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 Table of Contents  
CASE REPORT
Year : 2015  |  Volume : 23  |  Issue : 1  |  Page : 88-91

Abdominal wall blow out causing bowel evisceration due to high voltage electrocution: A unique presentation


Department of Surgery, University College of Medical Sciences and Guru Teg Bahadur Hospital, New Delhi, India

Date of Web Publication11-Dec-2015

Correspondence Address:
Dr. Ashesh Jha
Department of Surgery, University College of Medical Sciences and Guru Teg Bahadur Hospital, New Delhi - 110 095
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-653X.171665

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  Abstract 

A 32-year-old male presented to surgical casualty after 3 h of sustaining high voltage electrocution through palm of the right upper limb with prolapse of bowel from the anterior abdominal wall. Apparently, the current flow through the right upper limb exited from the right lower abdomen wall resulting in full-thickness abdominal wall defect causing small bowel to prolapse. He had clawing of right hand and semi-flexion at elbow with blackening and dry gangrene from mid-arm onward with distal two-third of the right upper limb being parched and black. There was 9 cm × 7 cm wound over right abdominal wall through which small bowel had eviscerated with multiple perforations discharging feculent content. Exploratory laparotomy with resections of perforated segments of small bowel with end-to-end anastomosis and right mid-arm guillotine amputation were done. The abdominal wound was debrided and temporarily covered with overlay plastic bag to prevent bowel herniation. A small enterocutaneous fistula arising from the small bowel was noted through the abdominal wound of blow out site, which was managed conservatively. The entry point of electricity is usually the skull or the upper extremity with resultant exit through the lower extremity. The exit point through the abdominal wall with resultant abdominal wall loss is rare and even remorsely seen is the abdominal wall blow out with the evisceration of bowel, a rare phenomenon.

Keywords: Abdominal blowout, electric burn, evisceration


How to cite this article:
Agrawal V, Jha A, Kumar K, Kalra G. Abdominal wall blow out causing bowel evisceration due to high voltage electrocution: A unique presentation. Indian J Burns 2015;23:88-91

How to cite this URL:
Agrawal V, Jha A, Kumar K, Kalra G. Abdominal wall blow out causing bowel evisceration due to high voltage electrocution: A unique presentation. Indian J Burns [serial online] 2015 [cited 2019 Aug 24];23:88-91. Available from: http://www.ijburns.com/text.asp?2015/23/1/88/171665


  Introduction Top


The incidence of electric burn in India is not precisely known. Male are predominantly affected, reflecting the occupational exposure to electric hazard. Tissue damage is determined by intensity of voltage and current, duration of contact, resistance of tissue, area of contact, and pathway of flow through the body until the point of exit of current. The energy generated at entry and exit point results in tissue vaporization, especially, at the exit site due to the resistance of the tissue to the exiting current. This resulted in an outward orientation of the tissue by this explosive force of the current leaving the body causes a blow out of the exit point and in case of abdomen causing evisceration of bowel. Blood vessels and nerves are the good conductor of electricity in human body. [1]

When electric current passes through a body, it causes cell death mostly affecting skeletal muscle myocytes and neurons. [1],[2]

The entry point of electricity is usually the upper extremities with resultant exit through the lower extremities. The exit point through the abdominal wall with resultant abdominal wall loss is rare and even remorsely seen is the abdominal wall blow out with the evisceration of bowel. Here, we are describing a case of abdominal wall blow out following high voltage electric current to upper extremity, a rare phenomenon. [2],[3]


  Case Report Top


A 32-year-old male presented to General Surgical emergency after 3 h of sustaining high tension electric injury to right upper limb with prolapse of bowel. Electrocution occurred while working in the field on a rainy day when he took support of the earthing wire of the pole carrying high tension electric line. The current flow through the right upper limb with exit wound over right lower abdomen resulted in full thickness abdominal wall defect with prolapse of small bowel.

On examination, the patient was conscious oriented with blood pressure of 109/56 mm of Hg in left arm and pulse of 110/min. His right upper limb was dried, shriveled, and blackened with flexor deformity up to the mid-arm. There was of 9 cm × 7 cm wound over right lower abdomen involving full thickness of abdominal wall including peritoneum through which small bowel prolapsed [Figure 1]. The bowel was hyperemic with multiple perforations discharging feco-bilious content. Rest of examination was normal, and there was no myoglobinuria.
Figure 1: Prolapsed small bowel with perforations through abdominal wall defect


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His hemoglobin was 9.9 gm/dl, TLC of 8000/mm 3 and platelets of 1,33,000/mm 3 . His Kidney function test and electrolyte profile were deranged (urea-151 mg%, creatinine-7.5 mg%, and K + -6.6 meq/L). Coagulation profile was normal. electrocardiogram (ECG) revealed the features of hyperkalemia.

