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Prognostic factors in children with Staphylococcus aureus sepsis
The Journal of Emergency Medicine, Vol. 25, No. 2, pp. 199 –202, 2003 Copyright © 2003 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/03 $–see front matter
Letters to the Editor e PROGNOSTIC FACTORS IN CHILDREN WITH STAPHYLOCOCCUS AUREUS SEPSIS
tests (p value of less than 0.05 was considered statistically significant). The clinical and laboratory findings of the patients are shown in Table 1. The patients’ ages ranged from 2 months to 15 years (7.75 ⫾ 4.64 years). The predominant symptoms were fever, arthralgia, joint swelling, and cough. None of the patients had a history of an underlying chronic disease. The history of trauma and local infection was noted in 17 (43.5%) and 5 (12.8%) patients, respectively. Sixteen (41%) patients received antibiotic therapy before admission to the hospital. On laboratory investigation, hemoglobin (Hb) levels ranged from 3 to 16 g/dL (10.51 ⫾ 2.61 g/dL), leukocyte count ranged between 3800 and 51400/mm3 (15712.8 ⫾ 10968.5/mm3). The normal ranges of Hb value and leukocyte count were 10 –16 g/dL and 4,000 –11,000/mm3, respectively. Anemia was diagnosed in a total of 17 (43.5%) patients; it was severe (below 6 g/dL) in 2 patients, and moderate or mild (below 10 g/dL) in 15 patients. Leukocytosis and leukopenia were noted in 24 (61.5%) and 2 (5.1%) patients, respectively. Erythrocyte sedimentation rate was studied in all patients except for 8; it was found to be between 20 and 171 mm/hour (80.1 ⫾ 37.7 mm/hour). Serum CRP level was studied in 11 (28.2%) patients; it ranged from 23 to 301 mg/dL (101.7 ⫾ 89.1 mg/dL). S aureus was cultured from blood culture in all except 8 (20.5%) patients. The duration of hospitalization ranged from 2 h to 103 days (35.4 ⫾ 24.5 days). Seven of 39 patients died; the mortality rate was 17.9%. The fatalities and survivors were compared statistically for age, sex, presence of malnutrition, fever, presence or absence of leukocytosis, arthritis, osteomyelitis, and lung, pleural or pericardial involvement, and applied treatment regimes. There was no statistically significant difference except for age between the dead and survivors; the death ratio was higher in patients aged 5 to 10 years than in the others (p ⬍ 0.05) (Table 1).
Sepsis caused by Staphylococcus aureus (S. aureus), a major cause of infection in infants, children, and adults, may be observed in both immunologically normal and immunodeficient children (1). Staphylococcal sepsis remains a significant clinical problem despite advances in antibacterial therapy. Untreated staphylococcal septicemia is associated with a mortality rate of 80% or greater. It is also reported that prognosis may be influenced by numerous host factors, including nutrition, immunologic competence, the presence or absence of debilitating diseases, and leukocytosis (1–3). In this study the clinical and laboratory findings of 39 patients with S. aureus sepsis were reviewed retrospectively to determine the prognostic factors in childhood S. aureus sepsis. The study included 39 patients with sepsis caused by S. aureus who were admitted to the Erciyes University Department of Pediatrics. The criteria for the diagnosis of sepsis were clinical evidence of infection plus hyperthermia or hypothermia, tachycardia, tachypnea and white blood cell abnormalities (4). Physical examination, routine blood and urine analyses, chest radiograph, and blood culture analysis were performed in all patients. In treatment, various drug combinations were used. The duration of treatment varied from 3 to 6 weeks depending on clinical and laboratory findings together with the response of the patients. Discharged patients were examined 1 week later, while for those who expired, blood culture analysis, cerebrospinal fluid (CSF) investigation, and histopathological examination of the lung and liver were performed at autopsy. The dead and surviving patients were compared for age, sex, presence of malnutrition, fever, presence or absence of leukocytosis, arthritis, osteomyelitis, and lung, pleural or pericardial involvement, and applied treatment regimes. Statistical analysis was performed by Chi-square and Fisher’s exact
