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ECG monitoring in severely burned patients - a simple solution!
printed in Great Britain
Burns (1993) 19, (6), 541
541
letters to the Editor
Pop Tarts - so hot they scald Dear Sir Kellogg’s Pop Tarts are a breakfast product recently launched in the UK, with the advertising slogan ‘So hot they’re cool’. They consist of a light pastry case with a strawberry, chocolate or apple filling and are designed to be heated in a domestic toaster. A notice on the packet warns they may be ‘too hot to handle’ after cooking. We report the case of a 28-year-old man who heated a strawberry-flavoured Pop Tart in a standard toaster, according to his interpretation of the manufacturer’s instructions, for 3 min. Having allowed it to cool for I min, he picked it out of the toaster using his right hand. On doing so, his fingers pierced the pastry, coming into contact with the jam. He sustained partial thickness scalds to his index, middle, ring and little finger tips. They were treated conservatively with tuJle gras dressings and healed after 12 days, without complication. In order to investigate the temperature achieved by the filling of Kellogg’s Pop Tarts after cooking, 18 tarts were cooked in a 300-w toaster for 3 min. They were removed immediately and left on a ceramic plate to cool at an ambient temperature of 20°C. The temperature of the filling was measured using an electronic thermometer attached to a fine metal probe every minute until it was less than 55°C. Figure I illustrates the average cooling curve of the Pop Tarts. The temperature immediately after cooking was 100°C. It took an average of 1Omin for the filling to reach a safe temperature of below 55°C. There was no significant difference between the different flavour fillings. Another, similar case was reported by the UK BBC television programme Watchdog (8 January 1993). Our experience is that the nature of the product, with its delicate pastry case which is easily pierced on lifting the tart from the toaster, means that the jam filling may come into contact with the finger tips when it is at its hottest temperature. Herd et al. (1986) recommended that domestic hot water thermostats should be set no higher than 55°C in order to reduce the number of bath water scalds. This is regarded as the temperature at which fluids can be considered safe. Mercer (1988)
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Time
(min)
Figure 1. Cooling curve of Kellogg’s Pop Tarts. 0 1993 Butterworth-Heinemann 0305-4179/93/060541-03
Ltd
1 10
found that boiled water in a kettle and white, filter coffee in a cup took 60 and 2 min respectively to reach 55°C. This compares with 10 min for the Pop Tarts in this study. When invited to comment on our findings, the manufacturer concurred that Pop Tarts do reach high temperatures when cooked according to the instructions on the packet. To their credit, they have now altered the warning on the packet to emphasize that the tarts should be cooked only on the very lowest setting of the toaster. This, according to Kelloggs, will heat for only 9Os, producing a maximum temperature of 55°C. However, we feel that it is unlikely that people who have been buying the product for some time will be aware of the altered instructions. The marketing strategy of the product is clearly aimed at children and young adults as the intended consumers. They may also fail to read the instructions and warnings on the packets correctly. The combination of a very hot filling and a fragile pastry case, in a product which is intended to be lifted by hand from a toaster is, in our opinion, dangerous. Perhaps, in addition to the warnings on the side of the packet, the manufacturer may wish to alter the advertising slogan to ‘So hot they scald. Kenneth J. Stewart and Sarah A. Pape, Department of Plastic and Reconstructive Surgery, Newcastle General Hospital, Newcastle upon Tyne, UK.
References Herd A. N., Widdowson P. and Tanner N. S. B. (1986) Scalds in the very young: prevention or cure. Burns 12,246. Mercer N. S. G. (1988) With or without? A cooling study. Bums 14,397.
ECG monitoring in severely burned patients - a simple solution! Dear Sir Electrocardiographic (ECG) monitoring during anaesthesia or intensive care may be complicated in severely burned patients because electrode contact may be poor or may contribute to skin damage, and there may be a limited area for electrode placement (Furman and Stiff, 1991). Therefore, such monitoring may require modification (Lamb, 1985; Furman and Stiff, 1991). Lamb (1985) suggested that ECG rhythm analysis may be obtained by using skin electrode sites distant from the standard ones, but this may make it difficult to interpret the shape of the QRS complex (Furman et al., 1991). Alternatively, needle electrodes or the oesophageal ECG may be of use, although the former may increase the risk of infection in a potentially susceptible patient and the use of the latter has found limited acceptance.
