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International Journal of Surgery Case Reports

j o ur na l h o m e p a g e :w w w . c a s e r e p o r t s . c o m

The treatment challenges and limitation in high-voltage pediatric electrical burn at rural area: A case report

Adi Basuki

^a,∗

, Agustini Song

^b

, Nabila Viera Yovita

^d

, Kevin Leonard Suryadinata

^c

, Asian Edward Sagala

^b

aDivisionofPlastic,Reconstructive,andAestheticSurgery,DepartmentofSurgery,Dr.CiptoMangunkusumoNationalGeneralHospital/Facultyof Medicine,UniversitasIndonesia,Indonesia

bS.K.LerikPublicGeneralHospital,KupangCity,EastNusaTenggara,Indonesia

cDivisionofPlastic,Reconstructive,andAestheticSurgery,DepartmentofSurgery,Dr.HasanSadikinGeneralHospital/FacultyofMedicine,Universitas Padjajaran,Indonesia

dDepartmentofPhysicalMedicineandRehabilitation,Dr.CiptoMangunkusumoNationalGeneralHospital/FacultyofMedicine,UniversitasIndonesia, Indonesia

a rt i c l e i nf o

Articlehistory:

Received1March2021

Receivedinrevisedform26March2021 Accepted28March2021

Availableonline1April2021

Keywords:

Electricalburn Pediatric Ruralarea Casereport

a b s t ra c t

INTRODUCTION:Althoughrare,electricalinjuryinpediatricsispotentiallylifethreateningandhassig- niﬁcantandlong-termimpactinlife.Itischallengingtomanagesuchcasesinruralareas.

PRESENTATIONOFCASE:Afullyconscious13-year-oldboywasadmittedtotheemergencyroomafter beingelectrocutedbyhigh-voltagepowercable,withsuperficialpartialthicknessburnoverrightarm, trunk,andleftleg(26%oftotalbodysurfacearea).Tachycardiaandnon-specificSTdepressionwasfound onECGexaminationandwasdiagnosedwithhigh-voltageelectricalinjury.Treatmentswerebasedon ANZBAalgorithmwithseveralmodifications,i.e.,administeringlowerconcentrationofoxygenwith nasalcannulainsteadofnon-rebreathingmaskaswellasKetorolacandAntrain^®foranalgesicinsteadof morphine.

DISCUSSION:Differentchoicesoftreatmentsweregivenduetolimitedresources.Despitepossiblecardiac andrenalcomplication,furthertestscouldnotbedone.Fortunately,afterstrictmonitoring,nosignsof abnormalitywerefound.Weusedsilversulfadiazine,Sofratulle^®anddrysterilegauzeasadressingof choicefollowingimmediatesurgicaldebridement.Thepatientwasobserveddailythrough7daysof hospitalizationandfollowed-upfor1year,achievingnormalphysiologicfunctionoftheaffectedarea butunsatisfactoryestheticresult.

CONCLUSION:Lackofinfrastructure,drugs,andtrainedpersonnelaresomeofthechallengesthatstill existinmostruralareas.Thus,implementationofavailablestandardizedguidelinessuchasANZBA,and givingsimilartrainingtopersonnelaswellasprovidingfeasibleequipmentfollowedbystrictmonitoring forthepatientareneededtoachievemaximumresults.

1. Introduction

Prevalenceofelectricalinjuryinpeopleyoungerthan18years oldis4.6%basedondatafromtheIndonesia’sNationalBurnCenter, CiptoMangunkusumoHospital[1].Eventhoughthepercentageis consideredlow,electricalinjurypossessespotentiallyseveredam- agewhichcancausepermanentchangestoappearance,function, andindependence[2].Itcancausesigniﬁcantandlongtermimpact inlife,especiallyinchildren[3].Despitethedamage,withthesup-

∗Correspondingauthor.

E-mailaddresses:basuki[email protected](A.Basuki),[email protected] (A.Song),[email protected](N.V.Yovita),kevin[email protected] (K.L.Suryadinata),[email protected](A.E.Sagala).

portofskilledpersonnelandtherighttreatment,theirfunctional outcomecanbemaximized[2].

EastNusaTenggaraProvinceranksamongthelowestinDistrict Own-SourceRevenueinIndonesia[4],whichmayhavestalledthe generaldevelopmentoftheprovince.Moreover,inadequatefacili- tiesinhospitals,complicatedgeographicalconditions,andlimited availabletransportationaresomeoftheproblemsthatmightcom- plicatethemanagementofcomplicatedinjuriessuchaselectrical burn,moreoverinthepediatricpopulation.Ourpatientwastreated inoneofthecommunityhealthcarewhichalsohadlimitedfacili- ties,humanresource,andchoiceoftreatmentmodality.Thispaper aimstoelaborateandtoevaluatehowtomanagesuchapatient orinjuryinanisolatedareawithlimitedavailableresources.This paperhasbeenreportedinlinewiththeSCARE2020criteria[5].

https://doi.org/10.1016/j.ijscr.2021.105857

creativecommons.org/licenses/by-nc-nd/4.0/).

