Question 22

College comments

Syllabus topic/section: 2.1.14.a Environmental injuries in ICU: Electrocution (L1 condition), 2.1.13 Trauma intensive care: severe and/or multitrauma (L1 topic)

Discussion: 

This question aimed to assess candidates’ understanding of high voltage electrocution related injuries. A standard answer was expected to include a spectrum of electrical injuries, including burns, and other trauma related injuries alongside relevant examination findings.
Candidates who did not recognise the complexity of injuries, particularly the potential of deep tissue injuries, electrical burns and cardiac sequelae of electrical injuries missed the key aspects of the question. Additionally, the below standard responses lacked the corresponding examination findings that were explicitly requested. Candidates are reminded to read the stem and follow the directions given to ensure maximum marks.

Given the broad range of potential injuries, a structured approach - such as organising the answer by system (e.g., cardiovascular, respiratory, neurological) or injury type (e.g., electrical injuries, traumatic injuries) - could have enhanced clarity and completeness. Using tabular format to align injuries with corresponding examination findings could have further strengthened the responses and demonstrated a systematic approach.

The rubric is provided to aid the candidate's future study.
 

	Below standard	At standard	Above standard
a) injuries (10 marks)	Limited detail without a logical systems base And /or only concentrating on one type of injury in this patient OR Inaccurate or generic only list of injuries 0 - 4.5 marks	The at standard answer will contain a mix of traumatic AND burn or electrical injury pattern (at least 2/3 pattern types) Reasonable depth of examination findings specific to each injury Must mention deep tissue injuries from electrical burn as part of at standard answer as this is a key feature of a high voltage electrical burn 5 - 7 marks	At standard PLUS All forms of injury patterns present ( traumatic -from being thrown and CPR ), AND burn AND electrical injury patterns) May include mention of HIE 2’ to LOC Detailed examination findings matched to injuries, detail would include specifications of burns , characteristics of high voltage electrical injury and detailed list of trauma sustained after a vertical deceleration injury +/_ complications of trauma 7.5 - 10 marks

Interpretation

The author's own preference is often to rely on a crude alphabetic structure because he would inevitably miss some organ system or injury pattern otherwise. Moreover, it is necessary to demonstrate that there are other ways of handling this, ratehr than usign a tabular structure.  What follows is in the format "injury (fndings)"

A: Inhalational burn injuries (airway ulceration, etrythema, soot, singed vibrissae)

B: Pneumothorax from CPR (decreased air entry unilaterally)

    Chest wall burns (erythema, reduced lung compliance)

    Lung contusions (creps, hypoxia, haemoptysis)

    Aspiration (creps, hypoxia, purulent sputum)

C: Myocardial stunning (cool extremities, motling, raised JVP, narrow pulse pressure, hypotension)

    Arrhythmias (irregular pulse, pauses)

    Vessel thrombosis (absent pulses)

    Compartment syndrome (decreased regional cap refill, tense compartments, pallor)

D: Hypoxic ischaemic encephalopathy (unconsciousness, myoclonus)

    Seizures

    Ruptured ear drums (otorrhoea)

    Autonomic dysfunction (fixed dilated pupils, hypotension, urinary retention)

E: Rhabdomyolysis (myoglobinuria)

    Hyperkalemia (peaked T waves)

F: Renal failure (anuria, haematuria)

I: Skin burns (obvious on inspection)

   Bony trauma (pelvic instability, features of spinal injury, angulated long bones)