TY - JOUR
AU1 - Khataniar,, Himsikhar
AU2 - Shashank,, Sama
AU3 - Rajan,, Sendhil
AU4 - Rajeev, Sreenath, Prabha
AU5 - Shetty,, Naren
AU6 - Mohan, Lakshmeshwar, Nagaraj
AB - Abstract Electrical injuries are among the most devastating of burn injuries. High-voltage electrical injuries result in extensive deep tissue damage and are associated with multiple complications, long-term morbidity, and a high mortality rate. We describe the case of a 16-year-old male cable operator who suffered high-voltage electric injury of left upper limb and anterior abdominal wall. Despite the exit wound causing transection of the ileum, the patient did not have any contamination of the peritoneal cavity as both ends of the bowel were sealed off due to electro-thermal energy. His management included multiple operative procedures, including intestinal resection and anastomosis, debridement, abdominal wall flap-based reconstruction, fasciotomies, split skin grafting, and left hand above elbow amputation. Electrical injury has the propensity to cause severe trauma due to a variety of mechanisms, which include disruption of cell membranes leading to altered biomolecule conformation and thermal injury, amongst others.1,2 In contrast to direct thermal burns, the cutaneous burn size does not correlate with the extent of damage seen in high-voltage (>1000 V) electrical injuries; electrical injuries result in extensive deep tissue injury, often concealed, in addition to various other systemic complications.1 Skin destruction associated with electric injury can be variable and misleading, often causing disproportionate injury to deeper tissues. There may be involvement of skin at two sites: at the point of contact with electric source and at the site of exit. These types of injuries increase the duration of hospital stay, co-morbidities, and number of operations. CASE REPORT A 16-year-old electrician, while working on an electric pole, lost control and grabbed a high-voltage cable while falling down, sustaining electrical injury to his nondominant left upper limb (entry wound) and abdomen at the right iliac fossa (exit wound). After arriving at the emergency department of the hospital (1 hour after the accident), primary survey revealed no head/spine trauma. Abdominal examination revealed a 5 × 2 cm area of abdominal wall defect in the right iliac fossa with loops of small bowel protruding through, similar to a penetrating abdominal injury (Figure 1A). The surrounding skin and abdominal wall was indurated, with varying areas of doubtful viability, occupying an area of 15 × 10 cm around the defect. The patient also had third-degree electrical burns of the left upper arm, forearm and axilla, contact wound over left palm, wrist, and forearm which was mummified 90%, whereas rest of the arm proximally was tense (Figure 1B). Due to severity of the patient and exposed bowel loops, the patient was immediately shifted to the operation room for laparotomy, within 1 hour of arrival at the emergency department. The patient had hematuria, myoglobinuria, and elevated creatine kinase levels in blood, but normal levels of urea and creatinine with no impending acute kidney injury; subsequently, a nephrologist was called in to evaluate the patient in Operation Theatre. Figure 1. Open in new tabDownload slide Patient at initial presentation, showing (A) abdominal injury (Exit Wound), (B) left upper limb (Entry Wound), and (C) sealed-off transection of the ileum (ends highlighted with arrows). Figure 1. Open in new tabDownload slide Patient at initial presentation, showing (A) abdominal injury (Exit Wound), (B) left upper limb (Entry Wound), and (C) sealed-off transection of the ileum (ends highlighted with arrows). Exploratory midline laparotomy revealed a sealed-off complete transection of the ileum (Figure 1C), 20 cm from the ileocecal junction, with no intraperitoneal contamination. Multiple areas of thermal necrosis of bowel were seen 15 to 20 cm proximal to the transected ileum. As a result, 40 cm of bowel was resected and an end-to-end single layered anastomosis was done. Minimal abdominal wall debridement was done and the abdominal wound was closed with loose approximating sutures (Figure 2A). Figure 2. Open in new tabDownload slide Abdominal wall management (A) after initial emergency laparotomy, (B) before secondary debridement, (C) after secondary debridement, and (D) after flap cover. Figure 2. Open in new tabDownload slide Abdominal wall management (A) after initial emergency laparotomy, (B) before secondary debridement, (C) after secondary debridement, and (D) after flap cover. At the same sitting, the left upper limb was managed with fasciotomy over the medial and lateral aspect of left arm to relieve compartment pressure. It was found out that the hand and forearm of the left upper limb was mummified and it was in a state of fixed flexion attitude, with