General Surgery · Year 3 · from General Surgery
Case 2: Electrical Burn
Patient Demographics
- Age: 45 years
- Sex: Male
- Occupation: Electrician
Chief Complaint
Found unresponsive after workplace electrical accident
History of Present Illness
The patient was working on a high-voltage power line (7,200 volts) when contact occurred. Coworkers witnessed him being thrown from the utility pole. CPR was initiated at the scene for approximately 2 minutes before return of spontaneous circulation. He has entrance wounds on his right hand and exit wounds on his left foot.
Prehospital Information
- Witnessed cardiac arrest (ventricular fibrillation)
- Defibrillated x2 with ROSC
- Intubated for airway protection
- C-spine immobilized (fall from height)
Primary Survey
- A: Intubated, secured
- B: Bilateral breath sounds
- C: BP 92/58, HR 116, irregular rhythm
- D: GCS 3T (sedated)
- E: Entrance and exit wounds, fall-related injuries
Burn Assessment
Visible Burns:
- Right hand: Full thickness contact burn (entrance)
- Right forearm: Deep partial thickness
- Left foot: Full thickness (exit wound)
- Surface TBSA appears small (~5%)
However: External appearance underestimates severity in electrical burns
Cardiac Monitoring
- ECG: Sinus tachycardia with occasional PVCs
- Troponin: 2.4 ng/mL (elevated - myocardial injury)
- Continuous telemetry monitoring required
Laboratory Results
- CK: 28,000 U/L (markedly elevated - severe rhabdomyolysis)
- Myoglobin: Markedly elevated
- Creatinine: 1.8 mg/dL
- Potassium: 5.8 mEq/L
- Lactate: 5.2 mmol/L
- Urinalysis: Tea-colored urine, positive for myoglobin
Rhabdomyolysis Management
- Aggressive IV fluid resuscitation (goal UOP 1-2 mL/kg/hr)
- Urine alkalinization (sodium bicarbonate)
- Monitor for compartment syndrome
- Monitor renal function closely
- Avoid nephrotoxins
Compartment Syndrome Evaluation
- Right forearm: Tense, painful with passive stretch
- Compartment pressures measured: 42 mmHg (elevated)
- Fasciotomy indicated
Fasciotomy
- Right forearm fasciotomy performed
- All compartments released
- Muscle appeared partially necrotic
- Wound left open with planned return to OR
Trauma Workup (Fall from Height)
- CT head: No intracranial hemorrhage
- C-spine CT: No fracture
- CT chest/abdomen/pelvis: No traumatic injury
- Thoracolumbar spine: No fracture
- Pelvis X-ray: Intact
Operative Management
First surgery (Day 0):
- Right forearm fasciotomy
- Debridement of necrotic tissue
Second surgery (Day 2):
- Further debridement of right forearm (necrotic muscle excised)
- Left foot debridement
- Wound VAC placement
Third surgery (Day 5):
- Delayed primary closure of forearm fasciotomy
- Right hand debridement - partial amputation of digits 3 and 4 required
- Split-thickness skin grafting to left foot
Hospital Course
- ICU x 7 days
- Renal function recovered (avoided dialysis)
- Cardiac enzymes trended down
- No further arrhythmias
- Extensive physical and occupational therapy
- Psychological support for traumatic injury and digit loss
- Discharged to rehabilitation Day 18
Teaching Points
- Electrical burns: "Tip of the iceberg" - external burns underestimate internal injury
- High-voltage injuries cause deep tissue damage along current path
- Cardiac monitoring essential (arrhythmia risk)
- Rhabdomyolysis management: Aggressive fluids, alkalinization
- High risk for compartment syndrome - low threshold for fasciotomy
- Multiple debridements often required
- Fall-related injuries must be evaluated (secondary trauma)
Clinical Image
Image Description: Clinical photograph of an electrical burn showing the characteristic entry wound with full-thickness tissue destruction. The surface injury often appears smaller than the extensive underlying tissue damage caused by electrical current passing through the body.
Attribution: Image from Wikimedia Commons, Category:Electrical burns. Source: https://commons.wikimedia.org/wiki/Category:Electrical_burns