The patient was resuscitated with intravenous fluids; Intravenous calcium gluconate was given followed by glucose insulin infusion to treat hyperkalemia and taken up for surgery for exploratory Laparotomy and mid-arm guillotine amputation [Figure 2]. Laparotomy was performed, and the prolapse bowel was thoroughly washed and reposited back. Multiple perforations in small bowel were seen, three resections anastomosis were done along with abdominal wound debridement. Rest of the large bowel and visceral organs were normal. The defect was left open and covered with overlay plastic bag to prevent bowel herniation [Figure 3], as we did not have expertise available in General Surgical emergency to provide flap coverage or to execute some other reconstructive options for the closure of abdominal wall wound.
Figure 2: Proximal progression of gangrene following guillotine amputation in upper limb A


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Figure 3: Temporary closure of abdominal blowout wound with overlay plastic bag


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In postop period patient remained hemodynamically stable, however, developed acute renal failure and proximal progression of the gangrene requiring multiple sessions of hemodialysis and revised more proximal guillotine amputation which finally terminated with the disarticulation at the shoulder. A small enterocutaneous fistula arising from the ileum [Figure 4] was noted through the abdominal wound of blow out site, which was managed conservatively. The abdominal wound gradually healed by secondary intention [Figure 5] leaving a fibrous scar at the wound site.
Figure 4: Enterocutaneous fistula at site of abdominal blowout wound


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Figure 5: Healing abdominal wall wound


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  Discussion Top


Electric burns are complex injuries which may affect the multiple organ systems and poses challenging problems for the clinical management. [1] By convention, electric injuries are classified into two group low tension, and high tension injuries with 1000 volt are the dividing line between them. [1] Electric injuries are of three types:

  1. Entry and exit wounds-entry point is the point of contact which is charred, depressed which may be blistered by vaporization of water from the tissues. Whereas the exit point usually circumscribed, dry, and may have outward orientation due to explosive force of current leaving the body.
  2. Arc burns-an arc is an external flow of current from a contact point as it jumps to a ground point usually associated with alternating current producing muscular contracture.
  3. Flame burns-it occurs due to ignition of the victims clothing of surroundings by heat generated by the electric current.


The most common points of entry are skull and upper extremity, with an exit point usually through the lower extremity. The electric current after the skin is penetrated usually flow along the path of least resistance not necessarily between the entry and exit wound. [2],[3]

Electrical force is capable of producing tremendous damage to human tissue. Electricity produces heat as it passes through the human tissue which causes damage and amount of heat produced is explained by Joule's law [3] :

H = 0.24 I 2 ×R×T

Another proposed mechanism of damage produced by electric injury is breakdown of cell membranes as it passes through the tissue known as "Electroporation" causing cell death. Electroporation is related to the surface area of the cell such that cells with largest membrane area such as skeletal muscle myocytes and neurons are likely to be affected. [1]

Literature reports few cases of electric burn with full thickness wound over the abdomen. JY Yang et al.[4] reported a case of high tension electric injury with an exit wound over left quadrant of abdomen involving full thickness including peritoneum which was managed by early debridement and exploratory Laparotomy with split skin graft to cover the wound on postburn day 5; however, the patient developed gastrocutaneous fistula in postop period. Wang Xuewei et al. [5] reported a case of high tension electric injury with deep burns over head, chest, abdomen, and both upper extremity. There was 3 cm diameter defect in abdominal wall in periumbilical area with prolapse of intestine showing perforation which was managed by early debridement and exploratory Laparotomy with the restoration of GI continuity with closure of abdominal defect by undermining the skin. Similarly, Takashi Honda et al. [6] reported a case of high voltage electric injury with direct wound over the abdomen involving full thickness which was managed by early debridement, exploratory Laparotomy, and temporary restoration of excised abdominal wall with a fascial prosthesis; however, developed duodenocutaneous fistula in postop period.

Respiratory and cardiac disturbances are usually seen with electric injury; therefore, need monitoring for the same, particularly of the ECG.