Untreated staphylococcal septicemia is associated
Guidelines for Letters—Letters will appear at the discretion of the editor as space permits and may be subjected to editing. Three typewritten, double-spaced copies should be submitted. The work was carried out in the Department of Pediatrics, Erciyes University, Faculty of Medicine, Kayseri, Turkey. 199
200
Letters to the Editor
Table 1. Comparison of Clinical and Laboratory Findings of the Survivors and Fatalities Signs Age ⬍5 years 5–10 years 11–15 years Sex Male Female Malnutrition Fever Presence of leukocytosis Absence of leukocytosis Arthritis Osteomyelitis Pulmonary involvement Pleural involvement Cardiac involvement Treatment method Two drugs combination Combination of three or two ⫹ three drugs
Survivors (n ⫽ 32) n (%)
Deaths (n ⫽ 7) n (%)
Total (n ⫽ 39) n (%)
10 (31.2) 11 (34.3) 11 (34.3)
0 (0) 6 (85.7) 1 (14.2)
10 (25.6) 17 (43.5) 12 (30.7)
23 (71.8) 9 (28.1) 19 (59.3) 19 (59.3) 20 (62.5) 12 (37.5) 15 (46.8) 13 (40.6) 27 (84.3) 11 (34.3) 6 (18.7)
4 (57.1) 3 (42.8) 5 (71.4) 4 (57.1) 4 (57.1) 3 (42.8) 4 (57.1) 1 (14.2) 5 (71.4) 1 (14.2) 2 (28.5)
27 (69.2) 12 (30.7) 24 (61.5) 23 (58.9) 24 (61.5) 15 (33.3) 19 (48.7) 14 (35.8) 32 (82.0) 12 (30.7) 8 (20.5)
23 (71.8)
4 (57.1)
27 (69.2)
9 (28.1)
with a mortality rate of 80% or greater. Mortality rates have been reduced to 20% by appropriate antibiotic treatment. Staphylococcal pneumonia can be fatal at any age but is more likely to be associated with high morbidity and mortality in young infants or in patients whose therapy has been delayed (2,5). In staphylococcal septicemia, prognosis may be influenced by numerous host factors, including malnutrition, immunologic competence, and the presence or absence of other debilitating diseases (1,2,6). In addition, it was noted that a total white blood cell count below 5000/ mm3 or a polymorphonuclear leukocyte response of less than 50% was a grave prognostic sign (2). In contrast, al Awar and Fryden reported that absence of leukocytosis was not an unfavorable prognostic sign in S. aureus septicemia (7). In a series of 281 cases of true bacteremia due to S. aureus, with ages ranging from 1 year to 100 years, the overall mortality rate was 33.6%. It was higher in patients with complicated bacteremia (bacteremia was considered to be complicated if a focus of infection was absent or untreatable) than the patients with uncomplicated bacteremia, and among patients with endocarditis as compared with patients with secondary foci of infection who didn’t have endocarditis, and in patients with primary bacteremia (bacteremia occurring in the absence of an apparent portal of entry was classified as primary) than in patients with secondary bacteremia (if a portal of entry was identified, bacteremia was defined as second-
3 (42.8)
2
p
6.41
⬍.05
0.10 0.03 0.10 0.03 0.03 0.01 0.78 0.07 0.35 0.00
⬎.05 ⬎.05 ⬎.05 ⬎.05 ⬎.05 ⬎.05 ⬎.05 ⬎.05 ⬎.05 ⬎.05
0.10
⬎.05
12 (30.7)