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Fig.1.Woundonpresentationattheemergencyunit.

Fig.2. Entrywoundonﬁngersofrightpalm.

2. Presentationofcase

A 13-year-oldmale patientwasbroughtintotheemergency unitbyprivatevehicle30minafterbeingelectrocutedbya20,000 Vwirewithoutanyfirstaidapplied.Onarrival,thepatientwas alert,oriented,andhemodynamicallystable.Pastmedicalhistory andfamilyhistorywereuneventful.Theburnwounds,classified assuperficialpartialthicknessburn,involvedtherightarm,trunk, andtheleftleg.Thetotalburnareawas26%totalbodysurface area(TBSA)(Fig.1)withidentifiableentrywounds(Fig.2)andnot identifiableexitwound.Nocompartmentsyndromewasidentified clinically.TheemergencytreatmentusingthealgorithmfromAus- tralian&NewZealandBurnAssociation(ANZBA)wasappliedby theemergencyroomgeneralpractitionerwithfocusonemergency treatmentandstabilization.Thecollarneckwasnotadministered

Fig.3.Woundaftersurgicaldebridementatoperatingroom.

asthere wasnohistory offalling, noinjury abovetheclavicle, andthepatientcouldmovehisneckwithoutanypain. Oxygen (3L/minute)wasthenadministeredusingnasalcannulasincea non-rebreathingmask(NRM)wasnotavailable,andclothingand accessoriesfromthepatient’sbodywereremoved.

FluidresuscitationwithLactatedRinger’ssolutionwasthenper- formedaccordingtothemodifiedParkland-Baxterformulawithout maintenancefluid,andhourlyurineoutputviaurinarycatheterwas measuredandmaintainedto1mL/kg/hour.Intravenous ketoro- lacwasusedastheanalgesicwithintravenousceftriaxoneasthe prophylacticantibiotic.Tetanusprophylaxiswasnotadministered becauseofcleanwoundandcompletevaccinationstatus.Alltests wereperformed-exceptforunavailableonesi.e.,arterialblood gas,troponin,lactatedehydrogenase,creatinephosphokinase,and urinemyoglobin.Thefollowing abnormalresultsweredetected from:routinebloodexamination(leukocytosis16.10×10⁹/L,SGOT 146.8U/L,SGPT58.5U/L,mildhypokalemia3.4mmol/L)anduri- nalysis(yellow,positiveblood(+++),erythrocyte20–25cellsper highpowerfield).Dailyserialelectrocardiography(ECG)wasper- formedfollowingsinustachycardiawithnonspecificSTdepression onleadIIandaVFfinding.Nasogastrictube(NGT)wasnotadminis- tered.UltrasoundorArterialDopplerexaminationwasunavailable andthusunabletoperform,henceconstantmonitoringofoxygen saturationoftherightupperextremity(theaffectedlimb)using pulseoximetrywasdonetoensureadequateperfusion.

Immediatesurgicaldebridementwasperformedbyanattend- ing general surgeon under general anesthesia (Fig. 3) and the wounddressing waschangedwithin3 days.Theanalgesicwas changed from ketorolac to Antrain^® (metamizole/dipyrone) to achieveoptimalanalgesiapriortodressingchange.Painfulgran-

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Fig.4.Day11:Woundwithcompleteepithelialization.

ulation tissueswith minimum sloughand some bleeding were detected.SerialECGwasstoppedonthethirddayafterthepatient resumednormalproﬁle.Neithersystemicinfectionnordysfunction ofinternalorganswasfoundduringthepatient’sstayinthehospi- tal.Thepatientwasdischargedatthe7thdayofhospitalizationas thepatientremainedstable.

The patient resumed wound care in the surgery outpatient setting withthesameattending surgeon.Wound dressingcon- sisted ofsilversulfadiazineincludingframycetinsulphateBP1%

(Sofra-tulle), and dry sterile gauze wasapplied,until complete epithelializationwasachievedontheeleventhday(Fig.4).Daily useofelasticbandagewithliberal amountof oliveoil(Mustika Ratu^TM)wasadvisedsoonaftercompleteepithelization.

On signs of mild depression, psychiatric consultation was encouraged,butrefusedbythepatient.Duringthe6-month-follow up,signiﬁcantwoundhealingprocesswithnormalpigmentation wasobserved.Therewerenosigniﬁcantmotoric,sensory,orautonomicdysfunction;neitherhypertrophicscarnorcontractureon 1-year post-injury (Fig. 5).However, severalhypopigmentation couldbeseeninthecentralpartofthewound,whichmadethe aestheticresultunsatisfying.

