Silent Blast in Oral Cabity: Is the Car Battery Innocuous
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《美国医学杂志》
1 Department of Anesthesiology and Critical Care, B.P. Koirala Institute of Health Sciences, Dharan, Nepal
2 Department of Dental surgery, B.P. Koirala Institute of Health Sciences, Dharan, Nepal
3 Department of Otorhinolaryngology, B.P. Koirala Institute of Health Sciences, Dharan, Nepal
Abstract
Low voltage energy source is not free from danger. An exceptionally rare and peculiar mode of facial blast injury is reported. The blast took place silently in the mouth of a 15-year-old boy, due to short-circuiting of wires connected to a12-volt car battery while peeling off insulation with the intent of running a musical instrument. Airway compromise due to soft tissue injury produced further problem during tracheostomy. Emergent airway management is discussed. Post-healing sequel resulted in loss of voice and prevented normal oral feeding. The case report emphasizes need for education to public in handling low voltage energy source.
Keywords: Facial blast injury; Low voltage; Short-circuiting; Car battery
Low voltage electrical source like car battery is used in homes in appliances for inverters etc and is frequently improvised for domestic lighting and playing musical instruments. Facial injury due to low voltage source is extremely rare.[1] We present a child who suffered massive orofacial trauma due to short circuiting of wires connected to 12 volt car battery, put inside mouth to peel off insulation. Rare and peculiar mode of injury sustained from a source commonly perceived to be harmless, emergent management of airway, and post-trauma sequel are discussed.
Case report
A boy aged 15 years was brought to Accident and Emergency Department of this hospital in great distress due to pain, fear and respiratory difficulty caused by isolated massive blast injury to mid and lower face. The child was pale with pulse rate of 130/ minute, blood pressure of 90/50 mm of Hg, respiratory rate of 40 bpm and oxygen saturation of 90% of Hb (Pulse Oximetry).
Apparently, the injury was caused when the boy, fiddling around with a 12 volt car battery; put the wires inside mouth to peel off insulation with intent to connect the battery to a music instrument. Suddenly, mother of the child noticed gush of blood erupting from the oral area of the child and extensive facial damage. Child was taken to local health center and after first aid was referred for further management to this hospital.
The injury was isolated facial blast injury with oral cavity extensively blown inside out. There was no active bleeding at the time of first examination. There was mutilation of orofacial structures with loss of bony part of premaxilla and anterior part of mandible with respective rows of teeth. Extensive damage of soft tissue, including loss of anterior two third of tongue was seen. Oropharynx was exposed to exterior Figure1.
There was no evidence of burn or tattooing around facial injury and no active bleeding or CSF leak from nose or ears. There was no evidence of injury to other part of the body and he could move all four limbs.
Although child was conscious with normal hearing and vision, he was unable to communicate verbally. Loss of support of base of tongue and soft tissue edema were obstructing the airway in supine position. Proper lateral positioning and oxygen supplementation with simple mask improved the respiration and oxygenation. Intravenous fluid administration and analgesics made the child comfortable.
Emergency management team included otorhinolaryngologist, dental surgeon and anaesthesiologist. Since mask ventilation and tracheal intubation were anticipated to be difficult, tracheostomy followed by wound debridement and repair were planned.
Tracheostomy was attempted under local anesthesia but probably irritation with blood and local anesthetic produced severe laryngospasm which resulted in oxygen desaturation. As an emergent management, remaining part of tongue was pulled with swab holding forceps by an assistant making larynx visible followed by endotracheal intubation with aid of Magill's laryngoscope. With the restoration of the airway, general anesthesia was provided with oxygen, nitrous oxide and halothane. After shifting the airway to tracheostomy, debridement and repair was done Figure2.
General course of post-operative period was uneventful. But after post-operative healing along with disfigurement, normal oral feeding was not possible and was maintained by Ryle's tube. Verbal communication was restricted to some gurgling sound due to loss of lips and anterior part of tongue. Figure3. This was reason for great psychological trauma and distress to both the patient and his parents. He was referred to specialized center for reconstructive surgery and further treatment.