Burns (1993) Vol. W/No.
542
II.
.
“’
6
:..
Figure 1. Rhythm strip ECG (II) with respiratory electrodes.
v4
Figure 2. Twelve-lead
waveform
(RESP) from patient with 80 per cent burns taken using saline/gauze
V5
V6
ECG from patient with 80 per cent bums taken using saline/gauze
pad ECG electrodes.
pad ECG
Letters
to the Editor
As such, these monitoring problems are similar to those encountered when anaesthesia is required in patients with severe skin disorders (Smith and Spargo, 1988), such as epidennolysis bullosa dystrophica (EBD). Indeed, in some patients with this condition, ECG monitoring is either not used during anaesthesia (Milne and Rosales, 1980) or is undertaken using non-adherent electrodes (Boughton et al., 1988). However, in 1983, Tomlinson successfully used wet pad electrodes in a patient with EBD and, recently, we utilized this technique in the ECG monitoring of a severely burned patient. A 4O-year-old man was admitted to the Accident Department of our hospital having suffered approximately 80 per cent burns. He was intubated, resuscitated and transferred to the Intensive Therapy Unit, however he rapidly developed multiple organ failure including anuria due to rhabdomyolysis, severe hypotension and refractory hypoxaemia. He was initially monitored using a non-invasive blood pressure cuffplacedon his right thigh, one of few unburned areas. Pulse oximetry was impossible due to the extent of his injuries and ECG monitoring was equally difficult due to the lack of intact skin over the chest wall. To overcome these difficulties, gauze swabs soaked in sterile saline were used as ECG contact electrodes in the usual sites; these produced not only a good ECG rhythm strip but also an accurate ventilation waveform by an impedance technique (Figure I). Furthermore, it was possible to record a 12-lead ECG (figure2) by using swabs placed in the usual limb and chest positions. The use of saline as the contact media for ECG recording is not new; in the past, the patients’ limbs were placed in large pots containing this solution. Later, saline pad contact electrodes were employed. However, problems of short circuiting, increased resistance due to drying and soaked bed clothes caused the development of dedicated electrodes. Saline is not the only useful contact medium; for example, Lewes (1965) reported that water, hand cream, toothpaste and even tomato paste were suitable. However, 0.9 per cent sodium chloride solution is cheap and readily available in sterile form in
543
most hospital departments. In our experience, it produces an ideal contact medium when combined with simple sterile gauze pads and may be useful for monitoring ECG in patients with extensive bums if adhesive electrodes cannot be used. It may therefore be the ideal solution to ECG monitoring in these difficult circumstances! D. F. Marsh, N. J. Whitehead, N. S. Meiklereid and G. B. Smith, Intensive Therapy Services, Queen Alexandra Hospital, Cosham, Portsmouth, UK.
References Boughton, R., Crawford M. R. and Vonwiller J. B. (1988) Epidermolysis bullosa - a review of 15 years’ experience, including experience with combined general and regional anaesthetic techniques. Anaesth. Intensive Care 16, 260. Furman W. R. and Stiff J. L. (1991) Burn anesthesia. In: Stene J. K. and Grande C. M. (eds), Trauma Anesthesia, 1st edn. Baltimore: Williams & Wilkins, p. 286. Lamb J. D. (1985) Anesthetic considerations for major thermal injury. CASJ 32, 84. Lewes D. (1965) Electrode jelly in electrocardiography. Br. Heart]. 27, 105. Milne B. and Rosales J. K. (1980) Anaesthesia for correction of oesophageal stricture in a patient with recessive epidermolysis bullosa dystrophica: case report. CAS] 27, 169. Smith G. B. and Spargo P. M. (1988) Anesthesia and severe dermatologic diseases. In: Stoelting R. K., Barash P. G. and Gallagher T. J. (eds), Advances in Anesthesia, vol. 5. Chicago: Year Book Medical, p. 261. Tomlinson A. A. (1983) Recessive dystrophic epidermolysis bullosa. The anaesthetic management of a case for major surgery. Anaesthzsia 38, 485.
