burns and injury are the third most common cause of burns after scald
and flame injury. The population most prone to electrical injury is
young children and teenagers. In children, the injuries tend to occur
in the household. In adolescents, they are most often associated with
misguided youthful exploration outside the home. Electrical
current can reach deep tissues and cause extensive deep injury to
tissues including nerve, bone, tendon tissue, muscle and skin. The
injury caused by electrical burns depends on the magnitude of the
electric current, the duration of exposure and the resistance of the
tissue involved. They are classified as high voltage when above 1000
volts or low voltage if it's less. The morbidity and mortality in cases
of high voltage injury are significant. Most cases involve males.
Hospitalization is longer for children with high-voltage burns.
Electrical burns accompanied by trauma are the result of falls from
height. Once the child arrives at the ER an assessment of total body
surface area compromised should be done and hydration according to
Parkland formula instituted. Cardiac rhythm and renal function should
also be examined with appropriate labs (myoglobinuria, BUN, serum
creatinine, CPK, etc). Clinical parameters such as the mechanism of
injury, voltage, burn size and depth, gross urine color and
myoglobinemia can be easily used to predict and estimate the muscle
damage. Myoglobulin and hemoglobin pigment in the child urine present
risk of acute renal failure and must be cleared promptly. Wound
dressing should be done daily and wound debridement, tangential
excision and grafting performed when necessary. Since it's difficult to
asses internal damage the child is observed closely for signs of
compartment syndrome and escharotomy or fasciotomy performed as needed.
Gadolinium-enhanced MRI has demonstrated potential viability in zones
of tissue edema with good correlation with histopathology of the
lesion. Wound complications and infections are associated with
electrical burns with Pseudomonas, Acinetobacter and Escherichia coli
leading the organism spectrum. Intravenous antibiotics are essential
component of management. Sepsis and renal failure are a common cause of
late death. Electrical burns are associated with complications
including orthopedic injury, amputation, and sensory and
neuropsychiatry disturbances. They reduce cardiopulmonary functional
exercise capacity to a greater degree than flame injuries.
1- Kurt A, Yildirim K, Yagmur C, et al: Electrical burns: Highlights from a 5-year retrospective analysis. Ulus Travma Acil Cerrahi Derg. 22(3):278-82, 2016
2- Hundeshagen G, Wurzer P, Forbes AA, Voigt CD, Collins VN, Cambiaso-Daniel J, Finnerty CC, Herndon DN, Branski LK: The occurrence of single and multiple organ dysfunction in pediatric electrical versus other thermal burns. J Trauma Acute Care Surg. 82(5):946-951, 2017
3- Foncerrada G, Capek KD, Wurzer P, Herndon DN, Mlcak RP, Porter C, Suman OE: Functional Exercise Capacity in Children With Electrical Burns. J Burn Care Res. 38(3):e647-e652, 2017
4- Arasli Yilmaz A, Kaksal AO, Azdemir O, et al: Evaluation of children presenting to the emergency room after electrical injury. Turk J Med Sci. 45(2):325-8, 2015
5- Alemayehu H, Tarkowski A, Dehmer JJ, Kays DW, St Peter SD, Islam S: Management of electrical and chemical burns in children. J Surg Res. 190(1):210-3, 2014
6- Roberts S, Meltzer JA: An evidence-based approach to electrical injuries in children. Pediatr Emerg Med Pract. 10(9):1-16, 2013
Calcinosis cutis means that aberrant calcium deposits have developed in the skin and subcutaneous tissue of the patient. According to the etiology four types of calcinosis cutis have been described: dystrophic, metastatic, iatrogenic and idiopathic. Dystrophic calcinosis is a calcification associated with infection, inflammatory process, cutaneous neoplasm or connective tissue disorders (juvenile dermatomyositis, systemic lupus erythematous and systemic sclerosis). Metastatic calcinosis cutis results from an elevated calcium or phosphate level in a child with cancer. Subepidermal calcified nodules and tumoral calcinosis are idiopathic form of calcifications. Idiopathic calcinosis as the names implies has no known cause for the calcinosis or when neither local tissue damage nor systemic metabolic disorder can be demonstrated. In all types of calcinosis cutis insoluble compounds of calcium (hydroxyapatite crystals or amorphous calcium phosphate) are deposited within the skin due to local or systemic factors. Commonly the skin and subcutaneous fat are involved, but deeper tissues such as muscle and visceral organs might also be affected. When muscle is affected this might cause contractures. If the calcium extrudes it will cause local ulceration and inflammation. Should the biopsy revealed calcinosis cutis serum calcium, serum phosphorus and ALP should be obtained along with a detailed history and physical exam looking for a malignant process, collagen vascular disease, renal insufficiency, excessive milk ingestion or Vitamin D poisoning. There is a very rare idiopathic calcinosis cutis known as milia-like characterized by multiple whitish to skin colored, firm, tiny milia-like papules mostly in the hands and feet. This subtype is equally frequent in both sexes and most commonly found in childhood and disappears spontaneously by adulthood without scarring. This milia-type has been associated with Down syndrome. Surgical excision of calcinosis cutis is both needed for establishing a diagnosis and symptomatic relief.
