Some principles of local and systemic care of patients with electrocution

Presenting author : Diana Larisa Suciu, student, 3 rd year , UMF Tg. Mures , Faculty of General Medical Assistance

Coordinator: Adrian Botan M.D. , PhD

Senior Consultant Plastic Surgeon& Chief, The Burn Centre & Plastic Surgery Department, Theang

of Targu Mures Medical School

INTRODUCTION

• Electrocution represents the most complex thermal injuries with high mortality and large destructions of the soft parts.

• These injuries are caused by the passage of electrical current through the human body and must be differentiated from other electrical injuries such as those produced by an electrical flame or voltaic arch.

• This paper will deal only with electrocutions; electric current penetrates a distinct anatomic area cross through the human body and escapes by an opposite site producing characteristic skin lesions known as electric marks.

MATERIAL AND METHOD

• In this paper it is presented the case of a 34 year old man, who climbed on a electric pole connected to the industrial electric network ( 20000 V) of on old factory, attempting to dismantle and to still the copper power line. The moment that he stretched out his left hand to detach the porcelain isolation, he was electrocuted, receiving an electric discharge through the index finger with several exit points on the anterior aspect of the elbow joint, the anterior aspect of the left armpit, the anterior aspect of his left thigh and the anterolateral aspect of his right thorax. He remained unconscious after the electric shock hanging on the electric pole about 6 meters above the ground until the military firefighters managed to get him down and to send him to the Burn Unit of Targu Mures County Hospital.

In the image from above one can see the deep electric mark on the lateral aspect of the PIP joint.

In this image one can see the exit point on the 1/3 of the superior anterior left thigh presenting a full-thickness burn.

The image from above shows 2 large exit points on the anterolateral chest.

Early removal of the full-thickness eschar large subsequent fasciotomy and extensive excision of all necrotic tissues has been done in order to prevent the most severe complication: rabdomyolysis with paroxistic myoglobinuria and acute renal failure.

Square-shape escharotomies has been performed on the exit points from the right chest in order to facilitate the autolytic debridement of the necrotic tissues.

Despite the large excisions ,the necrotic process of the left thigh continued ( muscle destruction was far more deep than could be seen during the initial operation). That is why several excisions have been necessary (in order to remove) all necrotic tissues,followed by a long WBP using different adequate synthetic dressings (such as alginates, hydrocolloids ,and PUR-Foam).

In this slide can be seen the same aspect: the necrotic process involves the full-thickness of the skin, the subcutaneous tissue, fascia and even the underlying muscles.

As for other similar cases the autolytic debridement has been performed, step by step on behalf of different synthetic dressings , such as Pur-Foam( the image from above shows the foam sheets applied on the wound surface, retaining sloughs, sanies, and exudates, thus facilitating natural wound cleaning and granulation.

The next image shows the progression of the natural wound cleaning and granulation from the exit points on the right chest, under adequate wound dressings (according to the 30 year experience of the Burn Unit of Targu Mures it is better to perform an autolytic debridement instead of the sequential sharp debridement thus avoiding multiple general anesthesia and accidental excision of healthy-tissue).

The same therapeutic principle of combined autolytic debridement with superficial tangential excision has been applied to the necrotic lesions of the anterior aspect of the left thigh and groin.

At the end of several weeks of local and systemic adequate treatment a very good wound bed has been obtained( red small granulations with non bleeding and low exudation).

The excellent wound bed from the previous image has been eventually covered with meshed autologous S.T.S.G. harvested from the right thigh.

Three weeks later one can see that all grafts had an excellent “take”, and the necrotic lesions shown in the initial images have been completely “covered” and healed.

The latero-thoracic wounds show a good granulation, but with cartilaginous sequestrae.

On behalf on the same synthetic dressings mentioned above the 2 cartilaginous sequestrae separate spontaneously from the healthy cartilage.

The above mentioned sequestrae are eventually removed in the dressing room with now anesthesia following blunt dissection of the parietal pleura using a blunt dissector, a Kocher forceps and a scalpel.

The autolytic debridement by synthetic dressings has been continued until a good granulation has been obtained; the remaining marginal osteocondritis continued to drain from 4 small fistulae for a short period.

The good granular bed mentioned above has been covered with meshed autologous S.T.S.G.; 4 perforations have been performed at the place of the 4 fistulae to facilitate the discharge of the remaining osteocondritis.

This next image shows the good take of the grafts applied on the chest wounds.

Two weeks later 3 fistulae closed the last one closing after other 10 days; all this period antibiotic treatment and adequate local care have been performed. At about 2 months from the accident this patient was completely healed and could leave the hospital.

RESULTS AND DISCUSSIONS

• A very good granulation bed has been attempted at the end of several weeks of adequate local treatment and intensive care in the Burn ICU; this very good granular bed has eventually been grafted with meshed autologous S.T.S.G. harvested from the right thigh.

• All grafts thus applied had a very good take.

CONCLUSIONS

• All electric injuries have to be admitted and cared as soon as possible in a burn centre; very large dissection and extensive excision are the only ways to explore all the damage determined by the electric current thus avoiding early and late complications such as sepsis, acute renal failure amputations and devastating scars.

Thank you very much for your attention!