Electrical shock by dislodged spark gap in bipolar electrosurgical device

Initial evaluation and management of the critical burn patient

The major improvement in burn therapy is likely to focus on the early management of hemodynamic and respiratory failures in combination with an aggressive and early surgical excision and skin grafting for full-thickness burns. Immediate burn care by first care providers is important and can vastly alter outcomes, and it can significantly limit burn progression and depth. The goal of prehospital care should be to cease the burning process as well as prevent future complications and secondary injuries for burn shock. Identifying burn patients appropriate for immediate or subacute transfer is an important step in reducing morbidity and mortality. Delays in transport to Burn Unit should be minimized. The emergency management follows the principles of the Advanced Trauma Life Support Guidelines for assessment and stabilization of airway, breathing, circulation, disability, exposure and environment control. All patients with suspected inhalation injury must be removed from the enclosure as soon as possible, and immediately administer high-flow oxygen. Any patient with stridor, shortness of breath, facial burns, singed nasal hairs, cough, soot in the oral cavity, and history of being in a fire in an enclosed space should be strongly considered for early intubation. Fibroscopy may also be useful if airway damage is suspected and to assess known lung damage. Secondary evaluation following admission to the Burn Unit of a burned patient suffering a severe thermal injury includes continuation of respiratory support and management and treatment of inhalation injury, fluid resuscitation and cardiovascular stabilization, pain control and management of burn wound.

Surgical Energy-Based Device Injuries and Fatalities Reported to the Food and Drug Administration

BACKGROUND

Energy-based devices are used in virtually every operation. Our purposes were to describe causes of energy-based device complications leading to injury or death, and to determine if common mechanisms leading to injury or death can be identified.

STUDY DESIGN

The FDA's Manufacturer and User Facility Device Experience (MAUDE) database was searched for surgical energy-based device injuries and deaths reported over 20 years (January 1994 to December 2013). Device-related complications were recorded and analyzed.

RESULTS

We analyzed 178 deaths and 3,553 injuries. Common patterns of complications were: thermal burns, 63% (n = 2,353); hemorrhage, 17% (n = 642); mechanical failure of device, 12% (n = 442); and fire, 8% (n = 294). Events were identified intraoperatively in 82% (3,056), inpatient postoperatively in 9% (n = 351), and after discharge in 9% (n = 324). Of the deaths, 12% (n = 22) occurred after discharge home. Common mechanisms for thermal burn injuries were: direct application, 30% (n = 694); dispersive electrode burn, 29% (n = 657); and insulation failure, 14% (n = 324). Thermal injury was the most common reason for death (39%, n = 70). The mechanism for these thermal injuries was most frequently direct application (84%, n = 59, p < 0.001 vs all other mechanisms). Fires were most common with monopolar "Bovie" instruments (88%, n = 258, p < 0.001 vs all other devices) when they were used in head and neck operations (66%, n = 193, p < 0.001 vs all other locations).

CONCLUSIONS

Complications due to energy-based devices occur from 4 main causes: thermal burn, hemorrhage, mechanical failure, and fire. Thermal direct application injuries are the most common reason for both injury and death.

Electrical injuries

Electrical injury is a relatively infrequent but potentially devastating form of multisystem injury with high morbidity and mortality. Most electrical injuries in adults occur in the work-place, whereas children are exposed primarily at home. In nature, electrical injury occurs due to lightning, which also carries the highest mortality. The severity of the injury depends on the intensity of the electrical current (determined by the voltage of the source and the resistance of the victim), the pathway it follows through the victim's body, and the duration of the contact with the source of the current. Immediate death may occur either from current-induced ventricular fibrillation or asystole or from respiratory arrest secondary to paralysis of the central respiratory control system or due to paralysis of the respiratory muscles. Presence of severe burns (common in high-voltage electrical injury), myocardial necrosis, the level of central nervous system injury, and the secondary multiple system organ failure determine the subsequent morbidity and long-term prognosis. There is no specific therapy for electrical injury, and the management is symptomatic. Although advances in the intensive care unit, and especially in burn care, have improved the outcome, prevention remains the best way to minimize the prevalence and severity of electrical injury.