Management of Electrical Burn with Compromised Circulation
Fasciotomy is the next step in managing a patient with an electrical burn of the leg who complains of pain on passive movement of the foot and has diminished pedal pulses. 1
Clinical Assessment of Electrical Burns
- Electrical burns can cause significant damage to deep tissues despite minimal external appearance, leading to compartment syndrome and vascular compromise 2
- Pain on passive movement (passive stretch pain) is a classic sign of compartment syndrome, which can rapidly progress to tissue necrosis and limb loss 1
- Diminished pedal pulses indicate compromised circulation that requires immediate intervention 3
Rationale for Fasciotomy
- Fasciotomy is the surgical procedure of choice for compartment syndrome to relieve pressure within the muscle compartments and restore circulation 4
- Unlike escharotomy (which only releases the burned skin), fasciotomy addresses the deeper tissue pressure that occurs with electrical burns 1
- Electrical burns cause more extensive deep tissue damage than thermal burns, making fasciotomy necessary to prevent irreversible muscle and nerve damage 2
Diagnostic Considerations
- The combination of pain on passive movement and diminished pulses strongly suggests compartment syndrome requiring immediate fasciotomy 1
- While some clinicians use oximetry (<90%) and Doppler flow measurements to guide decisions, the clinical presentation in this case already indicates the need for surgical intervention 1
- Delay in performing fasciotomy when indicated can lead to permanent tissue damage within 4-6 hours 3
Alternative Options and Why They're Not Appropriate
- Escharotomy (option A) is insufficient for electrical burns as it only releases the skin but doesn't address deep compartment pressure 5, 1
- Femoral angiogram (option B) would delay definitive treatment while compartment pressures continue to rise, risking limb viability 3
- Leg elevation and intravenous heparin (option C) are inadequate interventions for established compartment syndrome with diminished pulses 3
Post-Procedure Management
- After fasciotomy, the wound should be managed with appropriate dressings and the limb should be elevated 5
- Regular neurovascular assessments should be performed to ensure adequate perfusion 1
- Subsequent debridement of necrotic tissue may be necessary, with an average of 2.3 debridements required in high-voltage electrical injury cases 2
Long-Term Considerations
- Electrical burns have high rates of long-term morbidity, with significant neurological deficits persisting in 73% of patients 2
- Early and appropriate intervention with fasciotomy can significantly improve outcomes and reduce the need for amputation 4
- Rehabilitation should begin early to maximize functional recovery 2