CASE REPORT |
https://doi.org/10.5005/jp-journals-11006-0154 |
High-voltage Contact Electrical Injury to the Neck and Subsequent Delayed Onset Airway Edema: Case Report
1,3Department of Critical Care Medicine, Aster Ramesh Hospitals, Vijayawada, Andhra Pradesh, India
2Department of Plastic Surgery, Dr Pinnamaneni Siddhartha Institute of Medical Sciences and Research Foundation, Chinna Avutapalli, Gannavaram, Krishna, Andhra Pradesh, India
4Department of Pharmacy Practice, Koneru Lakshmaiah Education Foundation, Guntur, Andhra Pradesh, India
5College of Pharmacy, Koneru Lakshmaiah Education Foundation, Guntur, Andhra Pradesh, India
6Department of Practice Enhancement, Inpatient Services, Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA
Corresponding Author: Moturu Dharanindra, Department of Critical Care Medicine, Aster Ramesh Hospitals, Vijayawada, Andhra Pradesh, India, Phone: +91 9686347350, e-mail: newgenmedico@outlook.com
Received: 21 August 2024; Accepted: 16 December 2024; Published on: 25 February 2025
ABSTRACT
Aim and background: Electrical burn injuries are among the most severe forms of injury due to their high morbidity and mortality rates. They can significantly damage vital organs, with severity influenced by electric voltage, body resistance, and contact duration. In our country, they most commonly affect the extremities and the scalp. Electrical contact injury to the neck is an uncommon presentation and poses a challenge to treat due to critical structures in the neck and cervical region.
Case description: A 24-year-old male sustained a high-voltage electrical contact burn to the neck and both feet. He initially presented with normal airway, breathing, and circulation (ABC) and developed severe airway complications after 24 hours. This delayed onset of significant glottic and laryngeal edema underscores the importance of vigilant monitoring and preemptive airway management in patients with electrical contact injuries to the neck.
Conclusion: Continuous monitoring and early intervention are crucial in electrical contact injuries to the neck due to the risk of insidious airway edema. Prolonged observation beyond 48 hours is necessary to prevent life-threatening complications.
Clinical significance: Direct electrical contact injuries to the neck are uncommon. There is limited literature regarding their management. Contrary to burns to the head and neck leading to inhalational injury, which are common, we have clear-cut guidelines to secure a definitive airway early. A benign-appearing electrical contact injury to the neck with a normal airway examination can subsequently lead to life-threatening airway obstruction.
Keywords: Airway obstruction, Case report, Electric contact burns, Neck burns
How to cite this article: Dharanindra M, Parupalli TK, K Gontla VD, et al. High-voltage Contact Electrical Injury to the Neck and Subsequent Delayed Onset Airway Edema: Case Report. Indian J Crit Care Case Rep 2025;4(2):44–46.
Source of support: Nil
Conflict of interest: None
Patient consent statement: The author(s) have obtained written informed consent from the patient for publication of the case report details and related images.
INTRODUCTION
Electrical burn injuries occur due to the passage of electric current through the body.1,2 The heat and cellular changes caused by electricity can significantly damage the skin, tendons, muscles, bones, nerves, myocardium, and other vital organs.3,4 The severity of these injuries depends on the strength of the current (voltage), the body’s resistance, the parts of the body involved, the duration of contact, and any secondary events that can affect the severity of the injury.5,6
Electrical burn injuries most commonly affect the extremities and head. Direct electrical contact injuries to the neck are highly uncommon, and the presence of critical anatomical structures underscores the unique and complex nature of the case. Contrary to burn injuries to the body, about which significant clinical data and treatment modalities exist, this case poses a unique challenge due to the direct and isolated involvement of the neck.
CASE DESCRIPTION
A 24-year-old male sustained an accidental electric contact injury to his neck from a high-voltage powerline while standing and working on a truck. The incident occurred at night, and the patient lost consciousness and fell to the ground. Upon initial presentation, a primary survey was done per advanced trauma life support (ATLS) protocol. The individual was conscious and oriented with no focal neurological deficits. The Glasgow Coma Scale (GCS) score was 15. The airway examination was unremarkable—no cervical spine tenderness. A contact wound was noted on the neck, extending from one angle of the mandible to the other angle of the mandible and in the midline extending to the hyoid bone (U-shaped) (Fig. 1), accompanied by mild tenderness near the wound site and no significant local edema. Vital signs were stable at the time of arrival. Given the potential risk of delayed airway edema, the patient was admitted to the intensive care unit (ICU) for close observation. His initial computed tomography (CT) brain and cervical spine with soft tissue neck were normal. A local antiseptic wound dressing was applied.