nonviable fingers, forearm muscles, and necrotic biceps and brachialis muscles, with absent brachial artery pulsations below distal 1/3rd of arm. Hence, to prevent infections and further complications 2 days later, above elbow amputation was done with myomectomy of biceps and brachialis muscles, which were found out to be necrotic following which stump closure using viable skin and soft tissue of arm was done. Six days following initial presentation, debridement of the abdomen was done (Figure 2B and C) and a pedicle flap from the antero–medial thigh was harvested and inserted into the defect. The fascia harvested with flap was used to close the abdominal defect and skin of the flap to cover the skin defect. (Figure 2D). The patient required daily dressings and serial debridements in the following days. Two weeks later, split skin grafting was done again to completely cover the abdominal wound. Since the patient had to undergo total five operations spanning over 36 days from initial injury, excluding regular debridements and dressings, despite of not having any associated complications, the patient’s stay at the hospital was prolonged and he was ultimately discharged 49 days following the initial injury. The patient came for follow-up 4 months after the surgery. On examination no complications such as hernia was noted. The patient was mentally stable and acceptable towards his disability. Currently he was not working due to his disability and was undergoing prosthetic rehabilitation using myoelectric prosthesis. DISCUSSION Electric injuries are classified into two groups: high-voltage and low-voltage injuries. The current usually follows the path of least resistance. The usual points of injury are upper limbs, skull, and lower limbs. The abdomen is uncommonly affected by electrical injury, due to its large cross-sectional area and low electrical resistance, which can dissipate the electrical energy.1–3 There are only few reported cases of electrical injuries with full thickness abdominal wounds.4–6 The interesting feature in our case is that a large area of abdominal wall was involved, and, with a sealed-off transection of ileum, no contamination of the peritoneal cavity was seen. Successful management of these patients will require joint teamwork between the general/trauma surgical team and the plastic surgeons. There is high incidence of postoperative anastomotic leak and/or entero-cutaneous fistula especially when the bowel is involved in electrical injuries.4,5 Options for reconstructing the abdominal wound include skin grafts, pedicle flaps, and free flaps.6 High-voltage electric injuries are uncommon injuries associated with a fair degree of morbidity and mortality and require management at a higher level trauma/burn center to improve outcomes. Treatment includes resuscitation and surgery as early as possible. Prevention is the best way to decrease mortality and morbidity by public education and issuing safety precautions to those who handle high-voltage electricity.7 REFERENCES 1. Koumbourlis AC . Electrical injuries . Crit Care Med 2002 ; 30 : S424 – 30 . Google Scholar Crossref Search ADS PubMed WorldCat 2. Lee RC . Cell injury by electric forces . Ann N Y Acad Sci 2005 ; 1066 : 85 – 91 . Google Scholar Crossref Search ADS PubMed WorldCat 3. Lees VC , Frame FD. Electrical burns. In: Settel JA, editor. Principle and practice of burn management . New York : Churchill Livingstone ; 1996 . p. 369 – 76 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 4. Srivastava RK , Kumar R. Electrical burns of the abdomen . Indian J Plast Surg 2013 ; 46 : 587 – 90 . Google Scholar Crossref Search ADS PubMed WorldCat 5. Agrawal V , Jha A, Kumar K, Kalra G. Abdominal wall blow out causing bowel evisceration due to high voltage electrocution: a unique presentation . Indian J Burns 2015 ; 23 : 88 – 91 . Google Scholar Crossref Search ADS WorldCat 6. Zhang PH , Liu Z, Ren LCet al. Early laparotomy and timely reconstruction for patients with abdominal electrical injury: five case reports and literature review . Medicine (Baltim) 2017 ; 96 : e7437 . Google Scholar Crossref Search ADS WorldCat 7. Cancio LC , Jimenez-Reyna JF, Barillo DJ, Walker SC, McManus AT, Vaughan GM. One hundred ninety-five cases of high-voltage electric injury . J Burn Care Rehabil 2005 ; 26 : 331 – 40 . Google Scholar Crossref Search ADS PubMed WorldCat © The Author(s) 2020. Published by Oxford University Press on behalf of the American Burn Association. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)
TI - High-Voltage Electrocution Leading to Sealed Transection of Small Bowel
JF - Journal of Burn Care & Research
DO - 10.1093/jbcr/iraa124
DA - 2020-11-30
UR - https://www.deepdyve.com/lp/oxford-university-press/high-voltage-electrocution-leading-to-sealed-transection-of-small-r7nDnsi40a
SP - 1304
EP - 1305
VL - 41
IS - 6
DP - DeepDyve
ER -