Clinical Challenges in Burn Surgery: Electrical Burns - Part 1 of 2

Behind The Knife: The Surgery Podcast

Science, Health & Fitness, Medicine, Education

4.8 • 1.4K Ratings

🗓️ 18 September 2023

⏱️ 21 minutes

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Summary

While on your burn rotation, the emergency department calls due to a patient who may have been injured at his job site, coming in contact with a high-voltage line. Join Drs. Tam Pham, Clifford Sheckter, Alex Morzycki and Jamie Oh as they discuss the work-up, management, resuscitation, and subsequent complications and reconstruction for electrical injuries.
Hosts:
- Dr. Tam Pham: UW Medicine Regional Burn Center
- Dr. Clifford Sheckter: Stanford Medicine, Santa Clara Valley Medical Center
- Dr. Alex Morzycki: UW Medicine Regional Burn Center
- Dr. Jamie Oh: UW Medicine Regional Burn Center

Learning Objectives:
- Review the epidemiology and common mechanisms for electrical injuries
- Understand the impact of electrical injuries on different organ systems, including skin, musculoskeletal, cardiac, neurologic, and renal systems
- Be able to guide initial work-up and resuscitation of acute electrical injuries including upper extremity compartment evaluation and release
- Recognize possible long-term complications of electrical injuries and their subsequent management

References:
1. Daskal Y, Beicker A, Dudkiewicz M, Kessel B. [HIGH VOLTAGE ELECTRIC INJURY: MECHANISM OF INJURY, CLINICAL FEATURES AND INITIAL EVALUATION.]. Harefuah. 2019 Jan;158(1):65-69. Hebrew. PMID: 30663297.

2. Pawlik AM, Lampart A, Stephan FP, Bingisser R, Ummenhofer W, Nickel CH. Outcomes of electrical injuries in the emergency department: a 10-year retrospective study. Eur J Emerg Med. 2016 Dec;23(6):448-454. doi: 10.1097/MEJ.0000000000000283. PMID: 25969345.

3. Davis C, Engeln A, Johnson EL, McIntosh SE, Zafren K, Islas AA, McStay C, Smith WR, Cushing T; Wilderness Medical Society. Wilderness Medical Society practice guidelines for the prevention and treatment of lightning injuries: 2014 update. Wilderness Environ Med. 2014 Dec;25(4 Suppl):S86-95. doi: 10.1016/j.wem.2014.08.011. PMID: 25498265.

4. Zemaitis MR, Foris LA, Lopez RA, et al. Electrical Injuries. [Updated 2023 Apr 9]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK448087/

5. Leversedge F, Moore T, Peterson B, Seiler J; Compartment syndrome of the upper extremity. J Hand Surg. 2011; 36(4):P544-559. doi: https://doi.org/10.1016/j.jhsa.2010.12.008

6. Arnoldo B, Klein M, Gibran NS. Practice guidelines for the management of electrical injuries. J Burn Care Res 2006, 27(4): 439-47

7. Pilecky D, Vamos M, Bogyi P, et al. Risk of cardiac arrhythmias after electrical accident: a single-center study of 480 patients. Clin Res Cardiol 2019, 108(8): 901-908

8. Soar J, Perkins GD, Abbas G, et al. European Resuscitation Council Guidelines for Resuscitation 2010 Section 8. Cardiac arrest in special circumstances: Electrolyte abnormalities, poisoning, drowning, accidental hypothermia, hyperthermia, asthma, anaphylaxis, cardiac surgery, trauma, pregnancy, electrocution. Resuscitation 2010, 81(10): 1400-33

9. Kaergaard A, Nielsen KJ, Casrtensen O, Biering K. Electrical injury and the long-term risk of cataract: A prospective matched cohort study. Acta Ophthalmologica 2023, e88-e94

10. Richard F. Edlich, MD, PhD and others, TECHNICAL CONSIDERATIONS FOR FASCIOTOMIES IN HIGH VOLTAGE ELECTRICAL INJURIES, The Journal of Burn Care & Rehabilitation, Volume 1, Issue 2, November-December 1980, Pages 22–26.

