Noninfectious causes of fever include environmental factors, such as the following:
    • High external temperature (especially in the warmer weather months)
    • Over bundling of children in colder weather months
    • Malignancy
    • Rheumatoid diseases
    • Recent immunization administration
• Complications of routine administration of childhood vaccinations carry the risk of temperature elevation as a common adverse effect.
  • Administration of the diphtheria, tetanus, and pertussis (DTP) vaccine may cause fever within a few hours after administration and may persist up to 48 hours.
  • Administration of live-virus vaccinations, such as the measles, mumps, and rubella (MMR) vaccine, may result in temperature elevations up to 7-10 days after its administration.

Source : http://emedicine.medscape.com/article/801598-overview

Burns, Thermal

Introduction

Background

Burn injuries account for an estimated 700,000 annual emergency department (ED) visits per year. Of these, 45,000 require hospitalization. Approximately half of these patients are hospitalized at one of the 125 specialized burn treatment centers in the United States.

Most burns are not life threatening, but each burn causes a significant amount of pain for the patient and often some degree of psychological trauma. At temperatures greater than 120 degrees Fahrenheit, it takes only 3 seconds to burn a child's skin severely enough to require surgery. Rapid evaluation by the emergency physician (EP) is essential to address pain management, provide initial wound care, evaluate appropriate disposition, mitigate the psychological impact of the burn, and identify intentional burns. Follow-up for even superficial thickness burns is imperative, particularly when involving the hands, feet, face, genital area, or other particularly sensitive areas.

To effectively evaluate, treat, and prevent potential future burns, understanding the different methods of categorizing burns is helpful. The general categories include life-threatening versus non-life-threatening, accidental versus intentional, recreational versus occupational, and domestic (home or residence) versus industrial.

Identifying the type of burn is essential because interventions must be appropriately tailored to the underlying cause. Type of burns include thermal burns, chemical burns, and radiation burns. Thermal burns can be further classified according to skin depth and percentage of total body area burned. Additional descriptions for thermal burns include contact, flame, heat, and scalding. Accurate documentation of the burn location (such as ophthalmic, hand, face, inhalation, soles, or perineum) and measurement of involved surface area are essential for follow-up and specialist referral/consultation.

Pathophysiology

The skin is the largest organ of the body. While not very active metabolically, the skin serves multiple functions essential to the survival of the organism, which may be compromised by the presence of a burn, including the following:

• Thermal regulation and prevention of fluid loss by evaporation
• Hermetic barrier against infection
• Sensory receptors that provide information about environment

The skin is divided into 3 layers, as follows:

• Epidermis: This is the outermost layer of skin composed of cornified epithelial cells. Outer surface cells die and are sloughed off as newer cells divide at the stratum germinativum.
• Dermis: This is the middle layer of skin composed of primarily connective tissue. It contains capillaries that nourish the skin, nerve endings, and hair follicles.
• Hypodermis: This is a layer of adipose and connective tissue between the skin and underlying tissues.

The most common type of burns are thermal burns. Soft tissue is burned when it is exposed to temperatures above 115ºF (46°C). The extent of damage depends on surface temperature and contact duration. A thermal burn causes coagulation of soft tissue. As the marginally perfused areas become reperfused, it is thought that there is a release of vasoactive substances causing formation of reactive oxygen species, which leads to increases in capillary permeability. This causes fluid loss as well as increasing plasma viscosity with resultant microthrombi formation.¹

This third spacing of fluid "seals" at 18-24 hours, which is why the guidelines for fluid resuscitation are based on a 24-hour time scale. After the initial 24 hours, the fluid requirements abruptly drop as the capillary permeability returns to normal. Underresuscitation in this initial 24-hour time period leads to significant morbidity from hypovolemia and shock.

Burns may cause a hypermetabolic state manifested by fever, increased metabolic rate, increased minute ventilation, increased cardiac output, decreased afterload, increased gluconeogenesis resistant to glucose infusion, and increased skeletal and visceral muscle catabolism. Patients will need support of this state, which will continue until wound closure is complete.¹ To a large degree, how the individual responds to the increased energy demands will determine recovery.

Frequency

United States

Nearly one million Americans seek ED treatment of burns each year. According to data provided by the American Burn Association, the incidence of burn injuries in the United States has declined from 2 million annual injuries estimated from 1957-1961.

According to 2007 data from the US Fire Administration, in 2006, 3,245 Americans lost their lives and another 16,400 were injured as the result of fire. Notably, although the number of fires and deaths due to fires has decreased from 1997 to 2006, the direct dollar loss in millions has significantly increased from $8,525 to $11,307. Not included in these data are the deaths or the monetary value attributed to fires caused by the terrorist attacks of September 11, 2001. In 2002-2004, the United States had one of the highest fire death rates reported in the industrialized world at 12.4 deaths per million population, a slight decrease from 12.9 deaths per million population last reported in 2003.² The majority of these fatalities (79.5%) occurred in the home.