Burns (1993) 19, (6), 541
541
letters to the Editor
Pop Tarts - so hot they scald Dear Sir Kellogg’s Pop Tarts are a breakfast product recently launched in the UK, with the advertising slogan ‘So hot they’re cool’. They consist of a light pastry case with a strawberry, chocolate or apple filling and are designed to be heated in a domestic toaster. A notice on the packet warns they may be ‘too hot to handle’ after cooking. We report the case of a 28-year-old man who heated a strawberry-flavoured Pop Tart in a standard toaster, according to his interpretation of the manufacturer’s instructions, for 3 min. Having allowed it to cool for I min, he picked it out of the toaster using his right hand. On doing so, his fingers pierced the pastry, coming into contact with the jam. He sustained partial thickness scalds to his index, middle, ring and little finger tips. They were treated conservatively with tuJle gras dressings and healed after 12 days, without complication. In order to investigate the temperature achieved by the filling of Kellogg’s Pop Tarts after cooking, 18 tarts were cooked in a 300-w toaster for 3 min. They were removed immediately and left on a ceramic plate to cool at an ambient temperature of 20°C. The temperature of the filling was measured using an electronic thermometer attached to a fine metal probe every minute until it was less than 55°C. Figure I illustrates the average cooling curve of the Pop Tarts. The temperature immediately after cooking was 100°C. It took an average of 1Omin for the filling to reach a safe temperature of below 55°C. There was no significant difference between the different flavour fillings. Another, similar case was reported by the UK BBC television programme Watchdog (8 January 1993). Our experience is that the nature of the product, with its delicate pastry case which is easily pierced on lifting the tart from the toaster, means that the jam filling may come into contact with the finger tips when it is at its hottest temperature. Herd et al. (1986) recommended that domestic hot water thermostats should be set no higher than 55°C in order to reduce the number of bath water scalds. This is regarded as the temperature at which fluids can be considered safe. Mercer (1988)
I 0
I
I
I
I
I
I
I
I
I
1
2
3
4
5
6
7
8
9
Time
(min)
Figure 1. Cooling curve of Kellogg’s Pop Tarts. 0 1993 Butterworth-Heinemann 0305-4179/93/060541-03
Ltd
1 10
found that boiled water in a kettle and white, filter coffee in a cup took 60 and 2 min respectively to reach 55°C. This compares with 10 min for the Pop Tarts in this study. When invited to comment on our findings, the manufacturer concurred that Pop Tarts do reach high temperatures when cooked according to the instructions on the packet. To their credit, they have now altered the warning on the packet to emphasize that the tarts should be cooked only on the very lowest setting of the toaster. This, according to Kelloggs, will heat for only 9Os, producing a maximum temperature of 55°C. However, we feel that it is unlikely that people who have been buying the product for some time will be aware of the altered instructions. The marketing strategy of the product is clearly aimed at children and young adults as the intended consumers. They may also fail to read the instructions and warnings on the packets correctly. The combination of a very hot filling and a fragile pastry case, in a product which is intended to be lifted by hand from a toaster is, in our opinion, dangerous. Perhaps, in addition to the warnings on the side of the packet, the manufacturer may wish to alter the advertising slogan to ‘So hot they scald. Kenneth J. Stewart and Sarah A. Pape, Department of Plastic and Reconstructive Surgery, Newcastle General Hospital, Newcastle upon Tyne, UK.
References Herd A. N., Widdowson P. and Tanner N. S. B. (1986) Scalds in the very young: prevention or cure. Burns 12,246. Mercer N. S. G. (1988) With or without? A cooling study. Bums 14,397.
ECG monitoring in severely burned patients - a simple solution! Dear Sir Electrocardiographic (ECG) monitoring during anaesthesia or intensive care may be complicated in severely burned patients because electrode contact may be poor or may contribute to skin damage, and there may be a limited area for electrode placement (Furman and Stiff, 1991). Therefore, such monitoring may require modification (Lamb, 1985; Furman and Stiff, 1991). Lamb (1985) suggested that ECG rhythm analysis may be obtained by using skin electrode sites distant from the standard ones, but this may make it difficult to interpret the shape of the QRS complex (Furman et al., 1991). Alternatively, needle electrodes or the oesophageal ECG may be of use, although the former may increase the risk of infection in a potentially susceptible patient and the use of the latter has found limited acceptance.
