An otherwise healthy 20-year-old male working at a construction site was carrying a metal gutter, which contacted a transformer and overhead wires resulting in both electrical contact injury and flame burns from electrothermal discharge igniting his clothing. He developed pulseless ventricular dysrhythmia and received thirteen minutes of CPR by coworkers and first responders. He was defibrillated with return of spontaneous circulation en route to an outside hospital. He was intubated and transferred to this Burn Center. The care of this patient from admission to discharge is chronicled in Fig. 1. On arrival, his primary survey was significant for an established airway with an endotracheal tube and adequate oxygenation on mechanical ventilation. He had a heart rate of 108, blood pressure of 153/94, and a GCS of 3T. Total burn area was calculated to be 45.5% TBSA of mixed deep partial- and full-thickness burns to his back, left flank, and bilateral upper and lower extremities. He sustained a full-thickness circumferential burn to the right lower extremity with palpable distal pulses.
Intravenous fluid resuscitation with lactated ringer's (LR) was guided by the consensus formula, which totaled 16.6 L during the first 24 h from burn injury (4 mL/kg/%TBSA). Fresh frozen plasma was used as a colloid adjunct. A Foley catheter placed on admission returned dark urine that was positive for myoglobin (Fig. 2). Laboratory results on arrival were as follows: WBC 28.6 K/muL; Hgb 17.8 g/dL; Hct 52.4%; Platelets 342 K/muL; Potassium 5.3 mmol/L; Calcium 5.9 mmol/L; Bicarbonate 11 mmol/L; Creatinine 0.84 mg/dL; pH 7.09; pCO2 45 mmHg; pO2 166 mmHg; Carboxyhemoglobin 0.0%; Base Deficit -16.1 mmol/L. Creatinine Kinase peaked within 24 h at 33,760 units/L.
Whole-body X-ray was significant for metallic foreign bodies in the airway (Fig. 3). Computed tomography (CT) localized the objects to the right bronchus intermedius (Fig. 4A-B). Retrieval attempted with flexible bronchoscopy in the trauma bay was unsuccessful. Persistent acidosis despite resuscitation and diminishing pulses raised suspicion for compartment syndrome of the right lower extremity, prompting emergent operative intervention. A four-compartment fasciotomy revealed dusky bulging muscles responsive to electrocautery stimulation. Subsequently, rigid bronchoscopy was performed with successful retrieval of two metallic screws (Fig. 5). The airway was noted to be erythematous, attributed to repeated instrumentation.
Continuous RRT was initiated for persistent acidosis and electrolyte derangements secondary to rhabdomyolysis. Burn wound excision began on post-burn day (PBD) 2 and was complete by PBD67. On PBD3 he developed acute hypoxic respiratory failure. Flexible bronchoscopy revealed edematous and erythematous airways, copious secretions, and mucosal sloughing. This inhalation injury was caused by the aspiration of super-heated air and metal screws held in the patient's mouth at the moment of electrothermal discharge, and was not clear during initial management of the foreign bodies. He was diagnosed with grade III inhalation injury, initiated on protocolized nebulized pharmacotherapy (acetylcysteine, albuterol, bicarbonate, heparin) and placed in the prone position. Tracheotomy was performed (PBD14) given prolonged ventilator requirement. He required right lower extremity below knee amputation secondary to non-salvageable myonecrosis. He exhibited renal recovery and his tracheotomy was decannulated prior to discharge. He recovered well and was cleared to return to work just before the one year anniversary of his injury.
(A,B): Computed tomography (CT) images localizing foreign bodies to the right bronchus intermedius.