Background
High tension electrical burns are rare but devastating injuries with significant morbidity and mortality. Injuries caused by exposure to 1,000 Volts or more are defined as high-tension electrical burns [1] and the cables may carry up to 100,000 volts [2]. This form of burn injury usually involves electricity technicians [2,3], leading to sudden death from cardiac fibrillation and arrest. However, survivors present with varying degrees of injuries that pose a great challenge and if not properly managed they succumb to death from sepsis and multiple organ dysfunction syndrom. Some of the injuries may include multiple burns wounds in the extremities, head injury from fall from height, blunt trauma to the abdomen and skeletal injuries such as fractures and dislocations [4]. Management of victims of high-tension electrical burns should be undertaken in a tertiary center with multidisciplinary approach. Prompt decision on radical amputation may be a life-saving procedure to avert overwhelming sepsis and preserve lives. Bilateral shoulder disarticulation done for high tension electrical burns was found to be scarce in the literature. We report the case of a survivor of high-tension electrical burn incident who had bilateral shoulder disarticulation on account of thermal necrosis and gangrene of both upper extremities.
Case Report
A young male of 23years old, electrical technician was admitted into the Accident and Emergency Department of our hospital about 7 hours after sustaining major electrical burns to both upper limbs while working on high tension cables (with 11,000 volts) at the top of a pole. Details of his decent or duration of electrocution could not be ascertained as he immediately lost consciousness. He was said to have worn his safety hand gloves and he was secured to the pole with a safety belt at the time of the incident. He was then taken by sympathizers to a peripheral hospital where he had initial resuscitation, regained consciousness and was later referred to our hospital for expert care. He had no medical co-morbidities. Examination findings revealed a conscious young male, in severe painful distress, pale and severely dehydrated. During the first hour on admission, his vitals were that of temperature 37.7°C-38.3°C, tachycardia of 129-140/minute, Blood pressure 152-168/88-92 mmHg and respiration rate- 28-40 cpm. The musculoskeletal findings were: markedly swollen and edematous upper limbs with fasciotomy/escharotomy incisions on the arms and forearms; circumferential full-thickness burns of the whole upper limbs with exposed devitalized and charred muscles up to the axillae (Figure 1a and b). Both upper limbs had dusky, cold insensate fingers with no active movement. The total burns surface area (TBSA) was estimated at 25% using the Wallace rule of nines. There were no other physical or blunt organ injuries. An impression of bilateral upper limb ischemia due to unrelieved acute compartment syndrome from high tension electrocution was made. His blood tests revealed elevated urea and creatinine, deranged electrolytes with hyponatremia and hyperkalemia; anemia, leukocytosis and thrombocytosis. He also had elevated iron studies and creatine kinase suggestive of rhabdomyolysis. However, his clotting studies, electrocardiogram and chest X-ray on admission showed no abnormalities. He had resuscitation based on the advanced trauma life support. Within the first hour of presentation, he was admitted into the intensive care unit for ventilatory and organ support. He was immediately commenced on crystalloid infusion via a central venous line, his urgent packed cell volume was 19% and he had transfusion of packed cells. He was optimized for an emergency surgery on the same day of admission, which included urgent wound debridement of the right upper limb and above-the-elbow guillotine amputation of the gangrenous left upper limb (Figure 2a and b). However, his clinical condition deteriorated and obvious necrotic tissues with seropurulent malodorous discharge were noticed in both upper limbs on first wound inspection 48 hours post- surgery (Figure 3a and b). The family was counselled on the poor clinical state of the patient and potential treat to life if urgent decision on a more radical surgery- shoulder disarticulation was not taken. This proactive step was necessary to control sepsis and preserve life. The anesthetist advised staged surgeries to reduce metabolic response to trauma. He had the right shoulder disarticulation on the 5th day on admission and the left shoulder disarticulation and wash out of the right discharging stump on the 10th day on admission under general anesthesia. The clinical pictures of the disarticulated shoulders are as shown in Figure 4. He was pyretic for days with multiple foci of infection from central venous canula, disarticulated stump, urethral catheter and chest. He had prolonged course of sensitive antibiotics, incentive spirometry and change of catheters as indicated. On day 23, he had elevated iron, deranged international normalized ratio of 1.5 and activated partial thromboplastin time of 50 after he had received 29 units of packed cells and 6 units of fresh frozen plasma. He subsequently commenced on desirox, vitamin k therapy and tranexamic acid. While on admission, he had a total of 36 units of blood products transfusion, oxygen therapy, rehydration, antibiotics for treatment of sepsis, analgesics, anticoagulation, nutritional and other supportive care. Though the pre-operative course of treatment was turbulent, his post-operative course was predictable. He was discharged home after 35 days on admission with stable clinical condition and satisfactory healed stumps. At 12- month follow-up visit, patient still complained of phantom limb pain and yet to procure prosthesis due to financial constraints. He also relies on family members for feeding and social needs of the upper extremities such as bathing, dressing up, cleaning after toilet use; and finding it difficult to re-integrate back into the society. Other professionals that managed him included psychiatrist, occupational therapist, physiotherapist, prosthetist and pain specialist.
