Case Report: Burn injury on left hand ulceration and gangrene and debridement “Case report.”

Background

Electricity constitutes a fundamental component of contemporary life, powering the majority of appliances and devices, including indispensable ones such as refrigerators. Nonetheless, it is of paramount importance to exercise utmost caution when dealing with electricity, as even the slightest oversight or wiring hazard can precipitate tragic consequences, including loss of life.

A 27-year-old male presented to our hospital with burns on his thighs and feet. He reported a history of an electrical burn on his right hand caused by an electrical socket at home while attempting to replace the light bulb. The wire from the socket came into contact with the thighs and feet. Initially, the family took him to a private hospital, but he was subsequently referred to a tertiary healthcare facility. The patient had a history of loss of consciousness at home and had no reported chest discomfort, head trauma, or breathlessness. There had no family history of diabetes or hypertension. Initially, the family took him to a private hospital, but he was subsequently referred to a tertiary healthcare facility. The patient had a history of loss of consciousness at home and had no reported chest discomfort, head trauma, or breathlessness. There had no family history of diabetes or hypertension. Initially, we included a color dropper study of the right hand and radiographs. The patient underwent wound dressing using aseptic techniques, and was admitted to the surgical intensive care unit for further management. An imperative aspect of education and awareness involves proper instruction for safely handling electrical equipment, the use of appropriate clothing and protective gear while handling such equipment, and the importance of switching off power supplies to reduce the incidence rate of such incidents.

Introduction

Electrical power is an indispensable necessity for the majority of us in the modern world. It powers a wide array of essential equipment including refrigerators. However, it is crucial to recognize that even the slightest lapse in electrical safety or hazardous wiring can lead to catastrophic consequences, including loss of life.¹ Despite our profound dependence on electrical power, caution must be exercised in its utilization. The unsettling reality is that India, like many nations, has witnessed a distressing number of accidents resulting from electrical issues.² According to the National Crime Record Bureau (NCRB), in 2015 alone, over 2,200 individuals lost their lives because of unintentional fires triggered by short circuits. It is worth nothing that these statistics grim as they may be, pale in compression with the staggering figures of the subsequent year, which saw over 11,000 electrical incidents across the nation, with approximately 4,800 proving fatal.³ The term “burn” encompasses injures incurred through direct exposure to a variety of sources, such as electricity, heat, chemical, or radiation. Human skin, the largest organ, comprises several layers, each with distinct characteristics. Burns are (superficial) burns affecting the epidermis, second-degree (partial thickness) burns impacting the epidermis and possibly some dermal layers, and third-degree (full thickness) burns penetrating deep into tissues, including muscle and bone. Precise assessment of burn depth is vital for effective treatment, and various methods such as the Palmer method, the Lund Browder strategy, and the rule of nine aid in this determination.⁴ Among all types of burn injuries, electrical burns are the most devastating.

Although most thermal or electrical burns cannot be predicted by physical examination or by the size or severity of the burn, the heat produced by electric current causes tissue damage.⁵ Electric burn injuries are caused by the quantity of current that leaves the body upon contact as well as the source and timing of the contact. Heat is produced by electricity passing through nerves and blood vessels and along the outside of bones, which damages the adjusting tissue.⁶ In this compressive research, we delve into the intricate realm of electrical burn injuries, aiming to shed light on their multifaceted nature and the challenges they pose to medical professionals and patients. Exploring the various factors influencing the severity of electrical burns and examining the diverse and valuable resource resources for healthcare practitioners and researchers working in the field of burn injury management. Additionally, our study endeavors to increase awareness among the general population regarding the importance of electrical safety measures and the potential consequences of neglecting them. Through a thorough analysis of case studies, clinical insights, and the latest advancements in burn care, we aimed to contribute to the prevention and mitigation of electrical burn injuries, ultimately safeguarding lives and prompting safer practices in our technologically driven world.

Case presentation

A 27 years old male presented to our hospital with burn injuries affecting his thighs and feet. He reported a history of an electrical burn on his right hand sustained while attempting to fix a light bulb at home. During this incident, the electric socket wire contacted the thigh and foot. Initially, his family sought care at a private hospital where the initial management was provided. However, owing to the severity of his injuries, he was referred to our tertiary healthcare facility. The patient reported loss of consciousness at the time of the accident but denied experiencing any chest discomfort, head trauma, or breathlessness. In addition, there was no family history of diabetes mellitus (DM) or hypertension (HTN).