ary) (8). In another series, including 248 adult patients with S. aureus septicemia, the fatality rate was 19.4%. An age greater than or equal to 60 years, pre-existing cardiovascular disease, prior hospitalization within 30 days of onset of illness, and any neurological symptoms or signs were unfavorable prognostic factors (9). In our study the mortality rate was 17.9%. We did not find a difference between the fatalities and survivors in the presence of malnutrition, bronchopneumonia, and presence or absence of leukocytosis. The mortality ratio was the highest in patients aged 5 to 10 years (p ⬍ 0.05). We are not able to explain why the mortality was highest in the group aged 5 to 10 years. Our findings suggest that the mortality rate is 17.9% in childhood S. aureus sepsis, and there is no effect of the presence of malnutrition, presence or absence of leukocytosis, and a combination of two or three drugs. Age alone affects the prognosis of S. aureus sepsis. Hu¨ seyin C¸ aksen, MD Department of Pediatrics Yu¨ zu¨ ncu¨ Yıl University Faculty of Medicine Van, Turkey ¨ zu¨ m, MD Kazım U S¸ aban Yu¨ ksel, MD Department of Pediatrics Erciyes University Faculty of Medicine Kayseri, Turkey doi:10.1016/S0736-4679(03)00171-9
The Journal of Emergency Medicine
201
REFERENCES
CASE 2
1. Prince AS. Staphylococcal infections. In: Katz SL, Gershon AA, Hotez PJ, eds. Infectious Diseases of Children, 10th edn. St. Louis, MO: Mosby; 1998:474 – 86. 2. Todd JK. Staphylococcal infections. In: Behrman RE, Kliegman RM, Jenson HB, eds. Textbook of Pediatrics, 16th edn. Philadelphia, PA: WB Saunders; 2000:793–9. 3. Turnidge J, Grayson ML. Optimum treatment of staphylococcal infections. Drugs 1993;45:353– 66. 4. Saez-Llorens X, McCracken GH. Sepsis syndrome and septic shock in pediatrics: current concepts of terminology, pathophysiology, and management. J Pediatr 1993;123:497–508. ¨ ztu¨ rk MK, U ¨ zu¨ m K, Yu¨ ksel S˛ , U ¨ stu¨ nbas˛ HB. Pulmo5. C˛ aksen H, O nary complications in patients with staphylococcal sepsis. Pediatr Int 2000;42:268 –71. 6. Gransden WR, Eykyn SJ, Philips I. Staphylococcus aureus bacteremia. Br Med J 1984;288:300 –3. 7. al Awar B, Fryden A. Normal leukocyte counts in Staphylococcus aureus septicemia. Scand J Infect Dis 1990;22:25–30. 8. Lautenschlager S, Herzog C, Zimmerli W. Course and outcome of bacteriemia due to Staphylococcus aureus: evaluation of different clinical case definitions. Clin Infect Dis 1993;16:567–73. 9. Julander I. Unfavourable prognosis factors in Staphylococcus aureus septicemia and endocarditis. Scand J Infect Dis 1985;17:179 – 87.
A 36-year-old man was the driver of a motor vehicle involved in a head-on collision with another motor vehicle. He was restrained, and the driver’s-side airbag deployed at the time of impact. The patient was extricated and taken by ambulance to the ED. The patient had a subjective complaint of chest pain. A burn on the dorsum of the left arm below the elbow was noted. The patient also had a cough due to inhaled gases that had been released from the expanded airbag. Physical examination was normal except for partial thickness burns to the left forearm. Blisters and erythema of the surrounding skin was also noted. A chest radiograph showed no abnormalities. The patient’s burns were irrigated and dressed with silver sulfadiazine cream, and he was discharged. Follow-up dressing changes were arranged. During the first 5 days there was a moderate serosanguineous exudate. Over the next 5 days the exudate and surrounding erythema resolved. The wound healed with normal granulation tissue and epithelialization and a complete recovery was achieved without complication.
e BURNS FROM AUTOMOBILE AIRBAGS e To the Editor:
DISCUSSION
Automobile airbags have been shown to greatly reduce the incidence of injury and death after motor vehicle accidents compared to seat belts alone (1). Although the overall reduction in deaths is undoubtedly contributed to by the implementation of airbags in passenger cars, airbags have been implicated in causing injuries as a result of their deployment (1–3). We present two cases of partial thickness burns resulting from the detonation and deployment of automobile airbags.