(a and b) Intra-operative pictures after urgent debridement of the right upper limb and left above-the-elbow guillotine amputation.
Discussion
High tension electrical burns are accidental injuries resulting from improper handling of naked cable wires mostly by electrical technicians. The victims are mostly young active individual presenting with varying degrees of soft tissue damage, vascular thrombosis and consequent tissue ischemia [4]. The amount of voltage and the pathway of electricity through the body are important determinant of injury extent and outcome. The most common entry point for high- tension current is the hand, and the most common exit point is the foot [4,5]. However, the injuries in our patient were limited to both upper limbs only and he had no secondary flame burns in the lower limbs. This may be due to exit point being the axillae while the sole of the foot was off the ground. Faggiano et al. [6] noted that compartment syndrome sometimes develops because of massive perilesional oedema, with subsequent loss of tissue perfusion. Our patient presented to the referral hospital with compartment syndrome and subsequently had a fasciotomy in a bit to forestall further necrosis but this could not save the upper limbs. There was rapid progressive ischemia within 48 hours of injury, probably due to preference of the current pathway for least resistant tissues such as the vessels and nerves. The initial debridement and guillotine amputation served as first aid aimed at reducing the load of myoglobin and tissue toxins that could shut down the vital organs. Moreso, patient was not fit for a more radical surgery and we thought we could get away with the first surgical intervention. Most of the victims usually die from sepsis, acute kidney failure due to massive myoglobinuria, disseminated intravascular coagulopathy and direct damage caused by the electric current [6]. Hence, aggressive resuscitation coupled with radical debridement, amputations or disarticulations following this electrocution are usually life- saving surgical operations which require early decision making [7]. In view of the severity of the muscle necrosis and severe sepsis in our patient, both upper limbs had to be disarticulated at the shoulder level in a staged fashion to limit metabolic responses to trauma and improve survival. An interval of 5 days in-between the disarticulations was allowed based on his hemodynamic status and optimization. Soleh et al. [8] also reported a similar case with high- tension electrical burns which ended up with bilateral shoulder disarticulation. However, they disarticulated both shoulders on the same day. Abbas et al. [7] also reported two cases with high-tension electrical burns which culminated into unilateral shoulder disarticulations and in addition, other forms of amputations were undertaken because their patients had secondary flame burns in the lower limbs. This may be due to the fact that the exit point of currents in their patients was the sole of the foot. The game changer in the management of this index case with major electrical burns of 25% TBSA was early admission into intensive care unit, multidisciplinary approach and prompt decision making to disarticulate the shoulders. The rarity of bilateral shoulder disarticulation done for high tension electrical burns, therapeutic challenges imposed and the fact that we were able to achieve good clinical results despite the tortuous treatment course made our case report a unique one.
Conclusion
Early resuscitation, cardiovascular support in the intensive care unit, urgent wound debridement and radical amputation of devitalized limb would reduce the mortality from high -tension electrical burns. Though bilateral shoulder disarticulation poses significant challenges on activities of daily living and social needs, it was the only available option to preserve life in our circumstance.
What’s new?
The survival chances after high tension electrical burns is very low, bilateral shoulder disarticulation done for high tension electrical burns is rare in the literature, therapeutic challenges imposed and the fact that the authors were able to achieve good clinical results despite the tortuous treatment course made this case report a unique one. This report gives a guide that can assist in achieving survival.