11. Lee DH, Desai MJ, Gauger EM. Electrical injuries of the hand and upper extremity. JAAOS-Journal of the American Academy of Orthopaedic Surgeons. 2019 Jan 1;27(1):e1-8.

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Transcript

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0:00.0	Behind the Night, the Surgery Podcast, relevant and engaging content designed to help you dominate the day.
0:13.0	Alright, welcome everyone to Behind the Nice Podcast. My name is Altruir Justi and I'm going to be your host this evening.
0:29.0	I am my GY5 Plus Surgery just finishing at Edmonton, Canada, in incoming Ernest Surgical Critical Care Fellow at the University of Washington.
0:38.0	Hi, I'm Jamie O. I'm a Chief Resident at the General Surgery Program at the University of Washington and I'll be a Burnt Trauma Critical Care Fellow at Harbor V next year.
0:49.0	Alright, and this is Clip Shactor. I'm an Assistant Professor of Surgery at Stanford University. I'm a Burnt Surgeon, plastic surgeon, surgical intensivist and I direct a Regional Burnt Center at Santa Clara Valley Medical Center.
1:03.0	Hello there, Tom Femme. I'm a Burnt director. I've been to the Washington Burnt Center and I'm happy to be an artist on this podcast. They've decided to deal with you.
1:13.0	Okay, I'm going to start with our case. The case begins with a 40-year-old gentleman who contacts a high voltage power line while writing a tractor on his farm presents the emergency department in trauma bay with a cheap complaint of sphere pain and dominant right arm and upper extremity.
1:32.0	The initial assessment proceeds with the primary survey in the trauma bay, including the APCD and E assessment adjuncts, two large 4IVs, folic catheter, c-spinum mobilization, assessment of the patient's airway.
1:46.0	They're breathing, looking for any signs of obvious tension, pneumothorax, mass pneumothorax, flail chest segments.
1:52.0	Moving on to the patient's circulation, obviously for trauma patients, what's concerning is for hemorrhage, whether external or internal.
2:00.0	I'm looking for signs of unstable pelvis. Seating on neurological examination is completed and then finally environmental and exposure are then performed.
2:11.0	May physical findings from the patient's examination patients stable. They do have a flex and contracted wrist as well as flex and contracture at the level of the elbow.
2:21.0	They are unable to passively or actively extend their upper extremity, their wrist or their fingers and with severe pain on pass and extension of their upper extremity.
2:31.0	There's notable contact points on the right soul.
2:35.0	We're going to start with some discussion by Jamie here on the epidemiology of high voltage electrical injuries.
2:42.0	Yeah, I'll start with some general epidemiology. Electrical injuries make up about 3,000 hospitalizations in the U.S. every year, accounting for about 3 to 4% of all burn injuries.
2:54.0	Seems small, but there's high mortality associated with electrical injuries, especially high voltage, and about 40% of serious electrical injuries are fatal, leading to about 1000 deaths every year in the U.S.
3:05.0	With electrical injuries, there's a bi-modal distribution. Low voltage injuries tend to be in the pediatric population due to household appliances and high voltage injuries occur in the sort of working age population due to high-attention electrical power lines or heavy machinery.
3:22.0	And special group of electrical injuries is lightning injuries, which makes up about 300 injuries per year, which is quite remarkable given that there's an estimated greater than 25 million lightning strikes in the U.S. annually.
3:36.0	We're going to start talking about some of that mechanism regarding them.
3:40.0	We're going to have to delve into a little bit of the physics behind electricity to talk about mechanism here.
3:46.0	We think of electricity in terms of electrons, measured as voltage, current, and resistance. So electrons flow from high to low concentrations.
	...

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