JBUR-4282; No. of Pages 4 burns xxx (2014) xxx.e1–xxx.e4
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/burns
Case report, Case Reports
A baby with symmetrical hand injuries and rhabdomyolysis following nonfatal electrocution by an unusual mechanism Kam Lun Hon a,*, Wing Lim Tse b, Hon Ming Cheung a, Sung Tat Yip c, Kam Lau Cheung a, William Wong a a
Department of Paediatrics, Prince of Wales Hospital, Shatin, Hong Kong Department of Orthopaedics, Shatin, Hong Kong c University Safety Office, The Chinese University of Hong Kong, Shatin, Hong Kong b
article info
abstract
Article history:
Childhood electrical injuries are rare in the city of Hong Kong. We report the case of a 21-
Received 30 December 2013
month boy with severe electrical injuries of both hands and explored underlying mechan-
Received in revised form
ism for the incident. Meticulous orthopedic repair and reconstruction ensures satisfactory
19 January 2014
cosmetic and functional outcomes. Our case concurs with the literature that young children
Accepted 22 January 2014
may be predisposed to this mode of incident with their curious exploring hands. Despite
Available online xxx
regulations on electrical home safety standards, extension power boards can still pose a
Keywords:
strategies often involve commonsense approach in home safety measures such as (1) use
dangerous risk for severe morbidity in the household with young children. Prevention Electrical injury
proper fuses in electrical boxes, (2) do not overload outlets, (3) use insulated and grounded
Child
electrical cords, (4) keep electrical cords away from a child’s reach, and (5) cover electrical
Extension power board
outlets so children will not stick items in the outlet. # 2014 Elsevier Ltd and ISBI. All rights reserved.
Hand Prevention strategies
1.
Introduction
Childhood electrical injuries are rare in the city of Hong Kong. We report the case of a 21-month boy with severe electrical injuries of both hands and explored underlying mechanism for the accident. Our case concurs with the literature that young children may be predisposed to this mode of accident with their curious exploring hands. Despite regulations on electrical home safety standards, extension power boards can still pose a dangerous risk for severe morbidity in the household with young children.
2.
Case
In 2013, a 21-month-old child was admitted via the emergency department to the PICU of a regional trauma center in Hong Kong following an unusual episode of electrical injury in Mainland China. Allegedly, he was playing without supervision in the sitting room with a live power extension board not connecting to any electrical appliance when the incident occurred (Fig. 1). The father attended to the crying child and rinsed his hands with water. There was no history of loss of consciousness. After initially seen by local physicians, the
* Corresponding author at: Department of Pediatrics, The Chinese University of Hong Kong, 6/F, Clinical Sciences Building, Prince of Wales Hospital, Shatin, Hong Kong. Tel.: +852 2632 2859; fax: +852 2636 0020. E-mail address: [email protected] (K.L. Hon). http://dx.doi.org/10.1016/j.burns.2014.01.018 0305-4179/# 2014 Elsevier Ltd and ISBI. All rights reserved.
Please cite this article in press as: Hon KL, et al. A baby with symmetrical hand injuries and rhabdomyolysis following nonfatal electrocution by an unusual mechanism. Burns (2014), http://dx.doi.org/10.1016/j.burns.2014.01.018
JBUR-4282; No. of Pages 4
e2
burns xxx (2014) xxx.e1–xxx.e4
Fig. 1 – The seemingly faultless electrical extension board.