Upon examination, physical findings revealed significant blackening of the skin and ulceration of the right arm, indicative of a third degree. Contractures were observed at the dorsal phalanges and proximal phalanges of the right hand, affecting the second, third, fourth, and fifth digits. Furthermore, the index finger exhibited a 4 × 4 cm area of the third-degree burn with black discoloration of the lateral aspect of the forearm, thigh, and foot displayed similar third-degree burns, accounting for the respective areas as per the Rule of nine (figure 1). A color Doppler study of the right hand demonstrated non-visualization of the distal radial and ulnar arteries in the raw wound area. An X-ray scan of the affected tissues yielded normal findings. An aseptic dressing was applied and the patient was admitted to the surgical intensive care unit with a diagnosis of third-degree burns, ulceration, and gangrene.

The attending physician recommended debridement of the patient’s right hand. Laboratory investigations revealed the following results: hemoglobin (Hb), 13%; total red blood cells 4 million/ul, total white blood cells, 11,300/μL; mean corpuscular hemoglobin concentration (MCHC) 93.3 g/dl, mean corpuscular hemoglobin (MCH), 32.5 pg; hematocrit (HCT), 37.5%; and total platelet count 5.79 lakh/ul. Blood coagulation profiles were as follows: activated partial thromboplastin time (APTT) 29.5 second (control 30.7 s), prothrombin time (PT) 11.9 seconds, and intentional normalized ratio (INR) 1.97. Urinalysis was negative for albumin, with 1-2 pus cells and 1-2 red blood cells. Biochemical blood profile indicated a urea level of 31 mg/dl, creatinine levels of 0.7 mg/dl, sodium level of 140 mEq/L, and potassium levels of 4.9 mEq/L. The patient’s Glasgow Coma Scale (GCS) score was normal, and neurological assessment revealed no abnormalities.

The patient was diagnosed with ulceration of the hand resulting from an electrical burn black skin discoloration. The general surgeon recommended wound debridement and amputation, if deemed necessary. Subsequently, the patient underwent serial wound debridement was performed. The extent of amputation was determined based on the vascularity and burn depth. Local neurodebridement was performed to address existing wounds bilaterally on the thighs. Additionally, the left upper limb was immobilized using a plaster cast. Wound culture analysis was recommended and the surgeon suggested a groin flap procedure to cover the exposed tendons. Daily debridement and dressing of the right hand were initiated, along with split skin grafting on the left thigh after debridement. A Vac dressing was applied to the right arm. The patient was advised to lie in the supine position and perform active-assisted toe movements on both sides (20 repetitions), active-assisted knee bending exercises, and static quadriceps exercises (10 repetitions each). Upper limb mobility exercises (10 repetitions) were performed by the physiotherapist.

The patient’s dietary intake was supervised by a dietitian, with recommendations to consume 2200 kcal/day with a high-protein, low-fat, and high-fiber diet. The treatment plan consisted of the following postoperative interventions. NBM (nil by mouth) status for 8 hours, intravenous fluid: Dextrose Normal Saline (DNS) at 100 mL/hr, Intravenous antibiotics Inj Ceftriaxone 1.5 mg, gastrointestinal protection: Inj Pantoprazole 40 mg, Analgesic: Inj paracetamol 100 mL and Inj. Tramadol SOS, limb elevation, intramuscular “diclofenac sodium (Dynapar)” SOS and oral antibiotic Cefixime 200 mg, “Vitamin C (Limci) 2”. SOS, Regular assessment of the wound healing progress, including monitoring for signs of infection, necrosis, or delayed wound healing, was advised. After a couple of weeks, the patient demonstrated remarkable resilience and cooperation with the treatment plan. Serial wound debridement sessions, coupled with meticulous dressing changes, led to gradual improvement in the condition of the right hand the groin procedure flap procedure successfully covered the exposed tendon, contributing to the overall healing process. The left thigh, which had undergone split-skin grafting, exhibited healthy granulation tissue formation, signalling a positive response to treatment. Throughout hospitalization, the patient’s vital signs remained stable, with no signs of infection or systemic complications. Laboratory parameters consistently showed values within the normal range, indicating a positive response to treatment. Meticulous care provided by the healthcare team, coupled with the patient’s determination, yielded a promising outcome. The patient was educated on the importance of post-discharge care, including wound healing care and physical therapy, to optimize long-term recovery.