3. Discussion

Thiscasereportrevealsmanyaspectsofelectricalinjuryman- agementinahospitalwithlimitedresource.Theseaspects,while fullyreasonableandexpected,requireattentionandeffortofthe healthcarepersonneltoconstructsomemodificationsinorderto achievethebestpossibletreatmentplanforpatient’ssafetyand wellbeingdespitethelimitations.Inthiscase,ANZBAwasusedas theguidelinewhilesomemodificationswereperformedforthe aspects which wereunable tofulfill. The bestpossiblealterna- tivedevicesorprocedureswereutilizedwiththeaimofachieving optimalwoundhealingandreducingthepatient’smorbidityand mortality.

Fig.5. 1year:signiﬁcantwoundhealingprocesswithseveralhypopigmentedareas –unsatisfyingaestheticresult.

Firstaspectisabouttheﬁrstaidforburninjury.Immediatecopi- ousrunningwaterwasnotappliedduetoinadequateknowledge, whereascopiousirrigationwilllimittheseverityincludingthesize oftheinjury[6].Thecostconsiderationalsoaffectedthedecisionfor theamountofsalineusedforirrigation,andthismightcontribute toundertreatmentdespitethephysician’sadequateknowledge.

Thesecondaspectisaboutoxygenation.AccordingtoANZBA, thepatientshouldhavebeenoxygenatedusingNRM,butsinceit wasunavailable,weusednasalcannulaasthealternativeandfor- tunatelytheSpO₂wasmaintainedat≥95%.Thethirdoneisabout painmanagementwhichiscrucialasburninjuryispainful.Asthere wasnoprocurableventilator,wereplacedintravenousmorphine withanotheranalgesic,yetpainassessmentwasperformeddaily untilthepainwastolerable.

Thefourthandperhapsthemostcrucialpointisthefluidresus- citation.IncontrastwithANZBA,AdvancedTraumaLifeSupport (ATLS)9th Edition book usedat thetime didnot mentionany maintenancefluidwhenresuscitatingpediatricburns[7].ATLSwas commonlyheldasthebasicguidelineforalltraumabymostemer- gencydoctorswhomightnotknowthatthereisaspecificguideline e.g.,ANZBAforburns.Therefore,inaccordancewithATLSguideline, theemergencyunitdoctordidnotgiveanymaintenancefluidto thepatient.Thismighthampertheresuscitationeffortandputthe patientinriskofshock,butweconductedstrictmonitoringofthe patient’svitalsignsinpediatricintensivecareunitandthepatient resumednormalprofileduringhisstay.

Theﬁfthpointisaboutreferral.AccordingtoANZBAguideline electricalinjuryshouldideallybereferredtoaburncenter[2],yet thenearestcitywithsuchfacilityisapproximately1600kmand eventhoughit couldbereachedby planein 2h, theUniversal HealthCoverageofIndonesiadoesnotcoveranytransferbyplane, thereforethepatienthadtobetreatedwithlimitedresourceand facility.

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Our sixth and ﬁnal point is about thediagnostic and treat- mentmodalities.Eventhoughburninjurydiagnosisdidnotneed anysophisticatedmodalities,butthedeﬁnitivediagnosisforthe accompanyingcomplicationssuchasmyocardialinjuryandmyo- globinuriacouldnotbeperformedowingtothefactthatseveral testswerenotavailable,includingarterialbloodgas,troponin,lactatedehydrogenase,creatinephosphokinaseandurinemyoglobin [8].Wecouldonlyperformurinalysis,andalthougherythrocytes werepresent,nocolorchangeindicatedanunlikelypossibilityof myoglobinuria[9].Wesuggestthatitwasduetobloodcontam- inationfromaccidentalurethralinjurywhenplacingtheurinary catheter.

Inelectricalinjurycase,UltrasoundorArterialDopplerexami- nationiscrucialtoensureadequateperfusionoftheaffectedpart ofthebody,aselectricalinjurymaycausegreatdamagetothevas- cularandmusculaturewiththeriskofcompartmentsyndrome.

Unfortunately, our hospital didnot have suchfacility, and the patientwasnotabletobereferredduetocostissue.Asanalter- native,wemeasuredandmonitoredtheoxygensaturationofthe affectedlimbconstantlyusingpulseoximetryandfromadmission todischarge,thepatientresumednormaloxygensaturation.

Asforthetreatmentmodality,NGTshouldhavebeenadmin- istered during ﬁrst aid phase to prevent gastric dilatation [2].