Discussion
0Generally associated with war wounds[2], [3] civilian causes of facial blast injuries are now seen in terrorist attacks. Most of the injuries are common to adults and other parts of bodies are also involved. Some of reported rare causes of civilian facial injuries are letter bomb injury, beverage bottle blasts and recreational firework injuries.[4],[5],[6]
Facial electrical injury in children is common due to biting live wires of household electrical supply.[7] It is very rare to get injury due to short circuiting from wires of low voltage battery. Eye injury due to explosion of car battery and burning of fingers due to short circuiting of ring are reported.[8] To the best of our knowledge, only one similar mode of injury has been reported in the literature.[1]
Car battery is thought to be innocuous, however, it contains tremendous amount of energy. The low internal resistance of a car battery (approximately 0.03 ohms) when short-circuited, permits the flow of heavy current of approximately 200 amps. Short-circuiting of wires instantaneously vaporizes a minuscule portion of wire at approximately 2000 K resulting in a blast in closed cavity[1]. Sudden rise of intraoral pressure to nearly 30 kg cm-[2] can lead to extensive damage of circum oral structure.[1] Short-circuiting of live wires connected to 12 volt car battery can be very dangerous and can produce damage to the battery as well as things attached to it. This can be the probable explanation for the inside, out blast injury of face in the present case report.
Facial injury is not life threatening unless it is associated with airway problem.[9] The major risks to the airway in patient's management with massive facial trauma are due to anatomic alteration of airway patency through bony disruption, soft tissue swelling and the increased potential for aspiration of body fluids.[10],[11] Before the airway is secured, the patient should be allowed to maintain a position of choice or be placed in the lateral decubitus position.[12]
The patient presenting with presumably isolated massive facial trauma can be an airway disaster to happen.[10] In the present case, techniques like awake orotracheal, naso-tracheal and fibre-optic intubation were not feasible, so elective tracheostomy was planned.[11] Sudden deterioration of the patient during tracheostomy could be managed by endotracheal intubation through injured pharyngeal route. It is suggested that in case of emergency, if bag and mask are not feasible, orotracheal route, the most practiced one, should be attempted.[10] Preparation to deal with the situation, quickness of decision and intervention are the keys to successful management.
It is quite common for the age group of the patient to do maneuvers in ignorance, which can prove dangerous and can produce grievous injury. A small lapse in precaution can lead to not only physical trauma but also psychological trauma and distress due to facial disfigurement. The present case emphasizes the need of education to public about proper handling of electrical equipment. Low volt electrical source like car battery is not free from danger and can be potentially life threatening if not handled properly.
References
1. Singh SK, Jain P, Sinha JK. Extensive facial damage caused by a blast injury arising from a 6 volt lead accumulator. Br J Plast Surg 1999; 52: 149-151.
2. Danic D, Progmet D, Milicic D, Leovic D, Puntric D. War injuries to the head and neck. Mil Med 1998; 163: 117-179.
3. Shuker T. Maxillofacial blast injuries. J Craniomaxillofac Surg 1995; 23: 91-98.
4. Jamara FA, Halasa A, Salman S. Letter bomb injuries: a report of three cases. J Trauma 1974; 14: 275-279.
5. Efrati Y, Sarfaty S, Klin B, Eshel G, Segal S, Vinograd I. Oral blast injury caused by an accident. Ann Otol Rhinol Laryngol 1993; 102: 528-530.
6. Hubbard TJ, Dado DV, Izquierdo R. Massive craniofacial injuries from recreational fire works: a report of three cases. J Trauma 1992; 33: 767-772.
7. Pensler JM, Rosenthal AJ.Reconstruction of the oral commissure after an electrical burn. Burn care Rehabil 1990; 11: 50-53.
8. Atalla MF, El-ekiaabi S, Al-Baker A. Ring Burn- electric or contact Burns 1990; 16: 69- 70.
9. Ardekian L, Rosen D, Klein Y, Peled M, Michaelson M, Laufer D. Life-threatening complications and irreversible damage following maxillofacial trauma. Injury 1998; 29: 253-256.
10. Stephen V. Cantrill. Massive facial trauma and direct Neck Trauma. In Robert H. Dailey, Barry Simon, Gary P. Young, Ronald D. Stewart. The Airway: Emergency Management. Mosby Year book, Inc; 1992, 259-269.
11. Alexander W. Gotta. Maxillfacial Trauma. In Christopher M Grande,Peter J.F. Baskett, Nischolas G. Bircher et al, eds. Text Book of Trauma Anaesthesia and Critical Care. Mosby-Year Book, Inc St. Louis, Missouri; 1993: 529-539.