CASE 1 A 40-year-old man presented to the Emergency Department (ED) after a motor vehicle crash. The patient was restrained, and the airbag in his car expanded immediately after the impact. Physical examination was unremarkable except for partial thickness burns involving the dorsum of the left hand. The wounds were irrigated, cleansed and dressed with silver sulfadiazine cream and he was discharged. His wounds were dressed daily for 10 days. The wound margins remained clean. There was no necrotic tissue, slough or infection. There was minimal exudate. The wounds had epithelialized successfully by the 10th day and the patient had no permanent sequelae.
A United States Air Force engineer designed the first airbag in 1952; however, airbags were not installed as a safety feature in automobiles until the early 1970s (3). In addition to reduced fatalities, airbags have demonstrated a reduced severity of injuries sustained from motor vehicle crashes causing their deployment (1). Nevertheless, despite the apparent benefits of airbags in most situations, the necessary force involved in their deployment poses some risk (1). The majority of airbag-related injuries have been abrasions, contusions, and lacerations (1). In addition, both ocular and dermal burns have been seen from airbags (4,5). Airbag systems operate by a module in the center of the steering wheel. The module is connected to crash sensors at the front and front sides of the vehicle, which are activated by extremely rapid deceleration (6). Airbags contain several chemicals including sodium azide, ceramic fibers, 2,4-dinitrotoluene, boron, potassium nitrate, nitrocellulose, and cupric oxide (6). The principal chemical component of the system is sodium azide. After activation, the 60-liter airbag is filled with nitrogen, which is produced when about 70 to 80 grams of sodium azide is detonated in about 0.01 s (4,6). In addition to nitrogen, sodium hydroxide is also released as a byproduct of sodium azide combustion (6). Sodium hydroxide has been implicated as
Letters to the Editor e PROGNOSTIC FACTORS IN CHILDREN WITH STAPHYLOCOCCUS AUREUS SEPSIS
tests (p value of less than 0.05 was considered statistically significant). The clinical and laboratory findings of the patients are shown in Table 1. The patients’ ages ranged from 2 months to 15 years (7.75 ⫾ 4.64 years). The predominant symptoms were fever, arthralgia, joint swelling, and cough. None of the patients had a history of an underlying chronic disease. The history of trauma and local infection was noted in 17 (43.5%) and 5 (12.8%) patients, respectively. Sixteen (41%) patients received antibiotic therapy before admission to the hospital. On laboratory investigation, hemoglobin (Hb) levels ranged from 3 to 16 g/dL (10.51 ⫾ 2.61 g/dL), leukocyte count ranged between 3800 and 51400/mm3 (15712.8 ⫾ 10968.5/mm3). The normal ranges of Hb value and leukocyte count were 10 –16 g/dL and 4,000 –11,000/mm3, respectively. Anemia was diagnosed in a total of 17 (43.5%) patients; it was severe (below 6 g/dL) in 2 patients, and moderate or mild (below 10 g/dL) in 15 patients. Leukocytosis and leukopenia were noted in 24 (61.5%) and 2 (5.1%) patients, respectively. Erythrocyte sedimentation rate was studied in all patients except for 8; it was found to be between 20 and 171 mm/hour (80.1 ⫾ 37.7 mm/hour). Serum CRP level was studied in 11 (28.2%) patients; it ranged from 23 to 301 mg/dL (101.7 ⫾ 89.1 mg/dL). S aureus was cultured from blood culture in all except 8 (20.5%) patients. The duration of hospitalization ranged from 2 h to 103 days (35.4 ⫾ 24.5 days). Seven of 39 patients died; the mortality rate was 17.9%. The fatalities and survivors were compared statistically for age, sex, presence of malnutrition, fever, presence or absence of leukocytosis, arthritis, osteomyelitis, and lung, pleural or pericardial involvement, and applied treatment regimes. There was no statistically significant difference except for age between the dead and survivors; the death ratio was higher in patients aged 5 to 10 years than in the others (p ⬍ 0.05) (Table 1).
