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

Behind The Knife: The Surgery Podcast

Medicine, Health & Fitness, Education, Science

4.8 • 1.4K Ratings

🗓️ 21 September 2023

⏱️ 26 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	Welcome back on to part two of our electrical injury episode. We have Dr. Alex Woziki,
0:27.0	myself Dr. J. Mio, Dr. Cliff Schecter, and Dr. Tantfan, continuing this episode. To recap our first episode,
0:34.0	we started with a case of a 40-year-old male who contacted a high voltage power line while writing a tractor on his farm.
0:40.0	He presented with severe pain in his right upper extremity. In the first episode, we reviewed the epidemiology and pathophysiology of electrical injuries.
0:49.0	We covered the injury patterns, discussing the impacts on the cardiovascular system, the neurologic system, and of course the skin and musculoskeletal system.
0:58.0	Take a listen to part one if you missed it. Now into part two.
1:02.0	So I think the next part of the segment is going to be the period where the patient is currently being monitored or where we're looking at their upper extremity,
1:10.0	particularly paying close attention to this gentleman's upper extremity. For our compartment evaluation and compartment evaluation in general,
1:18.0	there's some controversy that exists in regards to whether this is simply a clinical diagnosis or whether this is something that is to be measured,
1:27.0	using either a device, such as a striker, or a Magyber device, such as a probe connected to an arterial line.
1:35.0	I don't know, Dr. Tantfan, would you like to discuss this or Jamie, would you like to discuss this a little bit further?
1:40.0	Yeah, sure. The major controversy is really in measuring the compartments.
1:45.0	A clinical diagnosis portion is less controversial, so we'll start there.
1:50.0	I think we've all heard of the five P's. So the clinical diagnosis for compartments syndrome, you have to suspect it based off your mechanism of injury,
1:59.0	have a tense compartment with the five P's, and those are pain generally at rest and with passive stretch, not improving with pain medications,
2:08.0	palar, paristhesias, ulceriness, and paralysis. You think of also time since injury generally about greater than six hours,
2:17.0	in terms of ischemia time and edema time. Compartment pressures are a little more controversial because,
2:23.0	at least in the world of general surgery, we talk about how this is truly a clinical diagnosis. If you suspected, you should do your fasciotomies.
2:31.0	But there is a way to measure them. So as you mentioned, there is a device, a striker device, or a take an 18 gauge needle,
2:38.0	attach it to an artual pressure monitor, and measure your pressures that way.
2:42.0	It's not required for diagnosis, at least in the world of general surgery, and we think of it as an adjunct to the clinical features that we mentioned.
	...

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