Scalp, electrical burn
A 25-year-old man was injured by a high voltage electric shock, affecting his scalp, right wrist, and left thigh. He initially presented at the emergency department of a large regional hospital in the Netherlands, where it was not recognized that he had sustained a high voltage injury. This led to an incomplete primary and secondary survey. Three days after the trauma, the patient was transferred to a Dutch Burn Center. This case study focuses on the impact of an electrical burn and the surgical treatment of the scalp burn.
The patient was referred to a Burn Center three days after the injury. He did not remember the exact circumstances of his injuries, but he remembered waking up on a patch of grass with multiple injuries. He went home and his mother found him in his bed with injuries that she suspected were burn wounds. Later, it was discovered that the patient had been attempting to steal copper wire from an electricity substation and sustained an electrical injury from a direct current of 10,000 Volts.
Once injuries were classified as electrical injuries, the patient’s body was evaluated for more wounds.
Scalp and face
The patient’s face was swollen, with hematomas around both eyes. The patient was able to open the right eye, revealing red conjunctiva. On the right temporal side of the face, a dry, charred, seemingly avital wound was seen. No capillary refill was present. This subdermal wound affected 1% of the total body surface.
The circular wound around the wrist was classified as a superficial partial thickness burn. The large left thigh wound was classified as a full thickness burn wound. No signs of compartment syndrome in the limbs were found.
The Burn Centre performed a series of diagnostic tests on the patient who as he had not received proper primary and secondary surveys at the referring hospital. These tests included an ECG, which showed no dysrhythmias, a full blood count, complete metabolic profile, lactate, troponin and CK. The CK was slightly elevated, but as urine was not pigmented, increasing the intravenous infusion was deemed unnecessary. Cultures were taken from all the wounds, and an ophthalmologist ruled out corneal involvement, recommending the use of artificial tears.
A CT scan performed at the ER of the first hospital revealed multiple facial fractures on the right frontoparietal side of the face, affecting the right orbital rim, the frontal, ethmoidal and maxillary sinuses. Daily wound dressing was done by applying a synthetic, non-adhesive gauze soaked in an ointment containing fusidic acid. The patient also started Nicotine replacement therapy to help in the healing process, as smoking would delay wound healing.
The success of the reconstruction in this case depended on the viability of the underlying structures. A MRI scan was performed and revealed that while the underlying skull was damaged, the inner lining of the skull, the dura mater, still appeared viable. Additionally, multiple facial fractures and edematous right masseter muscle were present.
To address the deep burn wounds and expected exposed bone after debridement, a temporoparietal fascia flap (TPF) flap was chosen for the reconstruction. The temporal artery was identified using color Doppler imaging, and the TPF flap was designed and drawn on the overlying skin.
After debriding the defect, the fascia flap was dissected and freed from the overlying skin from the cranial, posterior and anterior edges, and its pedicle, the temporal artery, was rotated into the temporal defect. An unmeshed split thickness skin graft (SSG) from the thigh was placed over the flap and fixed using monocryl 4.0. To allow for drainage, multiple incisions were made in the SSG and a drain was placed at the donor site.
The patient required a second surgery to repair the wound on his head. Initially, both local flaps and a free flap were considered, but it was determined that local flaps would not be able to cover the wound. As a backup plan, an anterolateral thigh (ALT) flap from the non-injured right leg was considered. However, due to potential damage from the high voltage current, the right temporal artery and veins were not considered as a viable receptor site.
After debridement of the wound, it was determined that necrosis was present only at the edges and anteriorly. Fortunately, an estimated 70% of the tissue pedicle flap (TPF) was still intact. Therefore, local advancement flaps were favored over a free flap.
Three local flaps were combined to repair the wound: a rhomboid flap from the preauricular area, an advancement technique for the forehead, and a large parietal rotation flap. The parietal rotation flap included the initial TPF flap and was advanced to cover the anterior portion of the wound. A split-thickness skin graft (SSG) meshed 1:1.5 was used to cover the posterior portion of the wound. However, a small part of the skull measuring 1 cm in diameter remained uncovered.
Shortly after the surgery, the culture taken at admission showed Staphylococcus aureus and group-A streptococci. The patient was treated with cephalosporin intravenously for 24 hours, followed by clindamycin orally. Two days after the surgery the SSG appeared viable.
One week after surgery the wound was covered with pus. It was debrided and dressed with Flaminal®. The periphery of the flap had become necrotic and approximately 30% of the flap was lost. Bone was exposed after one month.
One week after the initial surgery, the wounds were inspected and the remaining defect was dressed with Flaminal®. Three months after the surgery, it was observed that the small defect had grown from 1 centimetre in diameter to 2x3 centimetres. The patient and the surgical team decided to wait and see how the wound would heal before taking further action. After five months, the wound bed was deemed ready for a full-thickness skin graft to cover the last remaining defect. (See Surgery 2)
Assessing and classifying burn injuries can be challenging, especially when the patient is unable to provide reliable information. Structured assessment during the primary and secondary survey, along with input from family members or carers, can help to identify and classify the injury. This is particularly important in cases of electrical injury, as amnesia can be a symptom.
In cases of significant electrical injury, continuous cardiac monitoring for 24 hours is necessary to detect any potential dysrhythmias. The decision-making process for reconstructive surgery can also be complex. In this case, the local advancement techniques did not provide full coverage of the bone, and the small remaining defect took longer to heal than expected.
Clear communication is essential throughout the treatment process, particularly when addressing uncertainties. The patient and his mother emphasized the importance of discussing different surgical options and expressing concerns. This helped to build trust between the patient and the medical providers.