are responsible for approximately 1,000 deaths in the United States every year and are unique with respect to relatively low mortality rates but very high rates of short- and long-term morbidity. 1 The mortality of elec- trocution is estimated to be anywhere from 3% to 59%, depending on the voltage, with fatal heart arrhythmias the leading cause of death. 2 While any electrical trauma has the potential to precipitate cardiac arrhythmia, high-voltage injuries (>1,000 volts) are associated with a greater degree of tissue damage. Up to 35% of all victims require partial or total limb amputation following elec- trical trauma. Neurological complications are common irrespective of the type of electrical injury. 3 Neuronal death is followed by fibrosis and scarring. Retrospective studies have reported significant long-term neurologi- cal deficits in up to 73% of patients five years following electrical injury and chronic pain in up to 25%. 3 Poor perioperative pain control has been linked to the de- velopment of chronic postoperative pain syndromes, 4 which are caused by damage to inhibitory neurons and proliferation of excitatory afferent neurons. This case also highlights the utility of regional anesthesia for acute pain control. When considering re- gional techniques, a number of factors need to be taken into account, including the location of block placement, expected effects, and potential complications. In the case of our patient, a bilateral approach to the brachial plexus was clearly needed, and an axillary approachwas clearly precluded due to the presence of wounds in the axillae. Such an approach would have significantly increased the risk of local infection. Furthermore, an axillary bra- chial plexus block does not reliably alleviate pain in the entire upper extremity, 5 and is more appropriate for distal upper extremity indications. An interscalene approach to brachial plexus blockade is associatedwith a near-certain ip- silateral phrenic nerve blockade and subsequent ipsilateral diaphragmatic paralysis, 6 making the placement of bilateral interscalene blocks an unacceptable solution. 6,7 Compared to the interscalene approach, the supraclavicular brachial plexus block has a lower (though still considerable) risk of phrenic nerve paralysis. 5,6,8,9 We determined that a supracla- vicular approach for continuous brachial plexus blockade was the most viable option for this patient, despite concerns regarding the possibility bilateral phrenic nerve paralysis. A supraclavicular brachial plexus nerve block can be performed by eliciting paresthesia, by using nerve stimula- tion, by using ultrasound guidance, or any combination of these techniques. 10,11 Eliciting paresthesia becomes extremely unreliable in the event of trauma to the brachial plexus, and in the presence of extensive nerve damage due to electrocu- tion, it may be difficult to elicit a twitch response using the nerve stimulation technique, with apparent conduction of the electrical impulse potentially blocked or attenuated at multiple levels. Furthermore, given that the twitch response is typically observed at the hand or wrist, the anatomical correlation in this case was complicated by the fact that the patient had undergone bilateral below-elbow amputations.
reduction in the patient’s visual-analogue pain score was achieved (from 10/10 to 5/10). The patient was monitored for a further 30 minutes for signs of delayed complications, with none noted. The procedure was then repeated on the right side, with a bolus of 10 ml 0.5% ropivacaine following success- ful catheter placement. Once again, no complications were noted, and the patient reported a significant reduction in pain (10/10 to 2/10). Both supraclavicular brachial plexus nerve block cath- eters were connected to individual pumps and a continuous infusion of 0.2% ropivacaine was initiated at 8 ml per hour. The patient continued to report reduced pain and was able to tolerate physical therapy. A significant reduction in nar- cotic analgesic consumption was noted over the following three days. Both catheters were removed at the time of ICU discharge, and the remainder of the patient’s hospitalization was uneventful. DISCUSSION This case highlights the need for acute pain control in patients with electrical injuries. Adequate pain control is of paramount importance, not only for the management of acute distress symptoms, but for reducing the risk of subsequent chronic pain syndrome. Electrocution injuries Figure 1: Ultrasound-guided supraclavicular block showing anatomic landmarks and needle placement, brachial plexus (BP), needle tip (NT), pleura (PL), first rib (RIB), and subclavian artery (SA).
J La State Med Soc VOL 166 March/April 2014 61
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