Annals of Burns and Fire Disasters - vol. X - n. 3 - September 1997

THE STRATEGIC MANAGEMENT OF THE HIGH-VOLTAGE ELECTRICAL INJURY

Cerepani M.J., Leonard L., Slater H., Goldfarb W.I.

The Western Pennsylvania Hospital, Pittsburgh, Pa., USA

SUMMARY. The strategic management of the high-voltage electrical injury can be both challenging and complex. The challenge begins from the time of injury and continues through rehabilitation. The complex aspect of management is the complications that occur due to systemic effects. A 35-year-old male sustained a 65% T13SA partial- and full-thickness electrical burns to the lower extren~ties, posterior trunk, and occipital and parietal skull. He underwent sixteen operations over a period of four months. The operations began with abovethe-knee amputations of the bilateral lower extremities, multiple debridernent of hurried areas with application of cadaver skin graft, splitthickness skin graft and placement of cultured epidermal autograft, multiple debridement of open wound areas on the scalp, and a colostomy. Throughout hospitalization many serious complications occurred. Some were life-threatening and two remain unresolved. The lifethreatening setbacks included a long course of vancomycin to treat MRSA (methycillin-resistant Staphylococcus aureus), persistent diarrhoea, and inability to tolerate solid foods. The frequent surgeries presented a problem for the patient's nutritional status, together with mobility concerns. The unresolved problems remain an issue. A colostomy was performed early in the early stage of hospitalization. It is unclear if it will be reversed. The patient developed calcification of both shoulders, which has made movement extremely difficult. Although these two problems have remained unresolved, the patient and his family consider them to be a minor hurdle that they will conquen The challenge of this complex case of high-voltage electrical injury will be one to remember for a lifetime.

S.S. was a 35-year-old man who suffered extensive burns when he raised the bed of a truck that he was driving against high-voltage electric lines. Witnesses stated that the patient was electrocuted as he stepped from the truck to the ground. He was observed to be on the ground for several minutes, after which he attempted to return to the truck, which then caught fire. He was transferred to the Western Pennsylvania Hospital Burn Trauma Center and was found to have full-thickness burns on 65% of the body. The lower extremities from the mid-thighs distally were coagulated with areas of exposed bone and open knee and ankle joints. The entire posterior aspect of the body had a full-thickness burn extending deep into the perineum and the perianal and periscrotal tissues (Figs. 1 and 2.) There was a full-thickness burn on the occipital aspect of the skull which exposed the underlying cranium. There were scattered burns on the anterior trunk, arms, and neck. At the time of admission the patient was alert but had no memory of the accident. There was evidence of myoglobinuria. After an initial assessment it was our impression that the patient had a chance of surviving these terrible injuries and he expressed his willingness and desire for full treatment as might be necessary to treat his injuries.

Fig. 1 - Perineum. Fig. 2 - Perianal and periscrotal tissues.

When one encounters patients such as S.S., a long and complex hospital course may be anticipated. We feel that it is of great importance to make a strategic plan that prioritizes and organizes the patient's care. Specific early and late goals can be established and plans made to meet the goals. We felt that the treatment of S.S. could be divided into sequential and overlapping phases.
The first phase of S.S.'s treatment involved resuscitation. He received a combination of lactated Ringer's solution and fresh frozen plasma. The rate of fluid infusion was adjusted to obtain a urine output of I ml/kg/h and regulated to promptly dilute the myoglobin in the patient's' urine. This was accomplished with minimal weight gain. Despite deep burns about the head the patient did not require ventilatory support. When resuscitation was initiated the patient underwent fasciotornies on the lower extremities because of the deep nature of the burns. The fasciotomies revealed that the patient had coagulated, nonviable muscle in all compartments of the legs. He was placed on a cardiac monitor and a pulse oximeter and responded well to resuscitation. Additional sequential plans for his management were then devised.
We were of the opinion that the next phase of management involved debridement of nonviable tissue. We did not feel we had total knowledge of the extent of full-thickness damage early in the course of treatment. We also felt that we should limit blood loss and the duration of debridement operations and it was therefore our plan to operate on the patient early and return him to the operating room as necessary to complete the excision without undue stress to the patient. S.S. had relatively few donor sites for skin grafts as compared with the large area of his body that would require wound coverage. We anticipated the need for cultured epithelial cells to augment widely meshed autograft and to cover areas of the body where autograft was not available. We anticipated that the-patient would need a temporary or permanent colostomy because of the severe burns around the perineum. This operation would be timed to minimize the risk of sepsis secondary to faecal contamination of his burns. The need for long-term nutritional support was anticipated and plans were made to create a surgical jejunostomy so that early tube feeding could be initiated and maintained through the patient's anticipated long hospitalization.
This strategic plan was discussed with the patient and his wife so that they would have a sense of his overall management and of the magnitude of the problems to be faced in his treatment. Both had a good understanding of the general outline of the plan and were agreeable to its performance.
The patient responded well to resuscitation and was taken to the operating room on hospital day 2, when bilateral above-the-knee amputations were performed. In order to conserve as much femur and thigh length as possible, guillotine-type amputations were done. Two full-thickness skin specimens 2 cm in diameter were harvested at the time of the amputation. These were sent to Biosurface Technology Laboratories in Cambridge, Massachusetts for cultured epithelial cell coverage. On hospital day 4 the patient underwent a laparotomy in which a transverse loop colostomy was created and a catheter jejunostomy created. S.S. continued to be stable and on hospital day 6 he was returned to the operating room and his buttocks, perineum and posterior trunk, shoulders, neck, and occipital scalp were debrided and cadaver skin grafts were placed.
Between hospital days 7 and 30, S.S. was repeatedly returned to the operating room. Additional areas of nonviable tissue and nonadherent cadaver skin were excised and the wounds covered with new cadaver skin. On hospital day 30, the cultured epithelial autografts were flown to Pittsburgh and the patient's own skin was harvested in ten-thousandths of an inch thick sheets which were meshed at a 4:1 ratio. These meshed autograft sheets were placed on the patient's posterior trunk, neck, and shoulders. Cultured epithelial cells were placed over the 4:1 meshed autograft and over full-thickness wounds not covered with autograft. The patient was kept in a prone position for the next ten days. Nutritional support with tube feedings via the catheter jejunostomy was continued throughout this phase of treatment. The colostomy functioned well and there was no perineal soiling. On hospital day 40, the posterior aspect of the patient's body was undressed and we found an excellent take of the widely meshed autograft with complete healing of the interstices that had been covered with cultured epithelial autograft (Fig. 3). A few days later the patient was turned from a prone to a supine position and kept on an air flotation mattress.