Slightly different findings were released by the World Fire Statistics in 2007.³ They reported that the fire-related death rate in the United States was 1.39 deaths per 100,000 (18.6 per million) in the years 2002-2004. For comparison, fire-related death rates per 100,000 were higher in Finland and Hungary at 2.08 and 2.10, respectively.

States with the highest death rates in 2004 were the District of Columbia (36.1 per million), Mississippi (32.1 per million), and Alabama (25.6 per million). The states with the lowest rates were Colorado (4.3 per million), Vermont (3.2 per million), and Wyoming (2 per million).² Interestingly, in 2006, fire killed more Americans than all natural disasters combined.²

International

The incidence of burn injuries varies from country to country, typically peaking during the country's holiday period.

In 2007, the World Fire Statistics Centre released fire-related death data by country (from lowest to highest number of deaths per 100,000 person) from 2002-2004.³ The countries with the lowest incidences include Singapore (0.08) and Switzerland (0.51). Those with the highest include Finland (2.08) and Hungary (2.10).³

In the United Kingdom, more than 47 fire-related injuries occur every day.

In Greece, the estimated annual incidence of childhood firework injuries treated in EDs is 7 injuries per 100,000 children per year. Seventy percent of injuries occur in children aged 10-14 years. Boys sustain self-inflicted accidental injuries; girls are typically injured as bystanders. A sharp peak of firework injuries occurs in the spring when the Greek Orthodox Easter is celebrated4

Interesting data from Northern Ireland allows a comparison of burn incidence before and after the enactment of firework legislation. In the prelegislation series, the mean number of patients admitted annually was 0.38 per 100,000, whereas in the postlegislation series, the mean was 0.43 per 100,000. The authors concluded that legislation did not significantly affect the incidence of burns. Also in Northern Ireland, blast injuries to the hand account for more than 50% of injuries in this series5

Mortality/Morbidity

Although fire-related deaths still rank fifth in the leading causes of unintentional injury-related deaths,⁶ the number of deaths from fires and burns has declined since the 1960s. Improvements in burn care (ie, quality burn centers, recognition, and effective management of burn shock) have reduced the number of deaths in the early postburn period. Improved wound management and antibiotics have decreased deaths from burn wound infection as well. The legislature has passed acts aimed at the prevention of injury due to fires. In 1971, the Flammable Fabrics Act was passed in an attempt to regulate the sale of flammable children’s clothing, especially that of sleepwear in infants, as it was noted to be a major cause of morbidity and mortality. Over time, this decreased the number of fire-related deaths and injuries in children.7

However, the greatest factors in the reduction of burn-related deaths is the use of smoke detectors and regulations on hot water heater temperature. In the United States, most people killed in house fires die from smoke inhalation rather than from burns (see Smoke Inhalation and Toxicity, Carbon Monoxide).

Race

• Native American and African American children are more than 2 and 3 times as likely to die in a fire than white children, respectively.⁶
• Black children/adolescents had the highest rates of burn/fire-related deaths. This is attributed to the decreased likelihood of minorities to engage in safe practices (fireplace guards, smoke alarm use, and adjusting water heater temperature).⁶

Age

Minor burns are more common in younger adults, often as a result of cooking or occupational exposures. Teenaged males are at increased risk of injury from fireworks; scald injuries are more common in young children. Most scald injuries in young children result from improper setting of domestic hot water heaters and spillage of cooking pots or beverages. Both types of injuries are easily prevented.

• Infants and children: Most children aged 4 years and younger who are hospitalized for burn-related injuries suffer from scald burns (65%) or contact burns (20%).
  • Most scald burns to children, especially small children aged 6 months to 2 years, are caused by hot foods or liquids spilled in the kitchen or other areas where food is prepared and served.
  • Water heater temperature must be set lower than 120°F. Within 3 seconds, a child's skin can be burned severely enough to require surgery when they are scalded with water temperature greater than 120°F.
  • The EP must consider intentional injury when burn patterns, such as absence of splash marks, stocking glove distribution, sharply defined wound margins, soles, palms, and pinpoint "cigarette ash" burns, are identified. Children aged 4 years and younger and children with disabilities are at the greatest risk of burn-related death and injury, especially scald and contact burns.
• Adolescents and children younger than 14 years: The leading cause of residential fire-related death and injury among children aged 9 years and younger is due to carelessness. Fires kill more than 600 children aged 14 years and younger each year and injure approximately 47,000 other children. Approximately 88,000 children aged 14 years and younger were treated at hospital EDs for burn-related injuries; 62,500 were thermal burns and 25,500 were scald burns. The most common causes of product-related thermal burn injuries among children aged 14 years and younger are hair curlers, curling irons, room heaters, ovens and ranges, irons, gasoline, and fireworks.
• Elderly persons are also at increased risk not only for having a burn-related injury but for having increased morbidity due to their thinner skin and decreased healing abilities.

