Management of Critical Burn Injuries: Recent Developments

David J. Dries,John J. Marini 대한중환자의학회 2017 Acute and Critical Care Vol.32 No.1

Background: Burn injury and its subsequent multisystem effects are commonly encountered by acute care practitioners. Resuscitation is the major component of initial burn care and must be managed to restore and preserve vital organ function. Later complications of burn injury are dominated by infection. Burn centers are often called to manage problems related to thermal injury, including lightning and electrical injuries. Methods: A selected review is provided of key management concepts as well as of recent reports published by the American Burn Association. Results: The burn-injured patient is easily and frequently over resuscitated, with ensuing complications that include delayed wound healing and respiratory compromise. A feedback protocol designed to limit the occurrence of excessive resuscitation has been proposed, but no new “gold standard” for resuscitation has replaced the venerated Parkland formula. While new medical therapies have been proposed for patients sustaining inhalation injury, a paradigm-shifting standard of medical therapy has not emerged. Renal failure as a specific contributor to adverse outcome in burns has been reinforced by recent data. Of special problems addressed in burn centers, electrical injuries pose multisystem physiologic challenges and do not fit typical scoring systems. Conclusion: Recent reports emphasize the dangers of over resuscitation in the setting of burn injury. No new medical therapy for inhalation injury has been generally adopted, but new standards for description of burn-related infections have been presented. The value of the burn center in care of the problems of electrical exposure, both manmade and natural, is demonstrated in recent reports.

Histopathological clue in erythema ab igne by electric heater

( In Jae Jeong ),( Seung Hui Seok ),( Ji Hae An ),( Seon Gu Lee ),( Hee Jung Lee ),( Moon Soo Yoon ),( Dong Hyun Kim ) 대한피부과학회 2018 대한피부과학회 학술발표대회집 Vol.70 No.1

Pathological changes due to electrical or classic burn injuries are known mainly by autopsy to identify the cause of death. It is known that changes such as nuclear elongation and palisading appear in electrical lesions and intraepidermal separation is most frequent in electric burn lesions. Our case showed typical histopathologic changes of erythema ab igne by electrical heater. A 62-year-old woman presented with erythematous pruritic annular papules on the both forearms, which developed six month ago. Skin biopsy was performed in forearm lesions. Histopathology revealed elongated cytoplasmic processes extending into the vesicular space from the detached basal cells with elongation of basal and epithelial cell nuclei. Pathologic findings were indicative of electrical or classic burn injuries. Additional history taking revealed that lesions occurred at similar times in the abdomen. The lesion of the abdomen was clinically diagnosed as erythema ab igne. The patient has been using an electrical heater on the abdomen for 6 months. Therefore, the patient's lesions were likely to be caused by the same electrical heater, although the types were different. Use of electrical heater was discontinued and topical calcineurin inhibitor treatment was performed. Herein, we report a case of erythema ab igne by electrical heater highlighting a typical histopathological clue of electric burn.

고압 전기화상의 임상적 고찰

이해욱,김영수,이희송 大韓成形外科學會 1995 Archives of Plastic Surgery Vol.22 No.6

Thirty-eight patients with high-tension electrical burns managed in a 4-year period in the Department of Plastic and Reconstructive Surgery, Han-Il hospital were reviewed. The reviewed items were the sex, age, occupational and seasonal distribution, classification of the high-tension electrical burns, line of voltage, input and output, EKG findings on admission, distribution of % of TBSA and burn areas, amputation rate and sites, number of operation and reconstruction methods, distribution and rate of late complications and hospital days. Majority of patients were male electricians of 3rd and 4th decade, and frequently injured in spring and winter. Most patients were injured by direct electrical injury combined with are burn or thermal burn. Majority of the line of voltage at the time of injury were 22,900 volts. Most common input and output sites were hands and feet. Transient EKG abnormalities such as sinus tachycardia and sinus bradycardia were found in 4(9%) patients of all patients on admission. The extent of the burn was variable according to the type of injury, but most had burn area less than 40% of total body surface. Common burn areas were upper and lower extremities. Amputations were performed in 15(40%) patients and most common site of amputation was below the elbow. Most patients received several operations, and various flap techniques rather than skin grafting were more commonly required to manage the wounds. Late complications, not related to input, output, or surface burn, were noted in 19(50%) patients. Lower leg weakness due to spinal cord injury were noted in 10(53%) patients and cataracts were noted in 5(27%) patients and were common late complications.