parents took the child to Hong Kong for management. At the emergency department, the child was irritable. Vitals were: respiratory rate 30/min, heart rate 180/min, blood pressure 116/84 mmHg, and capillary refill 1 s. There were extensive hand injuries burns involving an estimated 1% of total body surface area (Fig. 2). The child was jointly cared by orthopedic and plastic surgeons at the pediatric intensive
care unit. Laboratory investigations showed normal electrocardiographic rhythm, normal plasma cardiac troponin, elevated creatine kinase 444 U/L (61–399 U/L), and urine positive for myoglobulin but negative for red cell. There was no apparent neuro-cardiopulmonary compromise. The child subsequently required multiple flap reconstruction, full thickness skin and autografts for both hands. The injury over the dorsal left ring finger was a third degree burn with the extensor tendon at metacarpo-phalangeal joint involved (Fig. 2). The tendon segment was excised and repaired, with the burnt skin also excised and sutured directly. The skin over the dorsal right index finger between the distal and proximal inter-phalangeal joints was also a third degree burn, with involvement of the external tendon segment (zone 2 and 3), the underlying periosteum and the dorsal capsule of proximal inter-phalangeal joint (Fig. 2). All these tissues were excised and covered initially with artificial dressing materials. Flap surgery was then performed in the second stage. The segment of lost extensor tendon was not reconstructed (Fig. 3a). The fascial tissue of flap served as connecting tissue bridging the tendon defect (Fig. 3b). The donor site was covered with original dorsal skin of middle finger. The fascial flap over index finger was covered with full thickness skin graft harvested from left groin (Fig. 3c). The injuries over palmar surface of both hands (between distal palmar crease and
Fig. 2 – Bilateral extensive electrical injuries of both hands, sparing the baby’s lower limbs and buttocks. Please cite this article in press as: Hon KL, et al. A baby with symmetrical hand injuries and rhabdomyolysis following nonfatal electrocution by an unusual mechanism. Burns (2014), http://dx.doi.org/10.1016/j.burns.2014.01.018
JBUR-4282; No. of Pages 4 burns xxx (2014) xxx.e1–xxx.e4
e3
Fig. 3 – Intraop photographs of the right hand. (a) Raising of ‘‘reversed cross finger fascial flap’’ from middle finger. (b) Absence of extensor tendon (zone II and III) and periosteum over middle phalanx exposed proximal interphalangeal joint with preserved articular cartilage, and application of the fascial flap to recipient site. (c) The donor site was covered with original dorsal skin of middle finger. The fascial flap over index finger was covered with full thickness skin graft harvested from left groin. (d) The palmar full thickness burn wounds were debrided and covered with full thickness skin graft from left groin.
palmar digital creases) were second-to-third degree burn. There was no involvement of the neurovascular structures or flexor tendons. After excision of the full thickness burnt skin, full thickness skin grafts were applied (Fig. 3d) Fourteen weeks postoperatively, all these wounds healed well and the patient had no problem extending his right index finger (Fig. 4).
Fig. 4 – Follow up at 14 weeks after operation.
3.
Discussion
Severe electrical injuries in the home are rare [1–5]. Using ICD9 coding of 944.00 (electric burn), E925.9 (incident caused by electric current), 994.8 (electrocution and nonfatal effects of electric current), this is the only case of over 1700 PICU admissions in our center between October 2002 and December 2013, giving an incidence of 0.05% of PICU admissions. The extension board was inspected by the safety officer and found to be of good quality meeting the Chinese Guobiao (GB) safety standards. The national standards (GB) administrated by the Standardization Administration of China (SAC) and developed by the National Professional Standardization Techniques Commission whose establishment was approved by SAC are formulated based on the technical requirements that need to be unified within the entire country, mainly covering technical requirements on basis, methods, general purposes and security. As there were no other injuries found, the entry and exit sites of electric current must have been the hands. There was no sharp metallic object found nearby and the child’s fingers were too big for the slit-shaped socket (see Fig. 1). We postulated that the child’s hands and chest might have been wet (possibly with saliva) to allow electric current to transmit from one hand to the other via the anterior chest, sparing deeper structure such as the heart. Also, the child might have been on an insulator (possibly his clothes) so that there was no
Please cite this article in press as: Hon KL, et al. A baby with symmetrical hand injuries and rhabdomyolysis following nonfatal electrocution by an unusual mechanism. Burns (2014), http://dx.doi.org/10.1016/j.burns.2014.01.018
JBUR-4282; No. of Pages 4
e4
burns xxx (2014) xxx.e1–xxx.e4
burn on his feet or buttocks [4]. Bailey et al. performed a chart review of 115 patients with electrical injuries and found none with arrhythmias or adverse outcomes. The authors believe that initial cardiac evaluation and monitoring do not appear to be necessary in children sustaining uncomplicated household electrical injuries [6]. Our observation concurs with the series by these investigators that cardiac complications are unusual [4,6]. Young children, especially males are prone to electrical injuries in the household [4,7]. Our patient is possibly the youngest child reported in the literature with electrical injuries [4,5,7]. Glatstein et al. reported that most electrical injuries are first degree burns, and no patient required amputation in their series [5]. However, Tarim et al. reported that 3.8% of severe burn patients underwent amputations of the digits or upper extremity proximal to the wrist or lower extremity above the ankle; amputations were significantly higher in males and the mean hospitalization time significantly higher in these patients [8]. Most of the mechanisms leading to amputations are easily preventable, albeit occur because of lack of awareness among the children and their guardians [3]. These authors conclude that education and compliance with safety measures, as well as common sense and respect for the potential danger of electricity are essential for avoiding these injuries [3,5,7,8]. Electrical burns generally have a relatively low mortality ratio but they exhibit a high incidence of morbidity [9]. The presence of preschool children at home and the neglect of preventive measures such as leaving the power sockets exposed or failure to ground the electrical installations are definite avoidable risk factors [9]. Prevention strategies often involve commonsense approach in home safety measures such as [1] use proper fuses in electrical boxes [2], do not overload outlets [3], use insulated and grounded electrical cords [4], keep electrical
cords away from a child’s reach, and [5] cover electrical outlets so children will not stick items in the outlet.