Sepsis caused by Staphylococcus aureus (S. aureus), a major cause of infection in infants, children, and adults, may be observed in both immunologically normal and immunodeficient children (1). Staphylococcal sepsis remains a significant clinical problem despite advances in antibacterial therapy. Untreated staphylococcal septicemia is associated with a mortality rate of 80% or greater. It is also reported that prognosis may be influenced by numerous host factors, including nutrition, immunologic competence, the presence or absence of debilitating diseases, and leukocytosis (1–3). In this study the clinical and laboratory findings of 39 patients with S. aureus sepsis were reviewed retrospectively to determine the prognostic factors in childhood S. aureus sepsis. The study included 39 patients with sepsis caused by S. aureus who were admitted to the Erciyes University Department of Pediatrics. The criteria for the diagnosis of sepsis were clinical evidence of infection plus hyperthermia or hypothermia, tachycardia, tachypnea and white blood cell abnormalities (4). Physical examination, routine blood and urine analyses, chest radiograph, and blood culture analysis were performed in all patients. In treatment, various drug combinations were used. The duration of treatment varied from 3 to 6 weeks depending on clinical and laboratory findings together with the response of the patients. Discharged patients were examined 1 week later, while for those who expired, blood culture analysis, cerebrospinal fluid (CSF) investigation, and histopathological examination of the lung and liver were performed at autopsy. The dead and surviving patients were compared for age, sex, presence of malnutrition, fever, presence or absence of leukocytosis, arthritis, osteomyelitis, and lung, pleural or pericardial involvement, and applied treatment regimes. Statistical analysis was performed by Chi-square and Fisher’s exact
Untreated staphylococcal septicemia is associated
Guidelines for Letters—Letters will appear at the discretion of the editor as space permits and may be subjected to editing. Three typewritten, double-spaced copies should be submitted. The work was carried out in the Department of Pediatrics, Erciyes University, Faculty of Medicine, Kayseri, Turkey. 199
200
Letters to the Editor
Table 1. Comparison of Clinical and Laboratory Findings of the Survivors and Fatalities Signs Age ⬍5 years 5–10 years 11–15 years Sex Male Female Malnutrition Fever Presence of leukocytosis Absence of leukocytosis Arthritis Osteomyelitis Pulmonary involvement Pleural involvement Cardiac involvement Treatment method Two drugs combination Combination of three or two ⫹ three drugs
Survivors (n ⫽ 32) n (%)
Deaths (n ⫽ 7) n (%)
Total (n ⫽ 39) n (%)
10 (31.2) 11 (34.3) 11 (34.3)
0 (0) 6 (85.7) 1 (14.2)
10 (25.6) 17 (43.5) 12 (30.7)
23 (71.8) 9 (28.1) 19 (59.3) 19 (59.3) 20 (62.5) 12 (37.5) 15 (46.8) 13 (40.6) 27 (84.3) 11 (34.3) 6 (18.7)
4 (57.1) 3 (42.8) 5 (71.4) 4 (57.1) 4 (57.1) 3 (42.8) 4 (57.1) 1 (14.2) 5 (71.4) 1 (14.2) 2 (28.5)
27 (69.2) 12 (30.7) 24 (61.5) 23 (58.9) 24 (61.5) 15 (33.3) 19 (48.7) 14 (35.8) 32 (82.0) 12 (30.7) 8 (20.5)
23 (71.8)
4 (57.1)
27 (69.2)
9 (28.1)