전기밥솥으로 인한 유아수부 화상의 임상적 고찰

차상훈,조용근,임동훈,안성열,황귀환 大韓成形外科學會 1993 Archives of Plastic Surgery Vol.20 No.2

We noticed a high incidence of infants burned by steam through the nozzle of the electric rice cooker. The infants were apparently attracted to the cooker by the high pitched sound made by escaping steam during the first minutes after the rice cooked. These burns seemed to manifest more uniform features than the usual child burns such as scalding and flame burns. During the past three and one half years we have studied 86 cases of these burn patients : I. e. burn patterns, environmental background of the family, treatment procedures, various hand deformities, and the timing of surgical intervention. Most of the patients ranged from 8 to 12 month old infants who were in the pediatric developmental stage of being able to creep and/or stand up by holding onto objects. The infants in this stage were attempting to catch the hot, hissing steam and suffered from third degree burns on the hand. The majority of burns were on the volar side of the hand. The unilateral hand was primarily involved. The predilection site was the index finger in one finger burns, and the index and middle finger in multiple finger burns. One finger was involved in 39.3% of all the patients. Cicatrical syndactyly was noted in 18 cases(21.2%) mostly in the second interdigital web. Contracture was also seen. In one-finger burns the PIP joint area was primarily involved(52.6%) : while in two finger burns the MP joint area suffered followed by syndactyly due to scarring. The children at greatest risk were those with less educated mothers, living in a rented traditional Korean home in one or two rooms, whose first child was under 1 year old. The optimal timing of the reconstruction of the scar contracture in the infant was at least 6 months after the burn injury when the scar tissue activity settles down. Earlier surgical intervention will cause post operative recontracture. The donor site for the skin graft were selected in the groin area and non-weight bearing portion of the sole, depending upon graft size needed. For prevention it is necessary that the parents and society learn to recognize the situations under which these infant burns occur.

응급실에 내원한 소아 전기 화상 환자의 임상적 양상과 예방을 위한 노출 요인 분석

박상준 ( Sang Jun Park ),김성욱 ( Sung Wook Kim ),정원중 ( Won Jung Jeong ),오상훈 ( Sang Hoon Oh ),박정택 ( Jeong Taek Park ) 대한외상학회 2015 大韓外傷學會誌 Vol.28 No.3

Purpose: The aims of this study were to discuss treatment and prevention under the age of 18 to identify the characteristics of the electrical burn patients. Methods: We retrospectively reviewed medical records of 97 patients with under age 18 of electric burn who were treated in emergency department of quarterly over 10,000 targets within the desired hospital for evaluation of electrical injuries between January 1, 2009 and December, 2013. We investigated age, gender, injury mechanism, season, degree of burn, surface of burn, complication, blood test, and voltage, kind of current. Results: Of the patients, 50 (50.5%) patients were in the first degree burn and 47 (49.5%) patients were in second degree burn. 68 (70.1%) patients had electric burn at home. 75 (85.2%) of 88 patients had normal sinus rhythm and other 13 people showed a RBBB, VPC, sinus bradycardia, sinus tachycardia. 41 (42.3) of 97 patients were in infants and 26 (26.8%) patients were in adolescence. Conclusion: The results of this study emphasize the need for prevention of electricity at home for childhood and education of the adolescence. [ J Trauma Inj 2015; 28: 170-176 ]

Transcranial magnetic stimulation can diagnose electrical burn-induced myelopathy

Seo, Cheong Hoon,Jang, Ki Un,Lee, Byoung Chul,Choi, Ihn-Geun,Kim, Jong Hyun,Chun, Wook,Jeong, Je Hoon,Kang, Tae-Cheon Elsevier 2011 Burns Vol.37 No.4

<P><B>Abstract</B></P><P><B>Introduction</B></P><P>We conducted motor- and sensory-evoked potential analyses and investigated their diagnostic value in differentiating between electrical burns without evidence of neurologic injury and those with clinical evidence of myelopathy.</P><P><B>Methods</B></P><P>We studied high-voltage electrical burn injury patients with lower extremity weakness and evidence of myelopathy and those without any evidence of neurological complications. Motor-evoked potentials (MEPs), somatosensory-evoked potentials (SEPs), and MRI studies of the spinal cord, as well as transcranial magnetic stimulations, were performed. The central motor conduction time (CMCT) was also calculated.</P><P><B>Results</B></P><P>The upper limb MEP and upper and lower limb SEP variables did not statistically differ between the 2 groups. The CMCT and total motor conduction time recorded in the lower limb were delayed in the burn myelopathy group. MRI revealed no abnormal signal changes in myelopathy patients.</P><P><B>Conclusion</B></P><P>Our study demonstrates that MEP is useful in identifying myelopathy in patients who have sustained high-voltage electrical burns.</P>

후경골 동맥 유리 피판에 의한 수부 전기 화상의 재건

최수중,서은민,이창주,장준동,김석우,이상훈,이동훈,서영진,Choi, Soo-Joong,Seo, Eun Min,Lee, Chang Ju,Chang, Jun Dong,Kim, Suk Wu,Lee, Sang Hun,Lee, Dong Hun,Seo, Young jin 대한미세수술학회 2004 Archives of reconstructive microsurgery Vol.13 No.1