Conflict of interest statement The authors have no conflicts of interest to declare.
references
[1] Hon KL, Leung TF, Cheung KL, Nip SY, Ng J, Fok TF, et al. Severe childhood injuries and poisoning in a densely populated city: where do they occur and what type? J Crit Care 2010;25(1):175–212. [2] Hon KL, Leung AK. Childhood accidents: injuries and poisoning. Adv Pediatr 2010;57(1):33–62. [3] Rai A, Khalil S, Batra P, Gupta SK, Bhattacharya S, Dubey NK, et al. Electrical injuries in urban children in New Delhi. Pediatr Emerg Care 2013;29(3):342–5. [4] Celik A, Ergun O, Ozok G. Pediatric electrical injuries: a review of 38 consecutive patients. J Pediatr Surg 2004;39(8):1233–7. [5] Glatstein MM, Ayalon I, Miller E, Scolnik D. Pediatric electrical burn injuries: experience of a large tertiary care hospital and a review of electrical injury. Pediatr Emerg Care 2013;29(6):737–40. [6] Bailey B, Gaudreault P, Thivierge RL, Turgeon JP. Cardiac monitoring of children with household electrical injuries. Ann Emerg Med 1995;25(5):612–7. [7] Roberts S, Meltzer JA. An evidence-based approach to electrical injuries in children. Pediatr Emerg Med Pract 2013;10(9):1–16. [8] Tarim A, Ezer A. Electrical burn is still a major risk factor for amputations. Burns 2013;39(2):354–7. [9] Saracoglu A, Kuzucuoglu T, Yakupoglu S, Kilavuz O, Tuncay E, Ersoy B, et al. Prognostic factors in electrical burns: a review of 101 patients. Burns 2013;1:9. pii: S0305-4179(13):10.
Please cite this article in press as: Hon KL, et al. A baby with symmetrical hand injuries and rhabdomyolysis following nonfatal electrocution by an unusual mechanism. Burns (2014), http://dx.doi.org/10.1016/j.burns.2014.01.018
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/burns
Case report, Case Reports
A baby with symmetrical hand injuries and rhabdomyolysis following nonfatal electrocution by an unusual mechanism Kam Lun Hon a,*, Wing Lim Tse b, Hon Ming Cheung a, Sung Tat Yip c, Kam Lau Cheung a, William Wong a a
Department of Paediatrics, Prince of Wales Hospital, Shatin, Hong Kong Department of Orthopaedics, Shatin, Hong Kong c University Safety Office, The Chinese University of Hong Kong, Shatin, Hong Kong b
article info
abstract
Article history:
Childhood electrical injuries are rare in the city of Hong Kong. We report the case of a 21-
Received 30 December 2013
month boy with severe electrical injuries of both hands and explored underlying mechan-
Received in revised form
ism for the incident. Meticulous orthopedic repair and reconstruction ensures satisfactory
19 January 2014
cosmetic and functional outcomes. Our case concurs with the literature that young children
Accepted 22 January 2014
may be predisposed to this mode of incident with their curious exploring hands. Despite
Available online xxx
regulations on electrical home safety standards, extension power boards can still pose a
Keywords:
strategies often involve commonsense approach in home safety measures such as (1) use
dangerous risk for severe morbidity in the household with young children. Prevention Electrical injury
proper fuses in electrical boxes, (2) do not overload outlets, (3) use insulated and grounded
Child
electrical cords, (4) keep electrical cords away from a child’s reach, and (5) cover electrical
Extension power board
outlets so children will not stick items in the outlet. # 2014 Elsevier Ltd and ISBI. All rights reserved.
Hand Prevention strategies
1.
Introduction
Childhood electrical injuries are rare in the city of Hong Kong. We report the case of a 21-month boy with severe electrical injuries of both hands and explored underlying mechanism for the accident. Our case concurs with the literature that young children may be predisposed to this mode of accident with their curious exploring hands. Despite regulations on electrical home safety standards, extension power boards can still pose a dangerous risk for severe morbidity in the household with young children.
2.
