A surgeon gets a newly autoclaved instrument that is too hot to use. He sets it down on the surgical drapes…
A warm compress is ordered to help a diabetic foot ulcer heal…
A patient undergoes MRI while wearing coiled electrodes for physiologic monitoring…
A thermal blanket is used for a patient in the OR…
A warming bottle for a neonate…
Yes, you know the answers – they all resulted in iatrogenic burns to patients. Could they occur in your hospital? We bet they could. That’s because with few exceptions, such as MRI suites and neonatal units, most patient care units lack protocols and systematic assessments to determine who might be at risk for burns.
When you look at the examples above examples you realize there are really 3 key conditions that predispose patients to burns. They are either insensitive to pain/temperature, unresponsive, or unable to communicate. There may be some additional predisposing factors, too, like impaired ability for the vasculature to help dissipate heat from the skin. And, of course, you need a heat source.
Patients who are obtunded or comatose or who are under anesthesia may not perceive heat or pain or be able to respond even if they could feel it. Patients who cannot communicate (infants, patients with aphasia, patients isolated in MRI suites, etc.) may perceive pain and temperature but may not be able to alert caregivers. And some patient cannot feel heat/pain because of local or regional anesthetic or certain neurological disorders (diabetic neuropathy, some other neuropathies, congenital insensitivity to pain, spinal cord problems, syringomyelia, certain CNS lesions, etc.).
The patient with the diabetic foot ulcer who suffered a burn due to a warm compress was obviously predisposed by a diabetic peripheral neuropathy – a key factor in development of diabetic foot ulcers. But even patients with normal sensation may get burns under certain circumstances. Has the following ever occurred to you? You test the water temperature before you step into the shower and it feels too hot. You turn the hot water knob down (or turn the cold water knob up) and the water temperature is comfortable enough for you to begin showering. After a few minutes you increase the water temperature. The increased warmth may, in fact, feel good. But when you finish your shower you notice your skin is much redder than you usually experience. What happened? This was adaptation to heat (adaptation probably occurs at both the peripheral receptor level and a central level). You were no longer bothered by water at the same temperature that frightened you at the start. Yet that hot water was capable of burning your skin. The same sort of adaptation takes place to cold (ever dive in a 65 degree lake? You shout out “It’s freezing” but after about a minute it becomes more tolerable).
So the point is this: even moderate heat applied for a long duration is capable of producing burns and patients may be surprisingly unaware that the burn is occurring. The potential damage to skin (or other organs) is a function of both temperature and duration.
The burn in the patient with the warm compress is interesting from another perspective. One of the first questions we always ask in a root cause analysis (RCA) after any adverse event is “was the procedure indicated in the first place?”. An AHRQ Web M&M (Cleland and Wasiak 2007) had an excellent discussion about warm compresses and burns. They point out that, though there is some basic science research suggesting that heat should improve wound healing, there is really a dearth of clinical evidence that heat therapy is efficacious for wounds. They also point out that wet heat (scalding) is more likely to cause a burn that dry heat.
Microwaved objects are particularly dangerous. Heating with microwaves is not uniform (ever sample safely the periphery of some food only to burn your tongue when you taste the middle?!). In addition, some of the “warmth remedies” for microwaving contain gels, or beans, or rice that retain heat for longer periods than the surface material.
Burns in the OR may occur when heat is applied over an area where drapes over or under the patient’s skin had been soaked with alcohol or any one of a number of other solutions used in the OR (this is also obviously a risk factor for surgical fires – see our December 7, 2007 Patient Safety Tip of the Week on Surgical Fires,). In fact, some may develop chemical burns from these liquids.
Anesthesia, whether local or regional or general, may predispose patients to burns. Even under general anesthesia, where a patient cannot respond, we wonder if there are subtle signs such as changes in heart rate, perhaps mediated reflexly at lower levels, that could alert the surgical team to a potential burn.
There are special considerations in the neonatal period (Möhrenschlager 2004 and Möhrenschlager 2003). The neonate has a reduced thickness of the stratum corneum, thus less protection against thermal injuries. Thermal injuries in neonates have resulted from exposure to 1) transilluminating devides 2) infrared lamps placed too closely 3) other lights 4) tap water 5) warming bottles 6) even overheated plastic surfaces of disposable diapers.
Burns may be an issue during MRI scanning. A 2006 article by Lange and Nguyen became the subject of an FDA alert on burns caused by cables and electrodes in patients undergoing MRI. They stress that even with electrodes that have been “approved” for use with MRI, a serious burn can develop if the electrodes aren’t in complete contact with the skin surface (for example, if excess hair hasn’t been removed or if there is an air gap between the electrode and the skin). Cables that are looped or coiled are especially likely to overheat during MRI so every attempt should be made to avoid looping or coiling and they should be kept off the patient’s skin by placing a blanket under them.
Transdermal drug patches may contain metal or ferromagnetic elements that may overheat during MRI scans and cause burns (see our March 2009 What’s New in the Patient Safety World column “Risk of Burns during MRI Scans from Transdermal Drug Patches”)
Our focus in this week’s Tip of the Week is primarily on burns to the skin. However, don’t lose sight of the fact that thermal injuries can also occur internally during surgery. Such are well known to structures such as bowel and ureters. Such injuries are often not recognized and result in tissue necrosis and delayed manifestations of symptoms.
Lastly, burns may result from inadvertent radiation overdoses. In the recent spate of radiation overdoses from CT scanning (see our October 20, 2009 Patient Safety Tip of the Week “Radiology Again…But This Time It’s Really Radiology!”), skin burns and hair changes appeared after delay periods such that patients and their physicians did not even connect them to the CT scans.
So what should you do in your organization to minimize the risks of iatrogenic burns?
Update: See our Patient Safety Tips of the Week for October 5, 2010 “December 23, 2014 “Iatrogenic Burns in the News Again”.” and
Cleland H, Wasiak J. Too Hot for Comfort. AHRQ WebM&M December 2007
[No authors listed] Iatrogenic burns: beware of microwaves! Prescrire Int. 2008 Aug;17(96):157-8.
Möhrenschlager M, Henkel V, Ring J. ABC of burns: Iatrogenic thermal injuries in the neonatal period BMJ 2004; bmj.com, 31 Aug 2004
Möhrenschlager M, Weigl LB, Haug S, et al. Iatrogenic Burns by Warming Bottles in the Neonatal Period: Report of Two Cases and Review of the Literature. Journal of Burn Care and Research 2003; 24: 52-55
Lange S, Nguyen QN. Cables and electrodes can burn patients during MRI. Nursing 2006; 36: 18
Update: See our October 5, 2010 Patient Safety Tip of the Week “”