However,inconsiderationofthecostissueandlackofpatient’s cooperation,supportedbynoclinicalevidenceofgastroparesis,we decidednottoinsertanNGTandmadesurethepatientreceived earlyoralfeedingwithin48hofinjury.Forthewounddressing,we preferredtousesilversulfadiazinecombinedwithSofra-tulle^®as astudyfromKaryouteSMshowedthatSofra-tulle^®usedaswound dressinginthiscasecoulddecreasetherateofinfectioninburns ofdevelopingcountries[10].Whilethiskindofdressingmaynot bethemostidealdressingforburnwound,costissuewasthemain consideration.ThemaximumBPJScoverageforsevereburninjury inEastNusaTenggaraasregion4,particularlyforthethird-class wardpatientintypeChospital,isRp6.466.400[11],equivalent to470USD.Itisobviousthattheinsurancewouldnotcoverthe goldstandardtreatment.Anestimatedfeeneededtobepaidfor non-insuranceholdersinourhospitalinvolvingtheintensivecare unit,drugs,anddebridementsurgeryisdoubletheamount,notyet includingthedoctor’svisitanddressingchangefee.Sofra-tulle^® andsilversulfadiazinecombinationwasthebestpossiblewound dressinginoursettingsupportedbyclinicalevidence.

Inadequatemanagementofsevereburninthiscaseisduetothe factthatmostofouremergencydepartmentpersonnelhavenot hadthechancetoparticipateinburninjurymanagementtraining due tothelocationwhichisfarawayfromthebigcitieswhere suchtrainingisusuallyconducted.Lackofpreventionprograms, inadequateburncarefacilities,lackofresources,lackoftrained staff,andpoorinfrastructureaswellascoordinationalsocontribute tothedifﬁcultyandarethedilemmasfacedbymostlow-middle incomecountries(LMICs)[12].

Butwebelievethat,asimportantasunveilingtheseobstacles, theoutcomeofthemodifiedmanagement shouldalsobetaken into consideration.Inthis case, thepatient’s final outcomewas betterthanwhatcouldbeexpectedinsuchcircumstance.Signif- icantwoundhealingwithnormalpigmentationwasobservedon the6thmonthaftertheincident.Therewerenosignificantmotoric, sensory,orautonomicdysfunction;neitherhypertrophicscarnor contracture on1-yearpost-injuryEventhoughseveralhypopig- mentationcouldbeseeninthecentralpartofthewound,which wasalsoexpected,theonlydrawbackinthiscasewasonlytheaes- theticaspect/appearance,yetnosuchdisruptionoffunctionwas found.Consideringthetypeandseverityoftheinjuryinalimited facility,perhapsitwasthebestoutcomepossibleforsuchpatientin suchcircumstance.Basedontheinterviewwiththepatientandhis family,theyfeltsatisfiedandgratefulforthereceivedtreatment

andfree routinefollow-upshomevisit fromtheauthorswhich hadhelpedthemsavingcostandtimewhilegettingappropriate careandadvice.Sincethescarsconsistedofareasmostlycovered byclothes,thepatientdidnotfeelsigniﬁcantlydisturbedbythe scarsandwerequitecontentwiththeprogressoneyearafterthe accident.

4. Conclusion

Inadequateﬁrstaidapplicationshowedthereisstillalackof burnpreventionprogramsinthecommunity.Intacklingthechal- lengeofmanagingpediatricelectrical burnina ruralareawith limitedresourcesandfacilities,thereisa needforacknowledg- ingandmaximizingtheimplementationofavailablestandardized guidelinesANZBAbygivinghomogenizedtrainingtopersonnelas wellasprovidingfeasibleequipment,andthenfollowedbystrict monitoringforthepatient.Inadditiontoadequateburnmanage- mentfor lifesavingand good woundhealing, thefocusshould alsobeaboutburnrehabilitation,psychosocialneedsandanycom- plaintsneedingexpertopinioninanoutpatientsetting.

DeclarationofCompetingInterest

Allauthorsdonothaveanyconﬂictofinterest.

Funding

Allauthors do not receive any sources of funding for their research.

Ethicalapproval

Thestudyisexemptfromethicalapprovalin theinstitution wherethestudywasconducted.

Consent

Writteninformedconsentwasobtainedfromthepatientfor publicationofthiscasereportandaccompanyingimages.Acopy ofthewrittenconsentisavailableforreviewbytheEditor-in-Chief ofthisjournalonrequest.

Authorcontribution

AdiBasuki:studyconceptanddesign,datacollection.

AgustiniSong:datacollection,writingthepaper.

NabilaVieraYovita:dataanalysisandinterpretation,writingthe paper.

KevinLeonardSuryadinata:studyconceptanddesign,dataanalysisandinterpretation.

AsianEdwardSagala:studyconceptanddesign,dataanalysis andinterpretation.

Registrationofresearchstudies

Clinicaltrials.gov, NCT04772573 available at: https://

clinicaltrials.gov/ct2/show/NCT04772573

Guarantor AdiBasuki.

AgustiniSong.

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Provenanceandpeerreview

Notcommissioned,externallypeer-reviewed.

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