Case
In 2013, a 21-month-old child was admitted via the emergency department to the PICU of a regional trauma center in Hong Kong following an unusual episode of electrical injury in Mainland China. Allegedly, he was playing without supervision in the sitting room with a live power extension board not connecting to any electrical appliance when the incident occurred (Fig. 1). The father attended to the crying child and rinsed his hands with water. There was no history of loss of consciousness. After initially seen by local physicians, the
* Corresponding author at: Department of Pediatrics, The Chinese University of Hong Kong, 6/F, Clinical Sciences Building, Prince of Wales Hospital, Shatin, Hong Kong. Tel.: +852 2632 2859; fax: +852 2636 0020. E-mail address: [email protected] (K.L. Hon). http://dx.doi.org/10.1016/j.burns.2014.01.018 0305-4179/# 2014 Elsevier Ltd and ISBI. All rights reserved.
Please cite this article in press as: Hon KL, et al. A baby with symmetrical hand injuries and rhabdomyolysis following nonfatal electrocution by an unusual mechanism. Burns (2014), http://dx.doi.org/10.1016/j.burns.2014.01.018
JBUR-4282; No. of Pages 4
e2
burns xxx (2014) xxx.e1–xxx.e4
Fig. 1 – The seemingly faultless electrical extension board.
parents took the child to Hong Kong for management. At the emergency department, the child was irritable. Vitals were: respiratory rate 30/min, heart rate 180/min, blood pressure 116/84 mmHg, and capillary refill 1 s. There were extensive hand injuries burns involving an estimated 1% of total body surface area (Fig. 2). The child was jointly cared by orthopedic and plastic surgeons at the pediatric intensive
care unit. Laboratory investigations showed normal electrocardiographic rhythm, normal plasma cardiac troponin, elevated creatine kinase 444 U/L (61–399 U/L), and urine positive for myoglobulin but negative for red cell. There was no apparent neuro-cardiopulmonary compromise. The child subsequently required multiple flap reconstruction, full thickness skin and autografts for both hands. The injury over the dorsal left ring finger was a third degree burn with the extensor tendon at metacarpo-phalangeal joint involved (Fig. 2). The tendon segment was excised and repaired, with the burnt skin also excised and sutured directly. The skin over the dorsal right index finger between the distal and proximal inter-phalangeal joints was also a third degree burn, with involvement of the external tendon segment (zone 2 and 3), the underlying periosteum and the dorsal capsule of proximal inter-phalangeal joint (Fig. 2). All these tissues were excised and covered initially with artificial dressing materials. Flap surgery was then performed in the second stage. The segment of lost extensor tendon was not reconstructed (Fig. 3a). The fascial tissue of flap served as connecting tissue bridging the tendon defect (Fig. 3b). The donor site was covered with original dorsal skin of middle finger. The fascial flap over index finger was covered with full thickness skin graft harvested from left groin (Fig. 3c). The injuries over palmar surface of both hands (between distal palmar crease and
Fig. 2 – Bilateral extensive electrical injuries of both hands, sparing the baby’s lower limbs and buttocks. Please cite this article in press as: Hon KL, et al. A baby with symmetrical hand injuries and rhabdomyolysis following nonfatal electrocution by an unusual mechanism. Burns (2014), http://dx.doi.org/10.1016/j.burns.2014.01.018
JBUR-4282; No. of Pages 4 burns xxx (2014) xxx.e1–xxx.e4
e3
Fig. 3 – Intraop photographs of the right hand. (a) Raising of ‘‘reversed cross finger fascial flap’’ from middle finger. (b) Absence of extensor tendon (zone II and III) and periosteum over middle phalanx exposed proximal interphalangeal joint with preserved articular cartilage, and application of the fascial flap to recipient site. (c) The donor site was covered with original dorsal skin of middle finger. The fascial flap over index finger was covered with full thickness skin graft harvested from left groin. (d) The palmar full thickness burn wounds were debrided and covered with full thickness skin graft from left groin.
palmar digital creases) were second-to-third degree burn. There was no involvement of the neurovascular structures or flexor tendons. After excision of the full thickness burnt skin, full thickness skin grafts were applied (Fig. 3d) Fourteen weeks postoperatively, all these wounds healed well and the patient had no problem extending his right index finger (Fig. 4).
Fig. 4 – Follow up at 14 weeks after operation.
3.
