Young children are vulnerable to orofacial burns, especially of the lips ( Fig 90.9 ) These full-thickness burns of the upper and lower lips and oral commissure usually involve mucosa, submucosa, muscles, nerves, and blood vessels The lesion usually has a pale, painless, well-demarcated, depressed center with surrounding pale gray tissue and erythematous border After a few hours, the wound margin extends and marked edema occurs Drooling is common The eschar separates in to weeks and bleeding may occur at this time; granulation tissue gradually fills the wound Scarring may produce lip eversion, microstomia, and loss of function Damage to facial or even carotid arteries may result in delayed hemorrhage Devitalization of deciduous and secondary teeth may occur FIGURE 90.9 Patient with electrical burns to the corner of the mouth after biting on an electrical cord (Courtesy of Evaline Alessandrini, MD.) Inadequately debrided burned or gangrenous tissue provides a medium for infection Staphylococcal, pseudomonal, and clostridial species are common pathogens in the extremities Streptococci and oral anaerobic organisms may infect mouth wounds Management and Diagnostic Studies The first step in emergency management ( Table 90.9 ) is to separate the victim from the current source The rescuer must be well insulated to avoid becoming an additional casualty If the current cannot be shut off, wires can be cut with a wood-handled ax or appropriately insulated wire cutters In cases of lightning, contact with the victim does not pose any threat to the rescuer, and treatment may be started immediately Any victim in cardiopulmonary arrest should be resuscitated promptly following the guidelines discussed in Chapters A General Approach to the Ill or Injured Child , Airway , and Cardiopulmonary Resuscitation Prolonged efforts to restore adequate cardiopulmonary and cerebral function, especially in the lightning victim, may be appropriate in the context of bizarre neurologic phenomena that inhibit ventilatory efforts, consciousness, or pupillary function The patient who fails to respond to resuscitative efforts over hours to days and meets standard brain death criteria should be pronounced dead Any patient who sustains electrical injury needs a comprehensive physical examination Bleeding or edema from orofacial burns may compromise the upper airway The head, particularly eyes, and neck should be examined carefully for evidence of trauma The skin should be examined carefully for burns and bruises Limbs should be evaluated for pulses, perfusion, and motor and sensory function, as well as for soft tissue swelling or evidence of fractures Burns and deep tissue injury may progress over hours to days, so repeated examination and monitoring are important Neurologic evaluation is especially important in all but the most minor, localized peripheral injuries Level of consciousness and mental status should be assessed and cranial nerve, cerebellar, motor, and sensory function should be evaluated Children who have sustained minor household electrical injuries and are asymptomatic usually not require laboratory evaluation, cardiac evaluation, or hospitalization In cases of a high-tension injury or lightning strike, evaluation should include ECG, CBC, CPK, troponin, BUN, creatinine, and urinalysis, including urine myoglobin Physical examination that reveals evidence of bruises, bony tenderness, or distorted long bones should prompt appropriate radiographic studies Most children who sustain burns of the oral commissure (usually after biting an electrical cord) not require extensive evaluation or admission In cases of severe orofacial burns, use of an artificial airway should be considered before progressive edema leads to catastrophe Mechanical ventilation may be necessary to overcome CNS depression or primary lung involvement Patients with coma and loss of protective airway reflexes should be intubated to avoid aspiration Good oxygenation and ventilation adequate to maintain a normal pH and PaCO must be ensured Seizure activity should be treated (see Chapter 72 Seizures ) The neck and back should be immobilized if the patient was thrown from the site of injury If the mechanism of injury was severe, a cervical collar should be maintained in place despite normal cervical spine radiographs until more definitive evaluation can be accomplished If a child fails to regain consciousness within a short time or shows signs of neurologic deterioration, a computed tomography scan will help exclude intracranial hemorrhage Cardiopulmonary support is nonspecific Most patients resume circulatory stability unless severe hypoxia and ischemia have weakened the myocardium Arrhythmias should be treated along usual lines (see Chapter 86 Cardiac Emergencies ) Patients struck by lightning require only maintenance fluids Patients with ordinary thermal burns should be treated according to standard recommendations (see Chapter 104 Burns ), although body surface area calculations may seriously underestimate fluid requirements It has been noted that burns caused by lightning not usually require special care Extensive vascular and deep tissue destruction may lead to extensive fluid sequestration Isotonic fluid should be given in amounts to maintain normal pulse and BP In all cases, fluids should be given with attention to possible CNS complications TABLE 90.9 MANAGEMENT OF ELECTRICAL INJURIES