Rationale. Taking into account the incidence and the severity of electrocutions, we consider it extremely necessary to find effective, appropriate and particularized therapeutic solutions aimed at improving the survival, decreasing the mortality, ensuring a superior functional and aesthetic effect and facilitating the social reintegration.
Given the severity of the general condition of the electrically injured patient and the fact that any worsening of the lesions has a systemic echo, the selection of the timing for re-excision is very important.
The postponement of the surgical timing can break the precarious metabolic equilibrium and can hasten the installation of the multisystem organ failure (MSOF).
Objective. The study is intended to establish a possible connection between the clinical evolution of the electrically injured patient and the dynamics of three important biological parameters, able to provide data concerning the therapeutic attitude to be followed.
The patients with a diagnostic of high-voltage electrocution, who will be admitted to the Clinic, will be followed for a period of 2 years. The parameters to be followed daily will be:
- Creatin-kinase, as a marker of muscular damage
- Hemoglobin, as a marker of tissue oxygenation
- Leukocytes, as an indicator of a possible septic evolution.
The therapeutic alternatives, including the administration of antiplatelet drugs will be studied.
Methods and Results. In the period October 2010-June 2013 a total of 12 cases of high-voltage electrocution were admitted in our clinic. Among these, some could be placed in the study of 7 cases, as the remaining patients died within the first 24 hours of hospitalization due to the endured lesions.
All the patients were admitted to the ICU ward that supported the treatment and monitoring until their stabilization, at which time they were transferred to the ward.
All the patients received anti-thromboxane treatment from their admission (injectable NSAIDs associated with antisecretory drugs). By mutual agreement with ICU service, Dipyridamole was not introduced because of the “steal effect” in the viable areas to the detriment of the already ischemic areas, the drug effect being obvious in vitro, but hard to be proven in the clinical case.
The relationship between the CK level and the clinical appearance of the ischemic areas is relative. We cannot conclude that an increased level of CK is equivalent to an enlarged ischemic area and even less it does not provide us direct information concerning the best time for re-excision.
The presence of a viable blood supply around the necrotic tissue will lead to an important resorption of degradation products in that area, a quasinormal level of CK having no value. The sealing of the necrosis areas and the lack of immediate resorption does not have a positive prognostic value. Taking into account that the electrocutions are mostly multiple injuries, the CK level can increase even after some muscular damages, fractures, independent of the actual electrocution lesion.
In one case, the patient suffered from electrocution at both thoracic limbs. With the carbonization of the hands and grifa installed up to the level of the elbow fold, he stayed for 6 hours at the accident site until he had been recovered. At the moment of presentation to the hospital, his consciousness condition was satisfactory but the CK level was of over 20000 IU, becoming rapidly non-detectable, in combination with black urine. The patient's condition deteriorated quickly, and, although the bilateral shoulder disarticulation has been carried out, he died in the next 12 hours.
Discussion. As a conclusion, the CK level did not prove itself a prognostic for the surgical timing or the actual surgical attitude and could be influenced by a whole series of factors, dependent or not on the electrocution lesion.
A radical attitude is to be preferred in cases with established ischemia; the prognostic being the more reserved the larger the damage and the longer the period of time from the event. The established treatment is of renal support and treatment of acute renal injury (AKI) subsequently installed.
An increased level of leukocytes is always present as in any severe trauma, even if there are no immediate signs of infection of the electrocution lesions.
Taking into account that the electrocution lesion as well as the one caused by burning destroys the natural defense barrier represented by the skin, the infection risk is major and that is why the therapeutic protocol stipulates the immediate establishment of a treatment with broad-spectrum antibiotics or with an association of antibiotics.
The increase of the leukocytes level under antibiotics treatment involves either the contamination with a germ that is not sensitive to the respective antibiotic or the persistence of necrosis areas which secondarily infect, and where antibiotic penetration is very low. Therefore, the excision of the compromised tissues is an absolute necessity.
In terms of prognostic, the increase of the leukocytes number signified an insufficient excision and indicated the resuming and deepening of the excisions. Taking into account that the patient has been admitted through the ICU service, the risk of contracting severe infections with selected germs is real. Another risk is that of infection with Clostridium difficile following the prolonged utilization of broad-spectrum antibiotics, especially in patients with associated diseases and reduced immunity per primam.
The existence of completely separate circuits should solve the problem of contamination with bacteria of selected species; unfortunately, in our cases, we have faced this problem and the utilization of last choice antibiotics (Imipenem, Vancomycin, Targocid, etc.) as well as the association of immunoglobulins was necessary.
All the patients admitted in the study received anti-thromboxane drugs in order to limit the ischemic process at tissue level. Despite the efforts we have made, the lack of blood and its derivatives or simply the negligence in patient monitoring, allowed the decrease, even transient of the Hb level, sometimes only for a few hours, but enough to allow the deepening of the ischemic lesions.
Excisions were carried out in all the patients in emergency or even amputations of the extremities, with the wish to limit the extension of the ischemic lesions and the resorption of cell degradation products.
The amputations performed in emergency did not always represent a saving solution; however, they remained the most effective measures when they were carried out immediately after the accident and obviously in viable tissue.
The increase of CK is not an indicative factor itself in making re-excisions but orients the therapeutic approach, the utilization of the dialysis when the values do not decrease by treatment for renal support and the forcing of diuresis is required.
The normalization of CK indicates the time when we can start the covering of the defects resulted as a consequence of the excisions.
The level of the leukocytes represents both a prognostic factor and an indicative factor for the re-excision of the ischemic areas. An increased level under antibiotic therapy signifies either an incomplete excision or the contamination with flora resisting to the antibiotic that has been used.
In the light of findings in the caring of the patients with electrocutions, I propose several caring/assessment protocols for the severe electrically injured patient.