Electrical contact of 15 years old and female without medical-surgical history of interest with victimized by ambulance from an electrical station where the Emergency Services came after the call for help of an emergency unit
Upon admission to the emergency department, the patient arrived sedo-analgesiated, intubated, and had a transsea route on the left physique.
The physical examination showed:
Necrosis area in the right parietal region of scalp of 11 cm in diameter, corresponding to 1.5% of total body surface (TBS).
Bone necrosis, external table exposure and blunt wound due to associated trauma.
Carbonized upper left limb up to upper third of the upper arm (9% TCS) and deep ipsilateral supraclavicular arm, suggesting contact point with the current passage.
Third degree burns on the dorsum of the right hand, middle lines of 2nd to 5th fingers and thumb pulp (1% SCT).
Third degree burn on the anterior surface of the left thigh with muscle involvement (2% TSS).
Right pretibial third-degree burn (0.5% TBS).
Total, 14-15% SCT.
We started a protocol of care for multiple trauma patients who have suffered burns.
We extracted analytical data, cannulated central femoral arterial and venous routes, started intensive fluid therapy and placed a bladder and nasogastric tube.
We administered tetanus vaccination schedule (toxoid and gammaglobulin).
After the initial assessment, we performed a body computerized axial tomography (CAT), ruling out, for the moment, the existence of brain lesions and associated fractures, with data of pulmonary involvement, visualizing a re-expanded atelectasis.
In the operating room, burns were cleaned, sloughs were removed and surface cultures were taken.
We performed fasciotomies in the left upper extremity and anterior compartment of the left thigh at the level of the vastus lateralis muscle, along with debridement of necrotic areas of the scalp and left thigh.
We also sutured the scalp wound, cured with 1% cream and admitted the patient to the Large Burns Unit.
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The admission laboratory showed CK's 19655U/L; CK-mb 154 U/L; Ph 7.25; bicarbonate 22mmHg; and metabolic acidosis situation, requiring bicarbonate for the treatment of myoglobinuria.
Renal function is conserved, using diuresis superior to 1.5-2ml/kg/h as a control parameter and is hemodynamically stable without the need to use vasoactive drugs.
We also performed CT angiography of the subio/axillary territory to assess the proximal vascular permeability of the left arm, seeing permeable vessels proximal to the humble artery and the posterior circumflex artery exit.
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Two days after admission, after stabilizing the patient, we performed the first surgical intervention.
First intervention (third day of admission).
We transcribe at that moment:
- Amputation of the left upper extremity at the transhuman proximal level, 3 cm below the head hum, and closure of the defect with deltoid remnant and posterior cutaneous remnant.
Cleansing with sterile water and saline solution.
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Debridement of pressure100 in the scalp; slapping of the external cranial table creating a bone defect of partial thickness with a spongy and exposed diameter of bone Smith Therapy of 3 x 4 cm Pressure WoundN mode,
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- Debridement and self-injection of lower limb and right hand burns.
On successive days we observed distal necrosis in the cutaneous edges and deep necrosis in the stump, with output of malloating secretion analyzed and sent for microbiological culture, with positive result for Acinetobacter Baumanii.
Four days after the intervention, the patient was cured under sedation and the negative pressure therapy device was replaced.
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Second intervention (11th day of admission)
- Sequential debridement of blade tissues of the amputation stump of the left upper limb ( communicating with the patient); cleaning with cold water, serum; curative injury to 1% Arg.
- Debridement of the left supraclavicular defect resulting in a 5x10 cm defect and coverage with a Biobrane® plate (Smith & Nephew, United Kingdom) of 13 x 13 cm.
- Pressure debridement -100 continuous fusion of the scalp; slapping of the external cranial table, causing a deeper partial thickness defect with spongy bone diameter exposed mode 6 x 7 cm.
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The patient leaves the operating room extubated and hemodynamically stable.
Settlement by oral and enteral route.
Bacterial Aureus Meticilin Resistant, Escherichia Coli, and Cloacae are positive surface cultures for A. baumanii.
Febrile syndrome persists and is being treated with colistin, meropenem and daptomycin.
Four days after the intervention, we again changed the vacuum device of the negative pressure therapy system.
Local necrosis of the head hump and left supraclavicular region were observed.
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Third intervention (19th day of admission).
In collaboration with the Traumatology Service, we performed:
- Partial amputation scapulohum, including coracoid process and distal clavicular third, with fixation of the remaining clavicular third to the scapulae by means of transosseous suturing
We closed the defect with regional flaps of the deltoid area.
- Debridement and direct closure of the left supraclavicular lesion.
- Nuevo is coupled with a ceftazidime lesion, continuing to create a deeper partial thickness bone defect with an exposed spongy bone diameter of 7 x 8 cm, and placement of a negative pressure therapy device.
The stump evolves favorably closing completely.
The vacuum therapy device was replaced after 4 days.
At this moment we have to solve the coverage defect of the right parietal region of the scalp, 11 cm in diameter.
Fourth intervention (25th day of admission).
In collaboration with the Neurosurgery Department, we practiced:
- Resection of the total thickness of the necrotic cranial bone of the right parietal region, resulting in a 6 x 5 cm diameter bony window, with an exposed dura mater of normal appearance.
Friedrich of the wound edges.
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- Design of biculate fronto-occipital flap 12 cm wide with perioperative expansion and transfer of the flap to the defect area.
We covered the donor area with 2 self-injectors of partial thickness skin (7 x 20 cm) over the periosteum, taken from the anterolateral surface of the right thigh.
The patient evolved favorably, leaving the Burn Unit 1 week after the last intervention.
He was discharged 45 days after admission, after a stay in the plant with adaptation treatment by Psychiatry for the serious sequelae suffered.
CT scan revealed a right parietal defect of 5.8 x 4 x 5 cm anteroposterior diameter by skull, transverse.
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Sequelae phase
6 months later, the patient was admitted again for fixation of the flap and coverage of the cranial bone window.
- A survey of the bi-occlusal flap of the frontal-occipital scalp through the previous scar and cranioplasty with a preformed plate of PEEK (polyetereterceton Switzerland) 4 dimensions
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- Correction and consolidation of the scar.
The postoperative course was within normal limits, with a clear improvement in the cranial contour.
The patient was discharged 3 days after the intervention with psychological support and rehabilitation.
At follow-up, 8 months after cranioplasty, the patient wears a wig and rejects reconstruction with expanders.
At present, there are no neurological sequelae.