12. Roger S, Cicala, Christopher M, Grande, John K, Stene, Eliazabeth C, Behringer. Emergency and elective airway management for trauma patients. In Christopher M Grande, Peter JF, Baskett, Nicholas G, Bircher et al, eds. Text Book of Trauma Anaesthesia and Critical Care. Mosby-Year Book, Inc St. Louis, Missouri; 1993: 344-380.(Bhadani Umesh Kumar, Trip)
2 Department of Dental surgery, B.P. Koirala Institute of Health Sciences, Dharan, Nepal
3 Department of Otorhinolaryngology, B.P. Koirala Institute of Health Sciences, Dharan, Nepal
Abstract
Low voltage energy source is not free from danger. An exceptionally rare and peculiar mode of facial blast injury is reported. The blast took place silently in the mouth of a 15-year-old boy, due to short-circuiting of wires connected to a12-volt car battery while peeling off insulation with the intent of running a musical instrument. Airway compromise due to soft tissue injury produced further problem during tracheostomy. Emergent airway management is discussed. Post-healing sequel resulted in loss of voice and prevented normal oral feeding. The case report emphasizes need for education to public in handling low voltage energy source.
Keywords: Facial blast injury; Low voltage; Short-circuiting; Car battery
Low voltage electrical source like car battery is used in homes in appliances for inverters etc and is frequently improvised for domestic lighting and playing musical instruments. Facial injury due to low voltage source is extremely rare.[1] We present a child who suffered massive orofacial trauma due to short circuiting of wires connected to 12 volt car battery, put inside mouth to peel off insulation. Rare and peculiar mode of injury sustained from a source commonly perceived to be harmless, emergent management of airway, and post-trauma sequel are discussed.
Case report
A boy aged 15 years was brought to Accident and Emergency Department of this hospital in great distress due to pain, fear and respiratory difficulty caused by isolated massive blast injury to mid and lower face. The child was pale with pulse rate of 130/ minute, blood pressure of 90/50 mm of Hg, respiratory rate of 40 bpm and oxygen saturation of 90% of Hb (Pulse Oximetry).
Apparently, the injury was caused when the boy, fiddling around with a 12 volt car battery; put the wires inside mouth to peel off insulation with intent to connect the battery to a music instrument. Suddenly, mother of the child noticed gush of blood erupting from the oral area of the child and extensive facial damage. Child was taken to local health center and after first aid was referred for further management to this hospital.
The injury was isolated facial blast injury with oral cavity extensively blown inside out. There was no active bleeding at the time of first examination. There was mutilation of orofacial structures with loss of bony part of premaxilla and anterior part of mandible with respective rows of teeth. Extensive damage of soft tissue, including loss of anterior two third of tongue was seen. Oropharynx was exposed to exterior Figure1.
There was no evidence of burn or tattooing around facial injury and no active bleeding or CSF leak from nose or ears. There was no evidence of injury to other part of the body and he could move all four limbs.
Although child was conscious with normal hearing and vision, he was unable to communicate verbally. Loss of support of base of tongue and soft tissue edema were obstructing the airway in supine position. Proper lateral positioning and oxygen supplementation with simple mask improved the respiration and oxygenation. Intravenous fluid administration and analgesics made the child comfortable.
Emergency management team included otorhinolaryngologist, dental surgeon and anaesthesiologist. Since mask ventilation and tracheal intubation were anticipated to be difficult, tracheostomy followed by wound debridement and repair were planned.
Tracheostomy was attempted under local anesthesia but probably irritation with blood and local anesthetic produced severe laryngospasm which resulted in oxygen desaturation. As an emergent management, remaining part of tongue was pulled with swab holding forceps by an assistant making larynx visible followed by endotracheal intubation with aid of Magill's laryngoscope. With the restoration of the airway, general anesthesia was provided with oxygen, nitrous oxide and halothane. After shifting the airway to tracheostomy, debridement and repair was done Figure2.
General course of post-operative period was uneventful. But after post-operative healing along with disfigurement, normal oral feeding was not possible and was maintained by Ryle's tube. Verbal communication was restricted to some gurgling sound due to loss of lips and anterior part of tongue. Figure3. This was reason for great psychological trauma and distress to both the patient and his parents. He was referred to specialized center for reconstructive surgery and further treatment.
