Question

Mr. J. is a 30-year-old electrical line worker brought to the emergency department by ambulance. Emergency medical service (EMS) personnel report that he was in a cherry picker that came into contact with an overhead 70,000-volt power line. He lost consciousness at the scene and was intubated. On presentation to the ED, Mr. J. is noted to have areas of black charring on his right arm, axilla, and upper thighs.

Questions

1. What are some potential causes of Mr. J.'s loss of consciousness?
2. What are the initial and secondary management priorities for Mr. J.?
3. During the secondary survey, an indwelling urinary catheter is inserted. You notice dark red-brown

urine draining. What is occurring? Describe the appropriate treatment(s) and rationale for

implementation.
4. During wound assessment, you note moist red and dry, black, charred-appearing areas of the inner

aspect of Mr. J.’s right hand, right arm, right axilla, and bilateral anterior thighs. What is the depth and extent (%TBSA) of his burn wounds? How does a high-voltage electrical injury impact your calculation of burn wound extent?

5. What type of wound care and/or surgical treatment should be expected during the resuscitative phase and later in the acute care phase?

6. Mr. J. weighs 82 kg. What is his estimated fluid requirement during the first 24 hours? Are there any special considerations and assessments that should be made?

7. Name several short- and long-term sequelae and complications that can develop with electrical burn injuries.

8. In addition to nurses and physicians, what multidisciplinary team members should be involved in Mr. J.’s care? When and why should they be involved?

9. What type and route of pain medication should be administered to Mr. J.? 10. What kind of nutrition plan should be implemented for Mr. J.?

Answer 1

1. Potential causes of loss of consciousness are :-

- due to lack of blood flow to the brain

- neurological syncope

- electrical shock

- cranial trauma

- bleeding inside the brain and hematoma formation

- increases intracranial pressure

- uncontrollable electrical activity in the brain lead to seizure the loss of consciousness post shock episode.

2. Initial care is resuscitative care and secondary care is acute or intermediate care which includes :-

- adequate circulation ( CPR and defibrillator)

- maintain airway (providing breathes in between CPR and intubation)

- oxygen therapy

- semi Fowler's position

- vital signs and neurovascular status assessment

- IV fluid therapy

- management of electrolyte imbalance

- prevention of infection

- prevention of hypothermia

- prevention of increased intracranial pressure

- prevention of seizure and fall

- dissolve the hematoma if any present

- strict input and output charting

- wound care

3. In electrical burns injury ,urine of patient is reddish brown in colour due to the presence of myoglobin( a protein present in muscle). Electrical burns cause extreme muscle damage leading to release of myoglobin in urine ( rabhaydomyolysis ) and acute kidney failure.

Sodium bicarbonate and mannitol is given to alkalinise the urine of patient and flush out myoglobin through renal system.

4. According to rule of nine :-

- right arm , right hand and axilla =9%

- anterior bilateral thighs =4.5 +4.5=9%

Total body surface area of burn =18%

There is no impact of high voltage electrical burn on the calculation.of burn surface area . We use rule of nine , palmer method ,lund and browser methods to calculate body surface area of burn.