with a mortality rate of 80% or greater. Mortality rates have been reduced to 20% by appropriate antibiotic treatment. Staphylococcal pneumonia can be fatal at any age but is more likely to be associated with high morbidity and mortality in young infants or in patients whose therapy has been delayed (2,5). In staphylococcal septicemia, prognosis may be influenced by numerous host factors, including malnutrition, immunologic competence, and the presence or absence of other debilitating diseases (1,2,6). In addition, it was noted that a total white blood cell count below 5000/ mm3 or a polymorphonuclear leukocyte response of less than 50% was a grave prognostic sign (2). In contrast, al Awar and Fryden reported that absence of leukocytosis was not an unfavorable prognostic sign in S. aureus septicemia (7). In a series of 281 cases of true bacteremia due to S. aureus, with ages ranging from 1 year to 100 years, the overall mortality rate was 33.6%. It was higher in patients with complicated bacteremia (bacteremia was considered to be complicated if a focus of infection was absent or untreatable) than the patients with uncomplicated bacteremia, and among patients with endocarditis as compared with patients with secondary foci of infection who didn’t have endocarditis, and in patients with primary bacteremia (bacteremia occurring in the absence of an apparent portal of entry was classified as primary) than in patients with secondary bacteremia (if a portal of entry was identified, bacteremia was defined as second-
3 (42.8)
2
p
6.41
⬍.05
0.10 0.03 0.10 0.03 0.03 0.01 0.78 0.07 0.35 0.00
⬎.05 ⬎.05 ⬎.05 ⬎.05 ⬎.05 ⬎.05 ⬎.05 ⬎.05 ⬎.05 ⬎.05
0.10
⬎.05
12 (30.7)
ary) (8). In another series, including 248 adult patients with S. aureus septicemia, the fatality rate was 19.4%. An age greater than or equal to 60 years, pre-existing cardiovascular disease, prior hospitalization within 30 days of onset of illness, and any neurological symptoms or signs were unfavorable prognostic factors (9). In our study the mortality rate was 17.9%. We did not find a difference between the fatalities and survivors in the presence of malnutrition, bronchopneumonia, and presence or absence of leukocytosis. The mortality ratio was the highest in patients aged 5 to 10 years (p ⬍ 0.05). We are not able to explain why the mortality was highest in the group aged 5 to 10 years. Our findings suggest that the mortality rate is 17.9% in childhood S. aureus sepsis, and there is no effect of the presence of malnutrition, presence or absence of leukocytosis, and a combination of two or three drugs. Age alone affects the prognosis of S. aureus sepsis. Hu¨ seyin C¸ aksen, MD Department of Pediatrics Yu¨ zu¨ ncu¨ Yıl University Faculty of Medicine Van, Turkey ¨ zu¨ m, MD Kazım U S¸ aban Yu¨ ksel, MD Department of Pediatrics Erciyes University Faculty of Medicine Kayseri, Turkey doi:10.1016/S0736-4679(03)00171-9
The Journal of Emergency Medicine
201
REFERENCES
CASE 2
1. Prince AS. Staphylococcal infections. In: Katz SL, Gershon AA, Hotez PJ, eds. Infectious Diseases of Children, 10th edn. St. Louis, MO: Mosby; 1998:474 – 86. 2. Todd JK. Staphylococcal infections. In: Behrman RE, Kliegman RM, Jenson HB, eds. Textbook of Pediatrics, 16th edn. Philadelphia, PA: WB Saunders; 2000:793–9. 3. Turnidge J, Grayson ML. Optimum treatment of staphylococcal infections. Drugs 1993;45:353– 66. 4. Saez-Llorens X, McCracken GH. Sepsis syndrome and septic shock in pediatrics: current concepts of terminology, pathophysiology, and management. J Pediatr 1993;123:497–508. ¨ ztu¨ rk MK, U ¨ zu¨ m K, Yu¨ ksel S˛ , U ¨ stu¨ nbas˛ HB. Pulmo5. C˛ aksen H, O nary complications in patients with staphylococcal sepsis. Pediatr Int 2000;42:268 –71. 6. Gransden WR, Eykyn SJ, Philips I. Staphylococcus aureus bacteremia. Br Med J 1984;288:300 –3. 7. al Awar B, Fryden A. Normal leukocyte counts in Staphylococcus aureus septicemia. Scand J Infect Dis 1990;22:25–30. 8. Lautenschlager S, Herzog C, Zimmerli W. Course and outcome of bacteriemia due to Staphylococcus aureus: evaluation of different clinical case definitions. Clin Infect Dis 1993;16:567–73. 9. Julander I. Unfavourable prognosis factors in Staphylococcus aureus septicemia and endocarditis. Scand J Infect Dis 1985;17:179 – 87.
