Emergency Department Management of Spontaneous Human Combustion
Written by Adam Blumenberg, MD
Introduction 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:
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.
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 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. 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. 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. 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.
Lactate: 28
WBC: 8.4, Hb/Hct: 14.0/45, Plt: 235
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.
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
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.
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