Introduction: The hand and wrist are particularly susceptible to electrical burn. Skin defect with damage or exposure of underlying vital structure requires coverage by skin flap especially in case of the need for late reconstruction. We are reporting 4 cases of electrical burned hand treated by posterior tibial arterial free flap. The commonly used skin flaps such as scapular flap or groin flap are too bulky so that they are not satisfactory in function and cosmetic appearance. So we tried to cover them with a more thin skin flap. Materials and Method: From January 2002 to June 2003, four cases of hand and wrist electrical burn were covered using posterior tibial arterial free flap. All the cases were due to high voltage electrical burn. Age ranged from 31 years to 38 years old and all the cases were male patients. Recipient sites were 2 wrist, one thenar area and one knuckle of 2.3rd MP joint. Additional procedures were flexor tenolysis (simultaneous), FPL tenolysis and digital nerve graft (later) and extensor tendon reconstruction (later). Result: All the flap have survived totally without any complication including circulatory concern about the donar foot. Posterior tibail arterial free flap was so thin that debulking procedure was not required. Conclusion: For skin coverage of the hand & wrist region, posterior tibial arterial free flap have many advantages such as reliable anatomy, easy dissection and easy anastmosis with radial or ulnar artery and possibility of sensory flap. The most helpful advantage for hand coverage is its thinness. So we think this flap is one of the very useful armamentarium for reconstructive hand surgery.

Toe Tissue Transfer for Reconstruction of Damaged Digits due to Electrical Burns

Kim, Hyung-Do,Hwang, So-Min,Lim, Kwang-Ryeol,Jung, Yong-Hui,Ahn, Sung-Min,Song, Jennifer K. Korean Society of Plastic and Reconstructive Surge 2012 Archives of Plastic Surgery Vol.39 No.2

Background : Electrical burns are one of the most devastating types of injuries, and can be characterized by the conduction of electric current through the deeper soft tissue such as vessels, nerves, muscles, and bones. For that reason, the extent of an electric burn is very frequently underestimated on initial impression. Methods : From July 1999 to June 2006, we performed 15 cases of toe tissue transfer for the reconstruction of finger defects caused by electrical burns. We performed preoperative range of motion exercise, early excision, and coverage of the digital defect with toe tissue transfer. Results : We obtained satisfactory results in both functional and aesthetic aspects in all 15 cases without specific complications. Static two-point discrimination results in the transferred toe cases ranged from 8 to 11 mm, with an average of 9.5 mm. The mean range of motion of the transferred toe was $20^{\circ}$ to $36^{\circ}$ in the distal interphalangeal joint, $16^{\circ}$ to $45^{\circ}$ in the proximal interphalangeal joint, and $15^{\circ}$ to $35^{\circ}$ in the metacarpophalangeal joint. All of the patients were relatively satisfied with the function and appearance of their new digits. Conclusions : The strategic management of electrical injury to the hands can be both challenging and complex. Because the optimal surgical method is free tissue transfer, maintenance of vascular integrity among various physiological changes works as a determining factor for the postoperative outcome following the reconstruction.

Capacitive coupling leading to electrical skin burn injury during laparoscopic surgery

Woo Jun Kim,손경모,In Young Lee,윤성욱,Gye Rok Jeon,신동훈,Myung Sook Kwon,Jae Yeong Kwak,백광렬 대한내시경로봇외과학회 2022 Journal of Minimally Invasive Surgery Vol.25 No.3

Purpose: Trocar-site burns occurring during laparoscopic surgery have been reported in various cases, and several efforts to reduce them are underway. This study aimed to analyze the effect of capacitive coupling on trocar site by observing electrical and histological changes for electrical skin burn injury. Methods: To measure the electrical changes relating to capacitive coupling, the temperature, current, voltage, and impedance around the trocar were measured when an open circuit and a closed circuit were formed using insulation intact instruments and repeated after insulation failure. After the experiment, the tissue around the trocar was collected, and microscopic examination was performed. Results: When open circuits were formed with the intact insulation, the impedance was significantly reduced compared to the cases of closed circuits (142.0 Ω vs. 109.3 Ω, p = 0.040). When the power was 30 W and there was insulation failure, no significant difference was measured between the open circuit and the closed circuit (147.7 Ω vs. 130.7 Ω, p = 0.103). Collagen hyalinization, nuclear fragmentation, and coagulation necrosis suggesting burns were observed in the skin biopsy at the trocar insertion site. Conclusion: This study demonstrated that even with a plastic trocar and electrosurgical instruments that have intact insulation, if an open circuit is formed, capacitive coupling increases, and trocar-site burn can occur. When using electrocautery, careful manipulation must be taken to avoid creating an open circuit to prevent capacitive coupling related to electrical skin burn.

전기감전 화상환자의 신경 손상에 대한 연구

김민욱,김재형,이종민,백남종,강민정,김병식 大韓再活醫學會 1999 Annals of Rehabilitation Medicine Vol.23 No.4