Large volumes of fluid may be required for resuscitation; however, fluid resuscitation cannot be based on standard formulae based on body weight and percentage body surface area of burn. The volume of dead tissue is very difficult to estimate from the surface, and there is no effective formulae which predict fluid requirements. The best guide of fluid requirement is the urine output which should ideally be maintained at a minimum of 30 ml/h or more. Mannitol can be used as an adjunct to ensure diuresis if fluid volume alone does not produce adequate urinary output. [1],[2]

Initial debridement needs to be aggressive. Fasciotomies are frequently required in electric burn and should be performed early to release the tense compartment or to disclose the necrotic or nonviable tissue which can lead to overwhelming sepsis. Amputation of charred or mummified extremity should be performed as soon as resuscitation is adequate. However, because of vessel thrombosis, delayed necrosis of tissue can occur requires repeated debridements. [2],[3]

In our case, patient sustained high tension electric injury which flows through the right upper limb resulting in abdominal wall blow out involving full thickness at exit point over the right lower abdomen with prolapsed of small intestine showing multiple perforations.

Abdomen is usually not affected as it has a greater cross-sectional area and low resistance to electricity. All these factors may dissipate the energy of electricity, thus making an abdominal blow-out due to electrocution a rare phenomenon. [7] Management of abdominal blow-out can be done following principles, as reported by Stone et al. [8] :

  1. Insertion of synthetic prosthesis to bridge any sizable defect in the abdominal wall rather than closure under tension via primarily mobilized flap.
  2. Use of end bowel stomas rather than exteriorized loops for primary anastomosis in the face of active infection, significant contamination and/or massive contusion.
  3. Delay in final reconstruction until all intestinal vents and fistulae have been closed by prior separation.


Even immediate reconstruction of chest and abdominal wall defect following high voltage electrical injury has been described in the literature. [9]

However, in our case due to nonavailability of expertise, we were able to provide just temporary coverage of the abdominal wound by applying overlay plastic bag. In postoperative period, the patient developed enterocutanous fistula leading to prolonged hospital stay. Proper wound coverage might have prevented the some of these complications and could have hasten the postoperative recovery.


  Conclusion Top


This case highlights the fact that the abdominal wall blow-out following electrocution is a rare phenomenon, and the underlying mechanism of such cases is not completely understood. Whenever possible immediate coverage of the abdominal wall wound following the principles of reconstructive surgery seems to be a preferred option, as it can hasten the postoperative recovery and may prevent some of the dreaded postoperative complications. These patients are at risk of developing abdominal wall hernia which should be repaired, if it becomes evident at later stage.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Lees VC, Frame FD. Electrical burns. In: Settel JA, editor. Principle and Practice of Burn Management. New York: Churchill Livingstone; 1996. p. 369-76.  Back to cited text no. 1
    
2.
Metcalf MM. Electrical injuries. In: Wagner MM, editor. Care of Burn Injured Patient: A Multidisciplinary Involvement. USA: PSG Publishing Company; 1981. p. 185-93.  Back to cited text no. 2
    
3.
Masters FW, Robinson DW, Ketchum LD. Symposium of burn. In: Lynch JB, Levis SR, editors. Management of Electrical Burns. USA: The CV Mosby Company; 1973. p. 82-92.  Back to cited text no. 3
    
4.
Yang JY, Tsai YC, Noordhoff MS. Electrical burn with visceral injury. Burns Incl Therm Inj 1985;11:207-12.  Back to cited text no. 4
[PUBMED]    
5.
Wang XW, Ye ZD. Successful treatment of a case of electric abdominal burn complicated by intestinal perforation. Chin Med J (Engl) 1981;94:181-4.  Back to cited text no. 5
    
6.
Honda T, Yamamoto Y, Mizuno M, Mitsusada M, Nakazawa H, Sasaki K, et al. Successful treatment of a case of electrical burn with visceral injury and full-thickness loss of the abdominal wall. Burns 2000;26:587-92.  Back to cited text no. 6
    
7.
Srivastava RK, Kumar R. Electrical burns of the abdomen. Indian J Plast Surg 2013;46:587-90.  Back to cited text no. 7
[PUBMED]  Medknow Journal  
8.
Stone HH, Fabian TC, Turkleson ML, Jurkiewicz MJ. Management of acute full-thickness losses of the abdominal wall. Ann Surg 1981;193:612-8.  Back to cited text no. 8
[PUBMED]    
9.
Kumar P, Varma R. Immediate reconstruction of chest and abdominal wall defect following high voltage electrical injury. Burns 1994;20:557-9.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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