Correspondence

Treatment of Burns

N Engl J Med 1997; 336:1392-1393May 8, 1997

Article

To the Editor:

In his review of the initial management of burns (Nov. 21 issue),1 Dr. Monafo does not mention the very first aid, which should be given at once — that is, putting cold water on the burned skin. This is a well-accepted practice, especially in children, to reduce burning of the deeper parts of the skin.2-5

I also want to mention another method of first aid, which I learned about from a mother. Instead of applying cold water to the burn one applies something frozen, such as a piece of meat, to the burned skin for a few minutes. There is no danger of a cold-induced injury to the skin from this short period of contact, and the results are much better than with water. This method works well for smaller burns.

Michael Schimmer, M.D.
Marktplatz 19a, D-94051 Hauzenberg, Germany

5 References

1
Monafo WW. Initial management of burns. N Engl J Med 1996;335:1581-1586
Full Text | Web of Science | Medline

2
Butenandt I. Verbrennungen bei Kindern. Dtsch Ärzteblt 1978;75:1547-51.

3
Sefrin P, Klaue P. Erstversorgung bei Verbrennungen. Intensivbehandlung 1983;8:26-33

4
Erhard J, Lackner CK, Schweiberer L. Verbrennungstrauma. Notfallmed 1995;21:464-472

5
Lemke H, et al. Der Verbrennungsunfall. Dtsch Ärzteblt 1996;93:A-1836–A-1840.

To the Editor:

In his excellent review of the initial management of burns, Monafo summarizes inhalation injuries and proposes carbon monoxide as a useful diagnostic marker of smoke inhalation. Although the predominant gas in smoke is carbon monoxide, there is increasing evidence of the toxicologic contribution of cyanide in fire victims, which requires a rapid, specific diagnosis and treatment.1-3

Blood cyanide measurement is neither readily nor widely available. Moreover, blood cyanide levels cannot be accurately predicted on the basis of the carbon monoxide concentration.1

A decreased arteriovenous oxygen difference may be a useful diagnostic tool.4 A central venous saturation value of more than 90 percent is abnormal in most clinical situations and suggests inhibition of oxygen use. An elevated plasma lactate concentration may indicate cyanide poisoning in fire victims who do not have severe burns.1 In the burned patient, severe, unexplained, refractory metabolic acidosis with signs of cardiac and neurologic deterioration should always raise a suspicion of cyanide poisoning. In this setting, a high blood lactate level and a decreased arteriovenous oxygen difference may provide rapid supportive evidence of cyanide toxicity, prompting the administration of a lifesaving antidote.

Rafael Martín Bermúdez, M.D.
Carmen Arenas Cabrera, M.D.
Hospital Universitario Virgen del Rocío, 41013 Seville, Spain

4 References

1
Baud FJ, Barriot P, Toffis V, et al. Elevated blood cyanide concentrations in victims of smoke inhalation. N Engl J Med 1991;325:1761-1766
Full Text | Web of Science | Medline

2
Silverman SH, Purdue GF, Hunt JL, Bost RO. Cyanide toxicity in burned patients. J Trauma 1988;28:171-176
CrossRef | Web of Science | Medline

3
Baskin SI, Horowitz AM, Nealley EW. The antidotal action of sodium nitrite and sodium thiosulfate against cyanide poisoning. J Clin Pharmacol 1992;32:368-375
Web of Science | Medline

4
Johnson RP, Mellors JW. Arteriolization of venous blood gases: a clue to the diagnosis of cyanide poisoning. J Emerg Med 1988;6:401-404
CrossRef | Medline

Author/Editor Response

Dr. Monafo replies:

To the Editor: The prompt cooling of superficial burns with water (20 to 25°C) alleviates pain and may minimize tissue loss.1 The application of ice or cooling to near-freezing temperatures may cause additional injury to the tissues and, in extensive burns, induce corporal hypothermia and therefore should be avoided.2 This caution would presumably apply as well to the use of frozen meat as a coolant.

It has been known for many years that blood cyanide levels are frequently elevated in patients who have had smoke exposure, especially in those found dead at the scene of a fire. The half-life of cyanide in blood is short, and cyanide levels in this setting do not necessarily correlate with the clinical findings or with outcome. The frequency of clinically important cyanide toxicity in patients with smoke inhalation and the importance of treatment with cyanide antidotes are therefore unknown. The suggestion by Drs. Bermúdez and Cabrera that some patients can benefit from specific therapy is not unreasonable; however, it is based on reports that are necessarily anecdotal.

William W. Monafo, M.D.
Washington University School of Medicine, St. Louis, MO 63110

2 References