Discussion
Severe electrical injuries in the home are rare [1–5]. Using ICD9 coding of 944.00 (electric burn), E925.9 (incident caused by electric current), 994.8 (electrocution and nonfatal effects of electric current), this is the only case of over 1700 PICU admissions in our center between October 2002 and December 2013, giving an incidence of 0.05% of PICU admissions. The extension board was inspected by the safety officer and found to be of good quality meeting the Chinese Guobiao (GB) safety standards. The national standards (GB) administrated by the Standardization Administration of China (SAC) and developed by the National Professional Standardization Techniques Commission whose establishment was approved by SAC are formulated based on the technical requirements that need to be unified within the entire country, mainly covering technical requirements on basis, methods, general purposes and security. As there were no other injuries found, the entry and exit sites of electric current must have been the hands. There was no sharp metallic object found nearby and the child’s fingers were too big for the slit-shaped socket (see Fig. 1). We postulated that the child’s hands and chest might have been wet (possibly with saliva) to allow electric current to transmit from one hand to the other via the anterior chest, sparing deeper structure such as the heart. Also, the child might have been on an insulator (possibly his clothes) so that there was no
Please cite this article in press as: Hon KL, et al. A baby with symmetrical hand injuries and rhabdomyolysis following nonfatal electrocution by an unusual mechanism. Burns (2014), http://dx.doi.org/10.1016/j.burns.2014.01.018
JBUR-4282; No. of Pages 4
e4
burns xxx (2014) xxx.e1–xxx.e4
burn on his feet or buttocks [4]. Bailey et al. performed a chart review of 115 patients with electrical injuries and found none with arrhythmias or adverse outcomes. The authors believe that initial cardiac evaluation and monitoring do not appear to be necessary in children sustaining uncomplicated household electrical injuries [6]. Our observation concurs with the series by these investigators that cardiac complications are unusual [4,6]. Young children, especially males are prone to electrical injuries in the household [4,7]. Our patient is possibly the youngest child reported in the literature with electrical injuries [4,5,7]. Glatstein et al. reported that most electrical injuries are first degree burns, and no patient required amputation in their series [5]. However, Tarim et al. reported that 3.8% of severe burn patients underwent amputations of the digits or upper extremity proximal to the wrist or lower extremity above the ankle; amputations were significantly higher in males and the mean hospitalization time significantly higher in these patients [8]. Most of the mechanisms leading to amputations are easily preventable, albeit occur because of lack of awareness among the children and their guardians [3]. These authors conclude that education and compliance with safety measures, as well as common sense and respect for the potential danger of electricity are essential for avoiding these injuries [3,5,7,8]. Electrical burns generally have a relatively low mortality ratio but they exhibit a high incidence of morbidity [9]. The presence of preschool children at home and the neglect of preventive measures such as leaving the power sockets exposed or failure to ground the electrical installations are definite avoidable risk factors [9]. Prevention strategies often involve commonsense approach in home safety measures such as [1] use proper fuses in electrical boxes [2], do not overload outlets [3], use insulated and grounded electrical cords [4], keep electrical
cords away from a child’s reach, and [5] cover electrical outlets so children will not stick items in the outlet.
Conflict of interest statement The authors have no conflicts of interest to declare.
references
[1] Hon KL, Leung TF, Cheung KL, Nip SY, Ng J, Fok TF, et al. Severe childhood injuries and poisoning in a densely populated city: where do they occur and what type? J Crit Care 2010;25(1):175–212. [2] Hon KL, Leung AK. Childhood accidents: injuries and poisoning. Adv Pediatr 2010;57(1):33–62. [3] Rai A, Khalil S, Batra P, Gupta SK, Bhattacharya S, Dubey NK, et al. Electrical injuries in urban children in New Delhi. Pediatr Emerg Care 2013;29(3):342–5. [4] Celik A, Ergun O, Ozok G. Pediatric electrical injuries: a review of 38 consecutive patients. J Pediatr Surg 2004;39(8):1233–7. [5] Glatstein MM, Ayalon I, Miller E, Scolnik D. Pediatric electrical burn injuries: experience of a large tertiary care hospital and a review of electrical injury. Pediatr Emerg Care 2013;29(6):737–40. [6] Bailey B, Gaudreault P, Thivierge RL, Turgeon JP. Cardiac monitoring of children with household electrical injuries. Ann Emerg Med 1995;25(5):612–7. [7] Roberts S, Meltzer JA. An evidence-based approach to electrical injuries in children. Pediatr Emerg Med Pract 2013;10(9):1–16. [8] Tarim A, Ezer A. Electrical burn is still a major risk factor for amputations. Burns 2013;39(2):354–7. [9] Saracoglu A, Kuzucuoglu T, Yakupoglu S, Kilavuz O, Tuncay E, Ersoy B, et al. Prognostic factors in electrical burns: a review of 101 patients. Burns 2013;1:9. pii: S0305-4179(13):10.
Please cite this article in press as: Hon KL, et al. A baby with symmetrical hand injuries and rhabdomyolysis following nonfatal electrocution by an unusual mechanism. Burns (2014), http://dx.doi.org/10.1016/j.burns.2014.01.018
