A 54-year-old man with a high-voltage electrical conduction injury

Published on 10/04/2015 by admin

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Last modified 10/04/2015

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Problem 10 A 54-year-old man with a high-voltage electrical conduction injury

John E. Greenwood

A 54-year-old man with a severe burn injury is brought into the emergency department by an emergency response medical retrieval team. The man had been standing on a mobile metal platform when it struck overhead power cables while elevating.

Q.1

While the initial assessment is being made, what key information should be sought?

The man was standing on the platform of a rising ‘scissor lift’. As the platform struck overhead cables, eye-witnesses reported a loud bang, sparks and arcing of electrical current. The patient was wearing steel toe-capped boots and was trapped for approximately 2 minutes, before co-workers pushed the platform away from the cables with a wooden pole. The incident occurred at 14.00. He was taken to his local hospital by ambulance before transfer to a level 1 trauma hospital by an airborne medical retrieval team. He arrived at the trauma centre at 20.45.

Q.2

Describe the important points of your initial assessment and calculate his initial intravenous fluid requirements.

The patient was intubated and ventilated and a urinary catheter inserted in preparation for transport. His blood pressure was 125/80 mmHg with a pulse rate of 130/min. His clothes were removed to allow an accurate assessment to be made of the extent and severity of his injuries. The photographs show the burned areas of his buttocks, left knee and right foot (Figures 10.1–10.3). There was a 6 cm burn on the scalp with a similar appearance to those on his buttocks. His back had four similar burns. The changes to the left foot resembled those seen on the right foot. Five similar-sized burns were present on the upper limbs. Blood samples were collected for haemoglobin estimation, cross-matching, serum electrolytes and creatinine kinase.

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Figure 10.1

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Figure 10.2

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Figure 10.3

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Figure 10.4

Q.3

Describe his burns.

The left calf was ‘rock hard’ on palpation; the left foot was white, cool to touch and displayed a capillary refill time of 5 seconds. His right foot was pink but there were severe burns to the digits with bone and joint exposure. There was a deep defect, an arcing ‘blow-out’ hole, lateral to the left knee. The compartments of the left forearm were ‘tight’. Some surgical interventions are required.

Q.4

What emergency surgical interventions are required here? Describe the difference between escharotomy and fasciotomy.

His urine output was 1 mL/kg/hour (appropriate for an adult); its appearance is shown in Figure 10.5.

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Figure 10.5

Q.5

Comment on the appearance of the urine, the likely cause, and state what measures need to be taken.

The patient attended the operating theatre as soon as trauma clearance was completed (21.30). A full assessment of his burns was possible after an aggressive scrub debridement of all skin lesions. The surgeon confirmed left lower leg compartment syndrome and that the hole over the anterolateral aspect of the left knee communicated with the knee joint. The left 1st to 4th toes were non-viable, the sole was cold and white. The right calf compartments were soft. There was a full-thickness burn (~1% total body surface area (TBSA)) over the lateral right ankle. The right 1st to 3rd toes were deeply destroyed and ‘burst’ open to reveal damaged joints and bones. The distal right foot was deeply burned. The left forearm compartments were swollen and tight. Full-thickness burns were noted over the right lateral thigh, lateral to the right knee, left elbow, radial and ulnar left forearm and on the scalp. Fasciotomies were performed medially and laterally to the left lower leg, lateral left thigh and radial and ulnar left forearm. Clearly demarcated non-viable tissue was excised at its visible margins effectively requiring a left forefoot amputation and an equally radical debridement of the right distal foot. Fascial excision of burn over the anterolateral left knee defect was performed and the knee joint was washed out (arthroscopy two days later would show the cartilages to be undamaged). Tangential excision of all deep burns was performed. The scalp burns were debrided down to galea aponeurotica. Superficial burns were recorded at left thigh and right lateral calf. All wounds were dressed.

The terminology for burns has changed and ‘first’, ‘second’ and ‘third degree’ burns are no longer described. The term ‘fourth degree burns’ persists.

Q.6

What is meant by ‘fourth degree’ burns?

Two days later there had been a sharp declaration of the left calf and foot necessitating below-knee amputation – if the arthroscopy had shown severe damage to the left knee joint, an above-knee amputation would have been likely, since this joint was open and the defect required complex free flap repair. This surgery would not have been merited if the knee joint was unlikely to be functional later. Necrosis of deep foot muscles was noted on the right and further debridement was performed. All wounds were redressed. A VAC (vacuum assisted dressing) was applied to the right forefoot debridement.

Q.7

What is meant by a ‘free flap’?

The patient began to recover physiologically and 4 days after his injury he was extubated. He was transferred to the burns unit 2 days later. He underwent skin grafting to the scalp, left forearm, hip and back wounds which healed well, but the right foot tissues deteriorated and further deep necrosis was evident. He returned to theatre for right below-knee amputation. Prior to amputation, some of the lateral right calf tissue (including the peroneal artery as its blood supply) was used to create a free flap which was used to close the left knee defect (with the flap peroneal artery anastomosed to the artery to the vastus medialis of the left leg).

Q.8

What are the important early complications that must be considered in the management of this patient?

The patient continued to improve, aided by strong support from family and friends. Approximately 6 weeks after his injury, he was transferred to a rehabilitation facility where he remained for a further 6 weeks. The patient today walks on bilateral below-knee prostheses, is independent and happy. No late sequelae had developed at 6 months post-injury.

Answers

A.1

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