Clinical

History

The EP must consider the type of burn (thermal, chemical, radiation) and the location during early burn management. Once it has been determined that the burn is a thermal burn, the EP can add to the description: contact (with source name), scald (with fluid or gas type), heat, and flame. Systemic injury, duration, intentional versus accidental, and location of the burn must all be considered during the critical early burn period.

Other important points to determine include the patient's tetanus immunization status as well as the components of the history including past medical history, medications, and allergies.

It is important to ascertain the history early, as often the paramedics may be the only source of information about the event.

History should also include the following:

• Medical personnel must consider abuse as a cause of burns in all children. As many as 10% of abuse cases involve burns (see Pediatrics, Child Abuse ).
• Components of the history that should raise suspicion of abuse include the following:
  • Multiple/conflicting stories of how injury was sustained
  • Injury attributed to a sibling
  • Injury claimed to be unwitnessed
  • Injury incompatible with developmental level of the child
  • Presence of adult male who is not child's father (such as mother's boyfriend) living in household
• Characteristics of the burn that should raise suspicion of abuse include the following:
  • Pattern burns that suggest contact with an object
  • Cigarette burns
  • Stocking, glove, or circumferential burns
  • Burns to genitalia or perineum
• It is the obligation of all health care personnel to contact appropriate law enforcement and protective services if they suspect the burn was intentional.
• Medical personnel must be aware that burns resulting from abuse or neglect may also be seen in the geriatric population.

Physical

• Burn depth is described as superficial, partial thickness, or full thickness (corresponding to first, second, or third degree). (See Causes for more information.)
• Superficial (first-degree) burns involve only the epidermis.
  • Tissue blanches with pressure.
  • Tissue is erythematous.
  • Tissue damage is minimal.
  • Edema may be present; generally blisters do not form.
  • Sunburn is a classic example of this type of burn (see Sunburn for more details and management).
  • These wounds are red, dry, painful, and generally heal in 3-6 days without scarring.⁸
• Partial-thickness burns (second-degree) are often further delineated into superficial and deep types.
  • Epidermis and portions of the dermis are involved.
  • Blisters usually form either very quickly or within 24 hours.
  • Superficial and deep partial-thickness can be difficult to differentiate at the bedside. The difference lies in the depth of penetrance into the dermis with the transition occurring at about 1/2 of dermal depth. Superficial partial-thickness burns usually blanch and do not result in scarring. Deep partial-thickness burns often do not blanch and do scar. The deeper the injury, the longer the healing time, which may vary from 7-21 days in the more superficial dermis burns to greater than 21 days in the deep dermis burns.
  • Adnexal structures (eg, sweat glands, hair follicles) are often involved, but enough of these structures are preserved for function, and the epithelium lining them can proliferate and allow for regrowth of skin.
  • If deep second-degree burns are not cared for properly, edema, which accompanies the injury, and decreased blood flow in the tissue can result in conversion to full-thickness burn.
  • These wounds are red, wet, and painful (with decreasing pain, color, and moisture with increasing depth into the dermis).⁸
• Full-thickness (third-degree) burns (see Media file 1) extend completely through the skin to subcutaneous tissue. They may involve underlying structures including tendon, nerves, muscle, or bone (sometimes previously referred to as fourth-degree burn).
  • These burns are characterized by charring of skin or a translucent white color, with coagulated vessels visible below.
  • The area is insensate, but the patient complains of pain, which is usually a result of surrounding second-degree burn.
  • As all of the skin tissue and structures are destroyed, healing is very slow. Full-thickness burns are often associated with extensive scarring because epithelial cells from the skin appendages are not present to repopulate the area.
  • These wounds vary from waxy white, to charred and black often with a leathery texture, they are dry and usually painless to touch. These wounds generally do not heal on their own.⁸
• Burn extent
  • The more body surface area (BSA) involved in a burn, the greater the morbidity and mortality rates and the difficulty in management. EMS personnel tend to overestimate the extent of the burn, while ED personnel tend to underestimate it.
  • An individual's palmar surface classically represents 1% of the BSA, but, in actuality, it represents about 0.4%, whereas the entire hand represents about 0.8%9,10 A simple method to estimate burn extent is to use the patient's palmar surface including fingers to measure the burned area. Burn extent is calculated only on individuals with partial-thickness or full-thickness burn.
  • Another quick method is to use the Rule of Nines to estimate the extent of burn injury (see Media file 2). The head represents a greater portion of body mass in children than it does in adults. Lund and Browder first described a method for compensating for the differences, and the Lund and Browder Chart is used to calculate BSA in children (see Media file 3). If the chart is unavailable, estimate BSA by the Rule of Nines and adjust for age as follows:
    • In children younger than 1 year, the head and neck are 18% of BSA and each leg is 15% of BSA. The torso and arms represent the same percentages as in adults (10% and 16%, respectively).
    • For each year older than 1 year, add 0.5% to each leg and decrease percentage for the head by 1% until adult values are reached.
• On the basis of burn extent and depth, EPs can determine the severity of burn injury and whether the patient requires transfer to a burn center. The American Burn Association has developed criteria for burn center admission, as follows:
  • Full-thickness (third-degree) burns over 5% BSA
  • Partial-thickness (second-degree) burns over 10% BSA
  • Any full-thickness or partial-thickness burn involving critical areas (eg, face, hands, feet, genitals, perineum, skin over any major joint), as these have significant risk for functional and cosmetic problems
  • Circumferential burns of the thorax or extremities
  • Significant chemical injury, electrical burns, lightning injury, coexisting major trauma, or presence of significant preexisting medical conditions
  • Presence of inhalation injury
  • Greater than 15% BSA in adults
  • Greater than 10% BSA in children
  • Hand and foot burns can lead to significant morbidity if not treated properly; therefore, most are treated with aggressive therapy. However, if there is careful follow-up the patient may be monitored on an outpatient basis.

