|Year : 2020 | Volume
| Issue : 1 | Page : 98-100
Arterial rupture: A delayed sequela of burn injury
Praveen Kumar Arumugam, Harnoor Momak Walia, Bhagyashri Talele, Sunil Sharma
Department of Burns, Plastic and Maxillofacial Surgery, VM Medical College and Safdarjung Hospital, Delhi, India
|Date of Submission||18-May-2020|
|Date of Decision||17-Jun-2020|
|Date of Acceptance||08-Aug-2020|
|Date of Web Publication||21-May-2021|
Dr. Praveen Kumar Arumugam
Department of Burns, Plastic and Maxillofacial surgery, VM Medical College and Safdarjung Hospital, Delhi
Source of Support: None, Conflict of Interest: None
Burn injuries, especially electrical burns, can lead to significant soft-tissue damage. A delayed sequela of both electric burn and firecracker injury is arterial rupture. The initial phase is characterized by occlusion of small vessels. Large vessels are prone to aneurysm formation due to medial necrosis. This can result in unanticipated bleeding, which can lead to loss of the limb or even be life-threatening. We are presenting here two cases treated in our burns department for electrical burns and firecracker injury involving the lower limbs. Both these patients presented with delayed vascular complications, which were successfully managed and limbs salvaged. We are presenting these cases to emphasize that timely intervention leads to better outcomes.
Keywords: Anterior tibial artery, arterial rupture, electric burn, femoral artery, firecracker injury
|How to cite this article:|
Arumugam PK, Walia HM, Talele B, Sharma S. Arterial rupture: A delayed sequela of burn injury. Indian J Burns 2020;28:98-100
| Introduction|| |
Vascular damage in burn injuries, especially in high-voltage electric burns, results from coagulative necrosis of vascular walls, leading to thrombosis and can later rupture, causing life-threatening hemorrhage. We present two cases of delayed arterial complications of burns – the first was due to firecracker injury which caused tissue destruction, whereas the second case was one of high-voltage electric contact burns.
| Case Reports|| |
A 26-year-old male sustained burn injury to the left leg when he was trying to light a firecracker, and it burst when his leg was in close proximity. The patient was referred from a private hospital after initial conservative management, with suspicion of an arteriovenous fistula. The patient presented to us with acute bleed from wound over the middle third of the left leg [Figure 1]a. He received fluid replacement therapy and blood transfusion for low hemoglobin (7.3 g/dl). A computed tomography (CT) angiogram done to rule out an arteriovenous fistula revealed cutoff at the middle third of the anterior tibial artery [Figure 1]b. The patient was taken up for exploration under spinal anesthesia, which revealed bleeding from anterior tibial artery and venous oozing from the bed. There was a loss of tibialis anterior muscle, along its middle third. Peroneal and posterior tibial vessels were intact. The anterior tibial artery was ligated, wound debrided and other bleeding points cauterized, surgicel (oxidized regenerated cellulose) was placed and dressing was done. The wound was reexamined after 24 h, and there was no oozing. Regular dressings continued till healthy granulation tissue [Figure 1]c formed over the wound, and the wound was skin grafted. The graft take was good, and the patient was discharged [Figure 1]d. The patient had about 15° of extensor lag with compensation by the long toe extensors and loss of sensation in the first web space. He was advised physiotherapy.
|Figure 1: (a) Postfirecracker injury wound over the left leg. (b) Computed tomography angiogram showing cutoff of anterior tibial artery. (c) Wound ready for grafting (d) At 1-month follow-up|
Click here to view
A 25-year-old electric lineman was working near a power station and accidentally came in contact with a high-tension power line (11,000 kV) sustaining severe electrical burns. Physical examination revealed burns to his left upper limb, trunk, and left thigh. The thigh wound was deep, involving the muscles of the anterior compartment [Figure 2]a. Total surface area involved was 15%. Fluid resuscitation was started, and sodium bicarbonate was added for urine alkalization. The urine output gradually improved, and by 4th hr postadmission, the urine was clear. Electrocardiogram done was normal. Prophylactic antibiotic was started. On day 11, the patient had blood soakage of the left thigh dressing. On examination, oozing was noticed from the wound. A tourniquet was applied to the limb, and compressive bandage was applied to the wound. He was promptly shifted to the operating room and found to have oozing from femoral artery rupture, which manifested as a sentinel bleed. Femoral artery was ligated. The common femoral artery was explored through a proximal incision over the healthy region, and on applying vascular clamps, there was perfusion of the lower limb, suggesting collateral circulation. The common femoral artery and vein were ligated at the level of the groin to prevent further risk of rupture. A CT angiogram demonstrated similar findings of collateral flow and reformation of the vessels at the popliteal level [Figure 2]b. The left lower limb was salvaged, and thigh wound healed well with granulation tissue. The wound was then grafted with split-thickness skin graft, which subsequently healed well [Figure 2]c and [Figure 2]d.
