Case Study - Electrical Burn in Disasters and Conflicts

Original Editors - Naomi O Reilly

Top Contributors - Naomi O'Reilly, Kim Jackson, Jess Bell, Chelsea Mclene and Rishika Babburu      

Title

Burns to right hand and both feet following a hi-voltage electrical injury.

Thanks to Humanity and Inclusion for Case study taken from Early Rehabilitation in Conflicts and Disasters - Field Handbook

Abstract

Mr K is a 23-year-old man who presented to to health services two days following a high-voltage injury resulting in burns to his right hand and both feet, while trying to gain access to electricity. Mr K was breathing spontaneously with no burns to the chest or abdomen and no obvious other life-threatening chest injuries or central neurological concerns.

Key Words 

Burns, Electrical, High Voltage

Patient Characteristics

Background

Mr K is a 23-year-old man who sustained a high-voltage electrical injury trying to get some electricity and has presented two days later with burns to his right hand and both feet.

Examination Findings

A: Airway and C-spine Control

• No history of added trauma and no C-spine injury suspected.
• He may have stopped breathing at the scene, no-one is sure: he is now awake but confused
• No C-spine management required.
• Give patient oxygen and monitor closely

B: Breathing

• Spontaneously breathing with normal breath sounds throughout.
• RR of 22 BPM
• There are no burns to chest or abdomen
• No obvious other life-threatening chest injuries

C: Circulation

• Patient is not bleeding from any wounds.
• Pulse is 130 but seems irregular.
• BP is 100/70
• He has deep burns to the volar aspect of his right forearm and wrist with some swelling but good capillary refill.
• He needs to be closely monitored, as he may require fasciotomy because he has had a high-voltage injury, which leads to significant muscle damage:
• Liaise with medical team Medical team to insert cannulas and start fluid therapy and set up ECG monitor for heart rate

D: Disability

• Mr K is conscious and talking when spoken to (V on the AVPU scale)
• There appears to be no central neurological concerns.
• Due to area of injury there will, however, likely be peripheral nerve damage
  • Median Nerve in Upper Limb
  • Peroneal Nerve in Lower Limbs

E: Exposure

• Patient is able to sit up independently
• Burns evident on right arm and both feet
  • Burn on left leg does not extend very far but it is circumferential and the foot is swollen, as is the right wrist (escharotomy may be necessary in both regions plus or minus fasciotomy).
• No other obvious injuries.
• Ensure patient is kept warm

F: Fluid Resuscitation

• From a TBSA point of view, 7% is not a ‘resuscitation burn’, but we are concerned for deeper tissue damage, therefore medical team needs to lead on this.
• Liaising with medical team is vital, as after 48 hours of initial injury, if Mr K was in need of escharotomy/fasciotomy, it might be too late: The patient would then have a high risk of requiring amputation.
  • It is important to then monitor urine output, pulse, BP and capillary refill and continue to assess HR with ECG
  • Continue to monitor for further swelling or signs of compartment syndrome in right arm and both legs

Pain Management

• Linking with medical team
• Ensure pain management is covered to include prechange of dressings (CODs)/therapy analgesia

Wound Care

• Discuss with medical team what the plan is for Mr K’s wound care
  • Likely he will need escharotomy and all wounds will need to be cleaned and dressed.
  • Therapy ties in well to COD’s and is a chance to check on wound healing/assess for complications

Rehabilitation

Treatment

• Currently there is no indication for the need for chest physiotherapy.
  • However, continue to monitor respiration/cough etc.
• Elevate arms gently, notably hand and wrist, and keep abducted and extended. Keep monitoring fingers to check on his circulation.
• Elevate feet and keep in position of function (plantigrade splint).
  • NB, it is highly likely he will require bilateral amputation; however, it is vital to maintain correct position, even if there is a later decision to amputate
• Splint right forearm/wrist.
  • Get patient to keep moving fingers
  • Use local foam to encourage palmar contours and to create web-spaces (especially between fingers two and three).
  • Aim to keep the interphalangeal joints extended and the metacarpal joints in neutral
• Continue to monitor cardiac signs for dysrhythmias and signs of swelling
• Teach appropriate active and passive ROM and stretching exercises
• Assess and advise on mobilisation
• Ensure patient is feeding and has sufficient analgesia
• Document everything clearly and COMMUNICATE everything clearly to patient and his family

Goals

Short-term

• The burns are very deep and will require debridement and graft and/or amputation.
• Nerve and tendon exploration by plastic surgeon:
  • Will need to be considered to check for damage to these tissues
  • Patient is deemed a complicated patient and needs to be managed in an advanced facility

Long-term

• Assess stage of scar maturation and patient’s acceptance of altered body image and function
  • NB, patients that present early from NON-war wound injuries should NOT need prophylactic antibiotics.

Expected Outcomes

The ideal outcome is that wound and soft tissue healing is complete with maximal ROM achieved. Additionally, ensuring previous function, cardiovascular endurance, independent ambulation and independent activities of daily living is key to optimal recovery. Longer-term, the focus should also encompass scar management and psychological motivation.

• Continuing prevention and treatment of contractures and joint deformities
• Continuous management scarring (hypertrophic)
• Possible need for surgery/further surgery for delayed healing wounds and/or contractures
• Pain management
• Management of scar hypersensitivity and pruritis (itching)
• Neuropathy
• Therapeutic pharmacologic and non-pharmacologic
• Reconditioning to activities and participation of functional activity
• Psychological considerations – burns are known to have psychosocial impact on patients, whether in the acute or longer rehabilitation phase:
  • Depression and/or PTSD (post-traumatic stress disorder)
  • Impact on relationships
  • Support for community Integration
• Body image dissatisfaction (culture may increasingly influence this)
  • Especially consider the greater cosmetic and psychological impact for the face
• Children – growth considerations
• Maintaining good nutritional and fluid intake,
• Seeking sun protection (for scarring)
• Padding to reduce shearing on scarring
• Waring of protective gloves for hands