Discussion
0Generally associated with war wounds[2], [3] civilian causes of facial blast injuries are now seen in terrorist attacks. Most of the injuries are common to adults and other parts of bodies are also involved. Some of reported rare causes of civilian facial injuries are letter bomb injury, beverage bottle blasts and recreational firework injuries.[4],[5],[6]
Facial electrical injury in children is common due to biting live wires of household electrical supply.[7] It is very rare to get injury due to short circuiting from wires of low voltage battery. Eye injury due to explosion of car battery and burning of fingers due to short circuiting of ring are reported.[8] To the best of our knowledge, only one similar mode of injury has been reported in the literature.[1]
Car battery is thought to be innocuous, however, it contains tremendous amount of energy. The low internal resistance of a car battery (approximately 0.03 ohms) when short-circuited, permits the flow of heavy current of approximately 200 amps. Short-circuiting of wires instantaneously vaporizes a minuscule portion of wire at approximately 2000 K resulting in a blast in closed cavity[1]. Sudden rise of intraoral pressure to nearly 30 kg cm-[2] can lead to extensive damage of circum oral structure.[1] Short-circuiting of live wires connected to 12 volt car battery can be very dangerous and can produce damage to the battery as well as things attached to it. This can be the probable explanation for the inside, out blast injury of face in the present case report.
Facial injury is not life threatening unless it is associated with airway problem.[9] The major risks to the airway in patient's management with massive facial trauma are due to anatomic alteration of airway patency through bony disruption, soft tissue swelling and the increased potential for aspiration of body fluids.[10],[11] Before the airway is secured, the patient should be allowed to maintain a position of choice or be placed in the lateral decubitus position.[12]
The patient presenting with presumably isolated massive facial trauma can be an airway disaster to happen.[10] In the present case, techniques like awake orotracheal, naso-tracheal and fibre-optic intubation were not feasible, so elective tracheostomy was planned.[11] Sudden deterioration of the patient during tracheostomy could be managed by endotracheal intubation through injured pharyngeal route. It is suggested that in case of emergency, if bag and mask are not feasible, orotracheal route, the most practiced one, should be attempted.[10] Preparation to deal with the situation, quickness of decision and intervention are the keys to successful management.
It is quite common for the age group of the patient to do maneuvers in ignorance, which can prove dangerous and can produce grievous injury. A small lapse in precaution can lead to not only physical trauma but also psychological trauma and distress due to facial disfigurement. The present case emphasizes the need of education to public about proper handling of electrical equipment. Low volt electrical source like car battery is not free from danger and can be potentially life threatening if not handled properly.
References
1. Singh SK, Jain P, Sinha JK. Extensive facial damage caused by a blast injury arising from a 6 volt lead accumulator. Br J Plast Surg 1999; 52: 149-151.
2. Danic D, Progmet D, Milicic D, Leovic D, Puntric D. War injuries to the head and neck. Mil Med 1998; 163: 117-179.
3. Shuker T. Maxillofacial blast injuries. J Craniomaxillofac Surg 1995; 23: 91-98.
4. Jamara FA, Halasa A, Salman S. Letter bomb injuries: a report of three cases. J Trauma 1974; 14: 275-279.
5. Efrati Y, Sarfaty S, Klin B, Eshel G, Segal S, Vinograd I. Oral blast injury caused by an accident. Ann Otol Rhinol Laryngol 1993; 102: 528-530.
6. Hubbard TJ, Dado DV, Izquierdo R. Massive craniofacial injuries from recreational fire works: a report of three cases. J Trauma 1992; 33: 767-772.
7. Pensler JM, Rosenthal AJ.Reconstruction of the oral commissure after an electrical burn. Burn care Rehabil 1990; 11: 50-53.
8. Atalla MF, El-ekiaabi S, Al-Baker A. Ring Burn- electric or contact Burns 1990; 16: 69- 70.
9. Ardekian L, Rosen D, Klein Y, Peled M, Michaelson M, Laufer D. Life-threatening complications and irreversible damage following maxillofacial trauma. Injury 1998; 29: 253-256.
10. Stephen V. Cantrill. Massive facial trauma and direct Neck Trauma. In Robert H. Dailey, Barry Simon, Gary P. Young, Ronald D. Stewart. The Airway: Emergency Management. Mosby Year book, Inc; 1992, 259-269.
11. Alexander W. Gotta. Maxillfacial Trauma. In Christopher M Grande,Peter J.F. Baskett, Nischolas G. Bircher et al, eds. Text Book of Trauma Anaesthesia and Critical Care. Mosby-Year Book, Inc St. Louis, Missouri; 1993: 529-539.
12. Roger S, Cicala, Christopher M, Grande, John K, Stene, Eliazabeth C, Behringer. Emergency and elective airway management for trauma patients. In Christopher M Grande, Peter JF, Baskett, Nicholas G, Bircher et al, eds. Text Book of Trauma Anaesthesia and Critical Care. Mosby-Year Book, Inc St. Louis, Missouri; 1993: 344-380.(Bhadani Umesh Kumar, Trip)