Electrical injuries and outcomes: A retrospective review.

Electrical burns (EI) differ from other burn injuries in the immediate treatment given and delayed sequelae they manifest. This paper reviews our burn center's experience with electrical injuries. All patients with electrical injuries admitted from January 2002 to August 2019 were included. Demographics; admission, injury, and treatment data; complications, including infection, graft loss, and neurologic injury; pertinent imaging, neurology consultation, neuropsychiatric testing; and mortality were collected. Subjects were divided into those who were exposed to high (>1000 volts), low (<1000 volts), and unknown voltage. The groups were compared. P < 0.05 was considered significant. One hundred sixty-two patients with electrical injuries were included. Fifty-five suffered low voltage, 55 high voltage, and 52 unknown voltage injuries. High voltage injuries were more likely to be male (98.2% vs. 83.6% low voltage vs. 94.2% unknown voltage, p = 0.015), to experience loss of consciousness (69.1% vs. 23.6% vs. 33.3%, p < 0.001), cardiac arrest (20% vs. 3.6% vs. 13.4%, p = 0.032), and undergo amputation (23.6% vs. 5.5% vs. 8.2%, p = 0.024). No significant differences were observed in long-term neurological deficits. Twenty-seven patients (16.7%) were found to have neurological deficits on or after admission; 48.2% recovered, 33.3% persisted, 7.4% died, and 11.1% did not follow-up with our burn center. Electrical injuries are associated with protean sequelae. Immediate complications include cardiac, renal, and deep burns. Neurologic complications, while uncommon, can occur immediately or are delayed.

Blunt rupture of the thoracic duct after severe thoracic trauma.

A 53-year-old man was admitted to our trauma center after sustaining thoracoabdominal injuries, secondary to a rear-end motor vehicle collision. As he stepped out of his vehicle, he was struck by a tractor trailer at 55 mph. The following were the initial vital signs on his arrival: heart rate 140 beats/min, blood pressure 142/80 mm Hg, respiratory rate 28 breaths/min, temperature 36.8°C, and oxygen saturation 93%. The Glasgow Coma Scale score was 15 and the Injury Severity Score was 59. He was evaluated and resuscitated per the advanced trauma life support protocols. The focused assessment with sonography for trauma examination was negative. Initial findings included bilateral chest wall and thoracic spine tenderness, subcutaneous emphysema in the chest and neck, and an unstable pelvis. He required bilateral chest tubes and a pelvic binder. CT imaging revealed a left temporal epidural hematoma, multiple facial fractures, a sternal fracture, a left scapula fracture, acromioclavicular fractures, bilateral hemopneumothoraces, pulmonary contusions, extensive pneumomediastinum compressing the right atrium, multiple rib fractures (2-10 on the left with a flail segment and 2-8 on the right) (figure 1), an unstable open-book pelvic fracture which included bilateral superior and inferior pubic rami fractures, sacral and left iliac wing fractures, and symphysis pubis diastasis.Figure 1Three-dimensional CT scan reconstruction demonstrating left-sided flail chest.The patient developed hypotension and severe respiratory distress, and was intubated. ECG revealed no dysrhythmias. Echocardiogram revealed significant left ventricular wall dysfunction consistent with myocardial contusion and right atrial compression. His troponins were also significantly elevated. He required significant resuscitation with crystalloids, blood products and vasopressors. He underwent bronchoscopy, esophagram and upper endoscopy to exclude tracheoesophageal injury, and these were negative. On hospital day 2, the patient was hemodynamically stable, and pressors were discontinued. His pelvic fractures were repaired using external fixation and sacral screws. Given his extensive left flail chest, he underwent reconstruction of his left chest wall on hospital day 5. Open reduction and internal fixation of his left ribs, 3 to 6 anteriorly and 4 to 7 posteriorly, with titanium plates was performed (figure 2). He had an epidural catheter inserted for analgesia. On postoperative day 2 after chest wall reconstruction, the patient was extubated and resumed enteral feeds. Overnight, the output from the left-sided chest tube changed from serosanguinous to milky. A sample was sent for triglycerides and lymphocyte counts confirming the diagnosis of chylothorax. His chest tube output increased to approximately 2000 mL/day. A lymphangiogram was performed with Lipiodol to diagnose the location of the chylous leak. It revealed contrast extravasation at the level of T3 to T4. An MRI was also performed to better define the anatomic course of the thoracic duct.Figure 2Postoperative chest X-ray demonstrating left chest wall reconstruction. WHAT WOULD YOU DO?: Conservative management: placing the patient nulla per os (NPO), and starting total parenteral nutrition (TPN), octreotide and midodrine.Thoracic duct embolization by interventional radiology.CT-guided thoracic duct disruption.Thoracotomy with thoracic duct ligation.

Beware of the aberrant innominate artery.

The anatomy of aortic great vessels is relevant in surgeries of the anterior neck, especially with a tracheostomy, thyroidectomy, or mediastinoscopy. Variations in their anatomy could lead to severe complications if not recognized. An aberrant high-riding innominate artery incidentally encountered during mediastinoscopy is presented.