High voltage electrical shock with multiple life-threatening injuries.

Dear Editor,

In unprotected form, electricity has the potential to produce devastating injuries with heavy functional and esthetic consequences.[1] The reported incidence of electrical current related burn injuries ranges from 3 to 17% of all admissions in burn units.[2] Because of widespread availability and commercial utilization of electrical current, there is increase in electrical current-related injuries from India.[3] A 26-year-old male was brought to the emergency room with the alleged history of burn injuries due to accidental fall of high voltage electric wire on his right shoulder. He tried to keep away the electric wire with his right hand and felt an electric shock. Following which he fell down on the ground. Since the time of injury, the patient was drowsy but arousable. There was no history of vomiting or seizures. On examination, he had tachycardia (pulse rate 120/min). Respiratory rate was 24 breaths/min, temperature was 99o F, and blood pressure was 110/90 mmHg. Oxygen saturation was 98% at room air. His chest examination was normal. Cranial nerves were normal. There were no focal neurological deficits. Random blood sugar was 97 mg/dL. Local examination revealed totally charred right upper limb, second-degree burns were extending up to the shoulder [Figure 1]. Brachial and radial pulses were not palpable. There was amputation of middle finger proximal and distal phalanges, and near total amputation of index finger at distal inter phalangeal joint (DIJ) of right hand [Figure 2a]. There was complete soft tissue loss around proximal phalanges of ring and little fingers of left hand [Figure 2b]. Left ulnar and radial pulses were absent; however, the brachial pulse was present. There were second-degree burns over the posterior aspect of trunk, head, and neck. There was exit wound over the right iliac region with an anterior abdominal wall defect (8 × 6 cm) and exposed intestinal parts [Figure 3]. Arterial color Doppler showed no flow in right brachial, radial, and ulnar arteries. In left upper limb, there was normal biphasic flow in axillary; and brachial arteries, there was no blood flow in radial and ulnar arteries. In right lower limb there was trickle flow in anterior tibial, posterior tibial, and dorsalis pedis arteries. The patient underwent wound debridement. On laparotomy a segment of ileum, 25 cm from ileocolic junction, was found gangrenous with a perforation. This was excised and ilesotomy was performed. The patient underwent right above elbow amputation and left below elbow amputation with wound debridement. Necrotic skin and soft tissue was excised. The patient was managed in burn critical care unit. However, he succumbed to burn injuries on 5th day of injury.

Figure 1

Clinical photograph of the patient showing extensive burns and edema involving whole right upper limb, axilla, and adjacent areas with charring and amputation of digits

Figure 2

(a and b) Clinical photograph showing extensive burns causing charring, tissue loss, and amputation of multiple digits involving both handsb

Figure 3

Clinical photograph showing skin and soft tissue loss exposing underlying structures over right groin

Injuries those are caused by exposure to higher voltage current (1,000 V or greater) are categorized as high-tension electrical bums.[245] Most of the high voltage electrical injuries are accidental; involve young males, particularly those who are electrical workers.[3567] In electrical injuries, electrical energy is converted into thermal energy that causes damage to the skin and underlying tissues.[18910] High-voltage electrical injuries can lead to extensive necrosis, subsequent tissue loss, and severe damage to underlying structures (muscles, nerves, blood vessels, and bones) resulting in amputations, renal failure, and many other systemic complications.[4561112131415] Exit wound on the body of a person is a crucial sign of an electric current and can be the only external evidence of fatal electric current injury.[6] Both entry and exit wounds are seen only in 20% of the cases (mostly on soles of feet).[616] In cases of severe burns with high-voltage current, because of thermal damage to tissue entry and exit, wounds may not be evident.[6] The treatment of high voltage electrical injuries is challenging and requires multidisciplinary team approach.[117] Immediate resuscitation is mainly directed to prevent cardiorespiratory complications as there is a risk to develop respiratory paralysis and ventricular fibrillation.[5] Prompt and vigorous resuscitation to maintain the vital parameters and wound debridement can help to prevent systemic complications and devastating physical disabilities.[141718] In comparison to low voltage current injuries, high voltage current injuries are associated with higher mortality rate.[136192021] There are case reports, where with prompt and appropriate resuscitative efforts patients have survived high voltage current injuries.[17] However, the survivors of high-voltage electrical burns may need extensive surgical debridement and multiple limb amputations.[417]

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