Discussion

Refrigerators are among the numerous modern appliances that rely on energy consumption for their operation. However, even the slightest negligence or wiring-related hazards can lead to catastrophic consequences. Our dependency on electricity necessitates a prudent approach for its use. The statistics of electrical accidents in India offer little solace, with the National Crime Record Bureau (NRCB) reporting nearly 2,200 fatalities resulting from unintentional fires caused by short circuits in 2015.⁷ It is worth noting that the subsequent year witnessed over 11,00 electrical mishaps nationwide, with 4,800 incidents resulting in fatalities. Burns, in this context, encompass injuries caused by direct contact with electrical, thermal, chemical, or radioactive sources.⁸

Classification of burns involves several layers of the skin, with first-degree burns affecting the epidermis and potentially the dermis, second-degree burns affecting the epidermis and potentially portion of the dermis, third-degree burns encompassing damage to the epidermis, dermis, and occasionally subcutaneous tissue, and fourth-degree burns extending their harm to deep tissue, muscles, and even bone.⁹ Techniques such as the palmer method, Lund- Browder strategy, and rule of nine are commonly employed for assessing burn extension. Electrical burns are the most severe and intricate cause of burn injuries.¹⁰ The heat generated by the passage of electrical current is responsible for tissue damage, although the size and severity of thermal or electrical burns are often challenging to predict through physical examinations.⁶ Electric burn injuries are influenced by factors such as the amount of current exiting the body upon contact, source of electricity, and timing of contact. Heat is generated as electricity courses through blood vessels, nerves, and along the surface of bones, causing damage to the surrounding tissue.

Illustrating the gravity of electrical burns, we present a case involving a 13-years-old boy who sustained severe burns while using a mobile phone in a bathtub. Upon hearing the child’s distress, the mother removed him from the bath and disconnected the charger, experiencing muscle spasms and momentary loss of consciousness. The boy was revived using a hard tap on his shoulder. Evaluation following the Advance Trauma Life Support guidelines revealed stable hemodynamic and respiratory conditions. Physical examination revealed two deep lesions: a circumscribed, oval-shaped lesion measuring approximately 1 × 1 cm on the palmar side of the hand between the thumb and index figure, displaying a central pallor, and a lacerated strip of skin measuring approximately 1 × 12 cm on the abdomen near the epigastric region. The total body surface area was less than 0.5%. Remarkably, the patient exhibited a significantly elevated blood creatinine kinase (CK) level of 1294 μ/L. Electrical heart scans yielded normal results. The patient was admitted to the pediatric ward for observation and a tertiary survey, during which his CK level increased slightly to 1400u/l. Myoglobinuria was detected in the urine, but no signs of rhabdomyolysis were observed. Given the absence of complaints or anomalies in the tertiary survey, the patient was discharged on post-burn day 2.¹¹

To mitigate the risk of electrical burns, it is imperative that users exercise caution when using electrical equipment in bathroom settings. Electrical devices or cords should never be connected to a power source when in close proximity to water or when exposed to moisture.¹²

A study conducted at Manipal shed light on the demographics of electrical burn victims, with the majority being male(99.0), aged between 18 and 40 (70.4%), and primarily consisting of unskilled laborers (56.8%), employed linemen or electricians (29.6), and farmers (11.1%).¹³

In another case, a 27-year-old male was admitted to our hospital with burns on his thighs and feet. He reported a history of electric burns on his right hand when a live wire from an electric socket made contact with his thigh and foot while he was fixing a light bulb at home. Initially, the family sought care at a private hospital before he was referred to our tertiary healthcare facility. Physical examination revealed skin blackening, ulceration, and third-degree burns on the right hand, with contractures affecting the dorsal and proximal phalanges, specifically the 2^nd, 3^rd, 4^th, and 5^th phalanges. Additionally, blackening of the forearm, thigh, and foot was observed, as per the rule of nine. A color Doppler study of the right hand indicated non-visualization of the distal radial and ulnar arteries due to the raw area, while X-ray findings were unremarkable. Aseptic dressing was performed and the patient was admitted to the surgical ICU with a diagnosis of third-degree burns, ulceration, and gangrene. The medical team recommended wound debridement and, if necessary, amputation of the right hand because of black discoloration of the skin. Local neurodebridement was performed for the exit wound in both thigh regions and limb elevation with plaster application was initiated in the left upper limb. Split skin grafting was performed on the left thigh after debridement, along with the application of a Vac dressing to the right arm. The patient was advised to remain in a supine position.¹⁴

Conclusion

In 2015, 2,200 lives were tragically lost due to unintended fires caused by short circuits, as reported by the National Crime Records Bureau (NCRB). The gravity of the statistic is further underscored by the subsequent year’s record, which revealed a staggering 11,00 electrical accidents nationwide, with a devastating 4,800 resulting in fatalities.

It is imperative to emphasize the significance of prompting safety practices in the use of electrical equipment. These include adhering to safety instructors, wearing appropriate clothing and protective gear, and diligently disconnecting power sources when not in use. It is also essential to address the specific risks associated with using home electrical equipment in bathrooms, ensuring strict adherence to safety regulations and standards.¹⁵

Consent

Written informed consent was obtained from the patient for the publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of the journal.