A 36-year-old man was the driver of a motor vehicle involved in a head-on collision with another motor vehicle. He was restrained, and the driver’s-side airbag deployed at the time of impact. The patient was extricated and taken by ambulance to the ED. The patient had a subjective complaint of chest pain. A burn on the dorsum of the left arm below the elbow was noted. The patient also had a cough due to inhaled gases that had been released from the expanded airbag. Physical examination was normal except for partial thickness burns to the left forearm. Blisters and erythema of the surrounding skin was also noted. A chest radiograph showed no abnormalities. The patient’s burns were irrigated and dressed with silver sulfadiazine cream, and he was discharged. Follow-up dressing changes were arranged. During the first 5 days there was a moderate serosanguineous exudate. Over the next 5 days the exudate and surrounding erythema resolved. The wound healed with normal granulation tissue and epithelialization and a complete recovery was achieved without complication.
e BURNS FROM AUTOMOBILE AIRBAGS e To the Editor:
DISCUSSION
Automobile airbags have been shown to greatly reduce the incidence of injury and death after motor vehicle accidents compared to seat belts alone (1). Although the overall reduction in deaths is undoubtedly contributed to by the implementation of airbags in passenger cars, airbags have been implicated in causing injuries as a result of their deployment (1–3). We present two cases of partial thickness burns resulting from the detonation and deployment of automobile airbags.
CASE 1 A 40-year-old man presented to the Emergency Department (ED) after a motor vehicle crash. The patient was restrained, and the airbag in his car expanded immediately after the impact. Physical examination was unremarkable except for partial thickness burns involving the dorsum of the left hand. The wounds were irrigated, cleansed and dressed with silver sulfadiazine cream and he was discharged. His wounds were dressed daily for 10 days. The wound margins remained clean. There was no necrotic tissue, slough or infection. There was minimal exudate. The wounds had epithelialized successfully by the 10th day and the patient had no permanent sequelae.
A United States Air Force engineer designed the first airbag in 1952; however, airbags were not installed as a safety feature in automobiles until the early 1970s (3). In addition to reduced fatalities, airbags have demonstrated a reduced severity of injuries sustained from motor vehicle crashes causing their deployment (1). Nevertheless, despite the apparent benefits of airbags in most situations, the necessary force involved in their deployment poses some risk (1). The majority of airbag-related injuries have been abrasions, contusions, and lacerations (1). In addition, both ocular and dermal burns have been seen from airbags (4,5). Airbag systems operate by a module in the center of the steering wheel. The module is connected to crash sensors at the front and front sides of the vehicle, which are activated by extremely rapid deceleration (6). Airbags contain several chemicals including sodium azide, ceramic fibers, 2,4-dinitrotoluene, boron, potassium nitrate, nitrocellulose, and cupric oxide (6). The principal chemical component of the system is sodium azide. After activation, the 60-liter airbag is filled with nitrogen, which is produced when about 70 to 80 grams of sodium azide is detonated in about 0.01 s (4,6). In addition to nitrogen, sodium hydroxide is also released as a byproduct of sodium azide combustion (6). Sodium hydroxide has been implicated as