1- Venkatesh Gupta SK, Balaga RR, Banik SK: Idiopathic Calcinosis Cutis over Elbow in a 12-Year Old Child. Case Rep Orthop. 2013;2013:241891. doi: 10.1155/2013/241891. Epub 2013 Nov 4.
2- Solak B, Kara RO, Vargol E: Milia-like calcinosis cutis in a girl with Down syndrome. An Bras Dermatol. 91(5):655-657, 2016
3- Meher BK, Mishra P, Sivaraj P, Padhan P: Severe calcinosis cutis with cutaneous ulceration in juvenile dermatomyositis. Indian Pediatr. 51(11):925-, 2014.
4- Alabaz D, Mungan N, Turgut M, Dalay C: Unusual Idiopathic Calcinosis Cutis Universalis in a Child. Case Rep Dermatol. 1(1):16-22, 2009
5- Niu DM, Lin SY, Li MJ, Cheng WT, Pan CC, Lin CC: Idiopathic calcinosis cutis in a child: chemical composition of the calcified deposits. Dermatology. 222(3):201-5, 2011
6- Rodriguez-Cano L, Garcia-Patos V, Creus M, Bastida P, Ortega JJ, Castells A: Childhood calcinosis cutis. Pediatr Dermatol. 13(2):114-7, 1996
rates has increased in all ages groups during the past ten years.
Suicide is the second leading cause of death in children aged 10 to 15
years. The risk factors associated with suicide in adolescents include
mental health problems, family history of suicidal behavior, biologic
factors, problems with family and most importantly peer victimization
and bullying. Relationship problems with parents are the most common
antecedents within these risk factors. There is a strong correlation
between adolescent smoking and substance use with psychosocial context
and suicidal behavior. Addressing these predictors would be crucial in
the development of effective strategies targeting the prevention of
smoking and substance use, which might consequently reduce suicidal
behaviors among adolescents. Suicidal thoughts and behaviors are
prevalent among young people with psychotic disorders relative to the
general population. Victims of cyber-bullying and school bullying have
a significantly higher risk of suicidal ideas, plans, and attempts. The
"Zero suicide" model developed by the US Action Alliance Strategy for
Suicide prevention provides administrators and providers the resources
for a systematic approach to quality improvement for suicidal
prevention in health care systems via seven essential elements (Lead,
Train, Identify, Engage, Treat, Transition, Improve). The Center for
Disease Control has published charts demonstrating that an increase
number of suicides in children/adolescent involve the use of firearms.
Case control and ecological studies investigating geographic and
temporal variations in firearm ownership and firearm suicide rates
indicate that greater firearm availability is associated with higher
firearm suicidal rates. Effective strategy for reducing the use of
lethal weapons as arms of self destruction include eliminating access
to guns in the house by storing them in locked firearm safes or handgun
lock boxes or outside the home. Also, having access to effective
management and care for adolescents with mental health and substance
abuse conditions working toward remission and reducing self harm injury.
1- Badr HE, Francis K: Psychosocial perspective and suicidal behaviors correlated with adolescent male smoking and illicit drug use. Asian J Psychiatr. 37:51-57, 2018
2- Zaborskis A, Ilionsky G, Tesler R, Heinz A: The Association Between Cyber-bullying, School Bullying, and Suicidality Among Adolescents. Crisis. 15:1-15. doi: 10.1027/0227-5910/a000536, 2018
3- Labouliere CD, Vasan P, Kramer A, Brown G, Green K, Rahman M, Kammer J, Finnerty M, Stanley B: "Zero Suicide" - A model for reducing suicide in United States behavioral health care. Suicidologi. 23(1):22-30, 2018
4- Stone DM, Simon TR, Fowler KA, Kegler SR, Yuan K, Holland KM, Ivey-Stephenson AZ, Crosby AE: Vital Signs: Trends in State Suicide Rates - United States, 1999-2016 and Circumstances Contributing to Suicide - 27 States, 2015. MMWR Morb Mortal Wkly Rep. 67(22):617-624. doi:10.15585/mmwr.mm6722a1, 2018
5- Grosswman DC: Reducing Youth Firearm Suicide Risk: Evidence for Opportunities. Pediatrics. 141 (3), March 2018:e20173884, 2018
6- Kann L, McManus T, Harris WA, et al: Youth Risk Behavior Surveillance - United States, MMWR Surveill Summ. 67(8):1-114. doi: 10.15585/mmwr.ss6708a1, 2017
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