Emergency Department Management of Spontaneous Human Combustion

Emergency Department Management of Spontaneous Human Combustion
Written by Adam Blumenberg, MD

Introduction

Spontaneous Human Combustion (SHC) is a rare but potentially life threatening condition. SHC typically affects flammable patients and conspiracy enthusiasts alike. Although most reputable scientists believe SHC to be an urban legend, it’s super real! Emergency physicians need to be familiar with this disease entity to provide patients with the best possible outcomes.

Case Presentation

HPI: A 47 year-old woman with a history of alcohol dependence and 47 pack-year smoking history is brought to the emergency department by EMS. She was found sitting on a chair surrounded by carbonaceous material. Patient was unresponsive and brought to ED within 5 minutes. The EMS crew provides you with a Polaroid of the scene:

Physical examination

General appearance: Patient is unresponsive. Head, thorax, arms, and abdomen are absent. Lower extremities are resting comfortably on stretcher, in no acute distress.
HEENT: absent
Cardio: absent
Pulm: absent
Abdomen: absent
Extremities: No clubbing, cyanosis, or edema. Proximal aspects of extremity display full thickness burns.

Labs

Na: 142, K: 25, Cl: 100, Bicarb: 8, Cr: 1.4, Glucose: 80
Lactate: 28
WBC: 8.4, Hb/Hct: 14.0/45, Plt: 235

ECG

Initial Management

The first step in resuscitation is applying nebulized halon to the patient. Halon autoinjectors are readily available in most emergency department Pyxis machines.

The next step in management of Spontaneous Human Combustion is to calculate the percent body remaining. The most practical method for this calculation is the Reverse-Parkland Burn Formula.

With our patient, there are only two legs. Therefore the remaining total body area is 36%. We can then apply the World Health Organization treatment rubric. Please note this rubric has not been approved by the Center for Disease Control and that treatment of WHO Grade II SHC remains controversial.

Grade	Criteria	Treatment
WHO I	< 5% remaining	Gentle hydration
WHO II	5 – 10% remaining	Colloid fluid resuscitation
WHO III	10 – 20% remaining	Extra Corporeal Membrane Oxygenation
WHO IV	> 20% remaining	Emergency Department Cardiac Transplant

According to WHO guidelines, the patient’s presentation is consistent with Grade IV Spontaneous Human Combustion and requires emergent cardiac transplant. For a review of this relatively straightforward procedure, please watch the following video:

As noted in the teaching video, it is imperative to assign one member of the team to run around in circles screaming. This crucial action is often forgotten in real-life scenarios. Consider asking your program’s simulation department to provide In-Service training on this life-saving intervention.

Once the patient is stabilized, they should be transferred to a burn center.

Pathophysiology

Clinical data on SHC is limited to historical case reports. An observational cohort study was performed in 2005 in which 50 healthy volunteers were observed for a period of 24 hours for development of SHC. Unfortunately none of the volunteers burst into flames during the study period, and the results were inconclusive.

The proposed mechanism of disease is from a combination of dehydration and ketosis, usually associated with alcohol consumption. Alcohol use induces diuresis, thereby diminishing the body’s total body water. Alcohol is ketogenic and induces acetone production. Over time, the ratio of flammable organic molecules to water increases. Once the patient is more than “50 Proof” they are susceptible to sudden explosion.

Prognosis

The long term survival of SHC is excellent. Below is an interview with a survivor:

Case Resolution

Given the complex nature of the patient’s presentation, their hospital course was complicated. Ultimately, however, the patient did very well and was discharged home thanks to the amazing Emergency Department team.