Burn Center Treatment of Patients With Severe Anhydrous Ammonia Injury: Case Reports and Literature Review:

A Case Report of Severe Accidental Acute Ammonia Exposure

Introduction

Burn injury during pregnancy is uncommonly studied, but represents a potentially devastating public health crisis. There is the potential for multiple people injured and lives lost. The aim of this study was to review our institution’s experience with this rare subgroup and to isolate specific trends.

Methods

A retrospective study of burn injuries in pregnant women, admitted from 2013-2023 to a single burn center, was conducted to determine outcomes of pregnant patients. Data on these patients were collected utilizing the burn registry and a manual chart review.

Results

Forty patients were identified and stratified by age, weeks of gestation, mechanism of burn injury, TBSA, length of stay, ICU status, surgical intervention, maternal and fetal mortality, and substance use. The mean average age was 27.6 years, and patients were, on average, 20.8 weeks pregnant. The majority of the injuries being sustained were from scald burns (22), followed by flame (12), chemical (3), contact (2), and electrical (1), with one reported inhalation injury. TBSA ranged from 0-40%, with an average TBSA of 4.5%. Length of stay averaged 5.3 days, and 12 patients were admitted to the ICU, with a mean ICU length of stay of 4.3 days. The majority of patients did not receive any surgical intervention, but for those who did, they received either skin replacement (11), or skin substitute (4). During this time, there was one live birth, and no maternal or fetal deaths. Of those admitted, 12 (30%) tested positive for illegal substance use (22.5% marijuana, 7.5% cocaine), and 5 (12.5%) identified as a smoker.

Conclusions

The high incidence of substance use in this population was a surprising finding and warrants further investigation. There is a need for a multi-center, retrospective study to better understand trends in this unique population, with a focus on substance use.

Applicability of Research to Practice

Investigating substance use in this population will help us understand how to better treat these patients.

Extracorporeal Membrane Oxygenation in Acute Respiratory Distress Syndrome Caused by Anhydrous Ammonia Burns: Two Case Reports

Acute anhydrous ammonia burns are relatively rare but lethal and often occur as a mass occupational incident worldwide. Anhydrous ammonia mainly leads to severe inhalation injury and skin/mucosa wound because of its high water solubility and strong alkalinity. Acute respiratory distress syndrome (ARDS) induced by inhalation injury is the main cause of death. Extracorporeal membrane oxygenation (ECMO), also known as extracorporeal life support, has been recommended as the salvage treatment for severe ARDS based on low-level evidence. However, the application of ECMO in ammonia burns is still limited. Here, we presented two cases of anhydrous ammonia burn patients, one 62-year-old man with 15% total body surface area (TBSA) and one 47-year-old man with 27% TBSA, accompanying severe inhalation injury. They both developed severe ARDS and started vv ECMO on 3, 6, and 15 days after injury, respectively. ECMO lasted 118, 247, and 72 h, respectively. All ECMO were successfully weaned off although only one patient survived. Meanwhile, one patient had the coagulopathy complication of ECMO, mainly bleeding, deep vein thrombosis, and hemolysis. In conclusion, this report provided evidence for use of ECMO as supportive care in ammonia burn patients with severe ARDS.

Inhalants

Toxic inhalants include various xenobiotics. Irritants cause upper and lower respiratory tract injuries. Highly water-soluble agents injure the upper respiratory tract, while low water-soluble inhalants injure the lower track. Asphyxiants are divided into simple asphyxiants and chemical asphyxiants. Simple asphyxiants displace oxygen, causing hypoxia, while chemical asphyxiants also impair the body's ability to use oxygen. Cyanide is a classic chemical asphyxiant. Treatment includes hydroxocobalamin. Electronic cigarette or vaping use-associated lung injury (EVALI) is a relatively new illness. Patients present with respiratory symptoms and gastrointestinal distress. EVALI appears to be associated with vaping cannabinoids. Treatment is supportive and may include steroids.

Chemical, Electrical, and Radiation Injuries

This article reviews the unique challenges presented by chemical, electrical, and radiation injuries. The authors discuss pathophysiology and diagnosis of these injuries and provide recommendations for management.

Evaluation of pseudoephedrine pharmacy sales before and after mandatory recording requirements in Western Australia: a case study

BACKGROUND

A community pharmacy real-time electronic recording program, ProjectSTOP, enables Australian community pharmacists to verify pseudoephedrine requests. In Western Australia the program was available for voluntary use from April 2007 and became mandatory November 2010. This case study explores the effectiveness of the program by reviewing the total requests for pseudoephedrine products, and the proportion of requests which were classified as 'denied sales' before and after mandatory implementation. Seasonal and annual trends in these measures are also evaluated.

METHODS

ProjectSTOP data recordings for Western Australia pharmacies between 1 December 2007 and 28 February 2014 were analysed. Data included a de-identified pharmacy number and date of each pseudoephedrine product request. The total number of requests and sale classification (allowed, denied, safety, or not recorded) were calculated for each month/pharmacy. The potential influence of mandatory reporting using ProjectSTOP was investigated using a Regression Discontinuity Design. Correlations between sales from the same pharmacy were taken into account by classifying the pharmacy number as a random effect. The main effects of year (continuous variable), and season (categorical variable) were also included in the model.

RESULTS

There was a small but steady decline in the total requests for pseudoephedrine per month per 100,000 population (per pharmacy) from the time of mandatory reporting. The number of denied sales showed a steady increase up until mandatory reporting, after which it showed a significant decline over time. Total sales were heavily influenced by season, as expected (highest in winter, least in summer). The seasonal pattern was less pronounced for denied sales, which were highest in winter and similar across other seasons. The pattern over time for safety sales was similar to that for denied sales, with a clear change occurring around the time of mandatory reporting.

CONCLUSION

Results indicate a decrease in pseudoephedrine product requests in Western Australia community pharmacies. Findings suggest ProjectSTOP has been successful in addressing suspicious sales and potential diversion however ongoing data review is recommended.