Causes

• Flame burns
  • Contact with open flame causes direct injury to tissue.
  • Flame may ignite clothing. While natural fibers tend to burn, synthetic fibers may melt or ignite, adding a contact burn component to the injury.
  • If the burn occurs in an enclosed area, the patient is also at risk for CO poisoning and cyanide poisoning as well as inhalational injury from the smoke and heat.
• Contact burns
  • Contact burns result from direct contact with a hot object.
  • Burn injury is confined to the point of contact.
  • Examples are burns from cigarettes and tools (eg, soldering irons, cooking appliances, curling irons).
• Scalds
  • Scalds result from contact with hot liquids (see Media file 4).
  • The more viscous the liquid and the longer the contact with the skin, the greater the damage.
  • Accidental scalds often show a pattern of splashing, with burns separated by patches of uninjured skin.
  • In contrast, intentional scalds often involve the entire extremity, appearing in a circumferential pattern with a line that marks the liquid surface.
• Steam burns
  • Steam burns most often occur in industrial accidents or result from automobile radiator accidents.
  • These burns produce extensive injury from the high heat-carrying capacity of steam and the dispersion of pressurized steam and liquid.
  • Steam inhalation can actually cause thermal injury to the distal airways of the lung.
• Gas burns
  • Inhalation of hot gas normally does not injure distal airways, as the heat-exchange capacity of the upper airway is excellent.
  • In this situation, the upper airway is at risk for thermal injury and subsequent occlusion due to edema.
  • Distal airway injury is more likely to be due to the direct effects of the products of combustion on the mucosa and alveoli.
• Electrical burns, including lightning¹¹
  • Electrical burns produce heat injury by passing through tissue.
  • Most problems from these burns present in patients exposed to >1000V.
  • Children can have significant injury after exposure to 200-1000V.
  • Ignition of clothing may produce some flame burn, but most of the injury is deep in the skin (see Electrical Injuries).
  • Cardiac injury is prominent, and patients must be monitored for 4-72 hours depending on the strength of the voltage and the age of the patient.
  • The EP must consider visceral injuries, long bone and spine fractures, myoglobinuria, and compartment syndromes.
• Flash burns
  • Flash burns are a subset of flame burns and are a result of rapid ignition of a flammable gas or liquid.
  • The body parts involved are those exposed to the agent when it ignites.
  • Areas covered by clothing are usually spared.
  • The face may be involved, but if this type of injury takes place outside, then the risk for inhalation injury is low. A careful examination of the airway is indicated.
  • A classic example of this type of injury occurs when a person pours gasoline on a trash or leaf fire to increase the flame and is burned by the subsequent fireball.
• Tar burns (see Emergency Department Care)
• Chemical burns¹¹
  • Alkaline substances and acid substances can burn the skin and can be associated with systemic toxicity.
  • Alkaline burns produce liquefactive necrosis and are considered higher risk burns due to their likelihood to penetrate deeper.
  • Acid burns are the result of coagulation necrosis, limiting the depth and penetration of the burn.
  • The upper GI tract and oropharynx may also be at risk if the chemicals were ingested; therefore, the EP should be aware that the airway may occlude due to edema.
  • Circumoral burns may be present if the agent was ingested.
    

Source : http://emedicine.medscape.com/article/769193-overview