Fig. 1: The electrical contact wound on admission
On postburn day 1, the patient remained conscious and oriented, with stable vital signs and oxygen saturation. There was mild edema around the burn site, but no stridor or breathing difficulties were observed. The patient was shifted to the surgical ward from the ICU after monitoring for 20 hours. However, his condition worsened subsequently, and he developed respiratory difficulty with breathlessness and inspiratory stridor 8 hours after moving to the ward. On examination, he had swelling of the submandibular region. The rapid response team (RRT) had to secure his airway with a 7 mm endotracheal tube and kept him on ventilatory support in the ICU (Fig. 2). The patient underwent a tracheostomy, followed by an escharotomy of the burn wound. Following this, the patient’s neck edema was reduced, and he was weaned from the ventilator. Later, the patient underwent multiple debridements followed by a musculocutaneous flap cover. The patient is doing well on 6-month follow-up (Fig. 3).
Fig. 2: Patient intubated with grossly edematous neck
Figs 3A and B: Patient post escharotomy and flap cover
DISCUSSION
The younger (20–30 years) age-group is more vulnerable to electrical burn injuries due to their propensity for risk-taking behavior. Electric burns of the head and upper limbs account for 61.4% of high- or low-voltage injuries.7
This case illustrates the potential complications of high-voltage electrical contact injuries to the neck, which are uncommon. Patients might appear stable initially, with no tissue and airway edema, but they can develop delayed life-threatening airway complications. This patient’s delayed airway swelling required definitive airway management. Eternal vigilance and definitive airway management, when required, are paramount even in initially benign electrical contact injuries to the neck.
An electric current that encounters the neck can lead to severe and potentially life-threatening effects due to many vital anatomical structures in the neck area, such as the carotid arteries, jugular veins, cranial nerves, and the spinal cord. Complications can include airway obstruction, aspiration, vocal cord paralysis, perforation of the esophagus, severe vascular injury, necrotizing infection, stroke, air embolism, pneumothorax, or hemothorax.8 The electrical current may lead to involuntary muscle contractions, potentially causing fractures or dislocations in the cervical vertebrae and disrupting the heart’s rhythm via the vagus nerve, leading to strokes or paralysis.
Traditional teaching is that the severity of electrical injury depends on Kouwenhoven’s factors:
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Type of current [direct current (DC) or alternating current (AC)].
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Voltage and amperage (measures of current strength).
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Duration of exposure (more prolonged exposure increases injury severity).
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Body resistance.
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Pathway of current (which determines the specific tissue damaged).
However, a newer concept, electrical field strength, predicts injury severity more accurately. Six common electrocardiogram (ECG) abnormalities from electrical exposure include atrioventricular block, bundle branch blocks, atrial fibrillation, QT prolongation, and ventricular arrhythmia. Patients may suffer from thermal or electrical damage to the myocardium, leading to myocardial infarction, pericardial injury, and cardiogenic shock.9
Respiratory arrest and cardiac arrest can occur following an electric injury. Thoracic tetany can lead to paralysis of the respiratory muscles. Trauma from falls caused by electrical exposure can lead to immediate life-threatening issues like pneumothorax, hemothorax, and pulmonary contusion. Late complications, such as pleural effusions, pneumonitis, or pneumonia, often appear within a week after exposure. Another possible late complication is pulmonary embolism due to deep venous thrombosis (DVT). The relatively higher electrical resistance of lung tissue compared to other thoracic structures may explain the lower incidence of direct pulmonary injury, as the current tends to pass through surrounding lower-resistance tissues.9
CONCLUSION
The patient’s initial stable presentation with benign-appearing direct electrical contact injury to the neck and insidious development of airway edema highlight the need for continuous monitoring and early intervention in similar cases. The decision to shift the patient out of the ICU within 24 hours was based on the benign appearance of the contact wound, normal CT cervical spine with soft tissue neck, which proved wrong in this case. The patient should have been monitored closely for at least 24–36 hours, and early intubation should have been done at the earliest sign of airway edema. Electrical injuries, particularly those involving the cervical region, require careful and prolonged observation for >48 hours to intervene and prevent life-threatening airway complications.
Clinical Significance
This publication is an attempt to communicate the insidious life-threatening airway obstruction after electrical contact injury to the neck. Conventionally, we are aware of burns to the head and neck leading to inhalational injury, where we have clear-cut guidelines to secure a definitive airway early. But in this case report, we came across a clinical scenario in which there is direct electrical contact injury to the neck, presenting initially as a benign-appearing lesion with normal airway, clinical, and radiological examination, subsequently deteriorating to life-threatening airway obstruction.
ORCID
Moturu Dharanindra https://orcid.org/0000-0002-9446-5460
Tarun Kanth Parupalli https://orcid.org/0009-0009-6267-8638
V Dinesh K Gontla https://orcid.org/0000-0001-9822-3808
Supriya Rayana https://orcid.org/0000-0001-9904-2574
Mohammad Noor Shaik https://orcid.org/0000-0001-9430-5531
Hari Chandanaa Kistipati https://orcid.org/0009-0009-2663-1947
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