Burns (1993) Vol. W/No.
542
II.
.
“’
6
:..
Figure 1. Rhythm strip ECG (II) with respiratory electrodes.
v4
Figure 2. Twelve-lead
waveform
(RESP) from patient with 80 per cent burns taken using saline/gauze
V5
V6
ECG from patient with 80 per cent bums taken using saline/gauze
pad ECG electrodes.
pad ECG
Letters
to the Editor
As such, these monitoring problems are similar to those encountered when anaesthesia is required in patients with severe skin disorders (Smith and Spargo, 1988), such as epidennolysis bullosa dystrophica (EBD). Indeed, in some patients with this condition, ECG monitoring is either not used during anaesthesia (Milne and Rosales, 1980) or is undertaken using non-adherent electrodes (Boughton et al., 1988). However, in 1983, Tomlinson successfully used wet pad electrodes in a patient with EBD and, recently, we utilized this technique in the ECG monitoring of a severely burned patient. A 4O-year-old man was admitted to the Accident Department of our hospital having suffered approximately 80 per cent burns. He was intubated, resuscitated and transferred to the Intensive Therapy Unit, however he rapidly developed multiple organ failure including anuria due to rhabdomyolysis, severe hypotension and refractory hypoxaemia. He was initially monitored using a non-invasive blood pressure cuffplacedon his right thigh, one of few unburned areas. Pulse oximetry was impossible due to the extent of his injuries and ECG monitoring was equally difficult due to the lack of intact skin over the chest wall. To overcome these difficulties, gauze swabs soaked in sterile saline were used as ECG contact electrodes in the usual sites; these produced not only a good ECG rhythm strip but also an accurate ventilation waveform by an impedance technique (Figure I). Furthermore, it was possible to record a 12-lead ECG (figure2) by using swabs placed in the usual limb and chest positions. The use of saline as the contact media for ECG recording is not new; in the past, the patients’ limbs were placed in large pots containing this solution. Later, saline pad contact electrodes were employed. However, problems of short circuiting, increased resistance due to drying and soaked bed clothes caused the development of dedicated electrodes. Saline is not the only useful contact medium; for example, Lewes (1965) reported that water, hand cream, toothpaste and even tomato paste were suitable. However, 0.9 per cent sodium chloride solution is cheap and readily available in sterile form in
543
most hospital departments. In our experience, it produces an ideal contact medium when combined with simple sterile gauze pads and may be useful for monitoring ECG in patients with extensive bums if adhesive electrodes cannot be used. It may therefore be the ideal solution to ECG monitoring in these difficult circumstances! D. F. Marsh, N. J. Whitehead, N. S. Meiklereid and G. B. Smith, Intensive Therapy Services, Queen Alexandra Hospital, Cosham, Portsmouth, UK.
References Boughton, R., Crawford M. R. and Vonwiller J. B. (1988) Epidermolysis bullosa - a review of 15 years’ experience, including experience with combined general and regional anaesthetic techniques. Anaesth. Intensive Care 16, 260. Furman W. R. and Stiff J. L. (1991) Burn anesthesia. In: Stene J. K. and Grande C. M. (eds), Trauma Anesthesia, 1st edn. Baltimore: Williams & Wilkins, p. 286. Lamb J. D. (1985) Anesthetic considerations for major thermal injury. CASJ 32, 84. Lewes D. (1965) Electrode jelly in electrocardiography. Br. Heart]. 27, 105. Milne B. and Rosales J. K. (1980) Anaesthesia for correction of oesophageal stricture in a patient with recessive epidermolysis bullosa dystrophica: case report. CAS] 27, 169. Smith G. B. and Spargo P. M. (1988) Anesthesia and severe dermatologic diseases. In: Stoelting R. K., Barash P. G. and Gallagher T. J. (eds), Advances in Anesthesia, vol. 5. Chicago: Year Book Medical, p. 261. Tomlinson A. A. (1983) Recessive dystrophic epidermolysis bullosa. The anaesthetic management of a case for major surgery. Anaesthzsia 38, 485.