|Figure 2: (a) Postelectrical burn wound over thigh. (b) Computed tomography angiogram showing collateral formation around the site of bleed (white arrow) and good distal vascularity. (c) Wound skin grafted. (d) At 1-month follow-up|
Click here to view
| Discussion|| |
In India, most of the blast injuries coming to tertiary care hospitals are due to firecracker injuries and homemade bombs. Like in our first case, these injuries are very commonly associated with the festival of Diwali, where different types of crackers are used. The blast potential of these firecrackers ranges from low intensity (deflagrating at rates up to 400 m/s) to high intensity (deflagrating at rates varying from 1000 to 9000 m/s). The most common body part affected in firecracker injuries is the hand, with lower limb injuries being rare., Young males make up the majority of the cases due to higher risk-taking behavior. The full extent of injury due to the blast is not evident on the first examination and hence requires treatment in stages. The first surgery is focused on debridement. Damage to local tissues and infection predispose to erosion of vessels and hemorrhage. Subsequent surgeries are required for soft-tissue coverage.,
Electrical injury causes tissue damage through electric current and also as a result of heat generation in the tissues. This depends on the intensity of the current. The Ohm's law shows that the intensity of the current flowing is directly proportional to voltage and inversely proportional to resistance (I = V/R). The heat generated in the tissues is directly proportional to resistance, square of current passing through and time, given by Joule's law (W [Joules] = R × I2 × T).
Blood vessels due to their high water content are excellent conductors of electric current. The effect of the current flowing through a vessel depends on its size. In large vessels, heat is dissipated due to their rapid flow, but is prone to medial necrosis, aneurysm formation, and rupture. In smaller vessels, coagulation necrosis occurs and is primarily affected in cases of electric contact burns. In the initial phase, the risk of vascular thrombosis exists. This is followed by the risk of hemorrhage. In our second patient, the initial phase of thrombosis caused collateral vessels to develop, which helped in salvaging the limb. To the best of our knowledge, rupture of the femoral artery following electric burn with limb salvaghas not been reported in literature.
Varying times to rupture has been reported in various case reports. This makes it important for diligent monitoring of the patient. In case of any obvious bleeding, direct pressure should be applied. An examination of heart rate, blood pressure, and neck veins gives an assessment of the state of the circulatory system. Two large-bore peripheral intravenous cannulas or a central line should be inserted, and fluid resuscitation started. The capillary refill and temperature of unburnt skin should be examined. In addition to arterial rupture, bleeding from a burn wound may also be due to secondary infection or coagulopathy. Burn-associated coagulopathy in early phases is due to direct tissue injury and the later phase is due to sepsis-induced coagulopathy.
All treating personnel must be aware of the complication so that patients may be managed better as some of these ruptures can be fatal.
| Conclusion|| |
Late arterial ruptures can result in endangerment to life and the limb. This delayed sequelae of burns, especially electric burns, must be borne in mind, and early intervention by the treating team results in better patient outcomes.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Adhikari S, Bandyopadhyay T, Sarkar T, Saha JK. Blast injuries to the hand: Pathomechanics, patterns and treatment. J Emerg Trauma Shock 2013;6:29-36. [Full text]
Mohan A, Nolan GS, Jain AFirework-related blast injury to the hand and treatment algorithmBMJ Case Reports CP 2019;12:e231804.
Puri V, Mahendru S, Rana R, Deshpande M. Firework injuries: A ten-year study. J Plast Reconstr Aesthet Surg 2009;62:1103-11.
Leon LR, Psalms SB, Labropoulos N, Mills JL. Infected upper extremity aneurysms: A review. Eur J Vasc Endovasc Surg 2008;35:320-31.
Ortiz R, Ozkan S, Chen NC, Eberlin KR. Firework Injuries of the Hand: An Analysis of Treatment and Health Care Utilization [published online ahead of print, 2019 Mar 17]. Hand (N Y). 2019;1558944719829905. doi:10.1177/1558944719829905.
Waldmann V, Narayanan K, Combes N, Jost D, Jouven X, Marijon E. Electrical cardiac injuries: Current concepts and management. Eur Heart J 2018;39:1459-65.
Koumbourlis AC. Electrical injuries. Crit Care Med 2002;30:S424-30.
Glas GJ, Levi M, Schultz MJ. Coagulopathy and its management in patients with severe burns. J Thromb Haemost 2016;14:865-74.
Reinbold C, Serror K, Mimoun M, Chaouat M, Marco O, Boccara D. Electrical burns and late spontaneous artery ruptures: About three cases. J Burn Care Res 2019;40:120-7.
[Figure 1], [Figure 2]