I. Summary of medical history 1. Present medical history: The patient is male, 24 years old, unmarried. The patient was accidentally burned on the head, face, neck, hands, both forearms and left shoulder by 10 kV high-voltage electricity at work six days ago, and fell from a height of eight meters, landing on his head. He was unconscious for 10 minutes and did not vomit. He was rushed to a local hospital for resuscitation treatment, where he was given fluids and a bilateral forearm scabotomy and reduction, and CT examination revealed bilateral occipital epidural hematomas and left occipital lobe cerebral contusion. He was transferred to our hospital after 6 days of symptomatic treatment. He complained of headache and blurred vision. 2. Past history: no special findings. 3. Physical examination: body temperature 36.9 ℃, pulse 78 times/min, respiration 20 times/min, blood pressure 145/83 mmHg (lower limbs)? Normal development and good nutritional status. He was clearly conscious with a clear airway. On auscultation, the breath sounds were coarse in both lungs, no dry and wet rales were heard, the heart rate was uniform, and no pathological murmur was heard in each valve. The abdomen was flat and soft, and the liver and spleen were not palpable under the ribs. Bowel sounds were normal. Burns: The burn wounds were distributed on the head, face, neck, both hands, both forearms, and the left shoulder. The majority of the head, face and neck trauma was located on the left posterior side with significant swelling. A 5×4 cm2 skin and soft tissue defect was seen in the occipital region, with the skull exposed and partially necrotic, surrounded by a 10×10 cm2 trauma surface with a leathery appearance and loss of pain sensation. The swelling of the left ear was obvious, with a red and white base and little exudation. The trauma surface of the left shoulder was hard and black crusty. The hands were flexed, with high swelling extending to the upper arms, and a large amount of necrotic muscle and flexor tendons were visible in the hypotonic incision, leaving some normal skin on the dorsal side of the wrist. No radial artery pulsation was palpable at the right wrist, and ulnar artery pulsation was palpable. The ulnar radial artery pulsation was palpable on the left wrist. 4. Laboratory tests: blood leukocyte count 15.59X109/L, hematocrit 162.00g/L, erythrocyte pressure 45.6%, platelet count 148.00X109/L, ghrelin 165IU/L, ghrelin 88IU/L, total bilirubin 25.4umol/L, direct bilirubin 10.2umol/L, phosphocreatine kinase 301 IU/L, lactate dehydrogenase 227 IU/L, α-hydroxybutyrate dehydrogenase 180 IU/L, creatine kinase isoenzyme 10 IU/L. Serum potassium 3.4 mmol/L, serum sodium 135 mmol/L, serum chloride 98 mmol/L. 5. Cranial CT scan results: bilateral abnormal density foci in occipital lobe and left cerebellum, consistent with the diagnosis of bilateral occipital epidural hematoma and left occipital lobe cerebral contusion. 6. Diagnosis: high-voltage electrical burns 7% (deep second degree 1%, third degree 3%, fourth degree 3%); epidural hematoma (occipital); cerebral contusion (occipital lobe); cranial exostosis; vascular, nerve and tendon injury (bilateral upper limbs). ? 7. Treatment: (1) Systemic treatment: ①. Systemic administration of fluids, nutritional support, anti-infection treatment. ②. Give organ protection treatment: including liver, heart and gastrointestinal tract. ③. For cranial trauma give mannitol 125ml intravenously every 8 hours. ④. Monitor electrolytes, renal function, and neurosurgery. (2) Local treatment: ①Treatment of electrical burns on the limbs: the limbs were repaired by preoperative preparation of bilateral abdominal flaps successively. (2) Treatment of cranial electrical burns: one week after admission, scabbing and expansion of allogeneic skin coverage were performed. The neurosurgical condition was gradually stabilized, and the hematoma did not continue to expand on review CT. Four weeks after admission, a local flap transfer with expanded chisel bone was performed. During the operation, the necrotic skull was removed layer by layer, the central part was charred, and the whole layer of cranial necrosis of about 6×5cm2 was seen. A scalp flap containing the parietal branch of the superficial temporal vein was formed to cover the wound and the donor area was implanted. Postoperative healing was performed in one stage. (3) Treatment of electrical burns of the trunk: healing of the granulation wound with skin graft after debridement. (3) Treatment effect: The patient’s wound healed and he was discharged after 8 weeks. Second, the case analysis human study of electrical phenomena only 200 years of history. 1746, two Dutch physicists in charging the Leiden bottle electrocution, is about the earliest clear report of electrical injury. With the development of modern civilization, electric current is more and more widely used in industry and daily life, and the number of accidents in which electric current damages the human body is increasing day by day. According to the statistics of the burn department of Beijing Jishuitan Hospital, patients with electrical burns account for about 8% of inpatients. Electrical engineering to ground voltage of 1000 volts or more is called high voltage. Clinical practice is generally accustomed to 380 volts or more current injuries are classified as high-voltage electrical burns. High-voltage electrical burns are characterized by “multiple”, “segmental”, “jumping” injuries and “filling” of muscles. The complex and diversified manifestations of high voltage burns are characterized by “multiple”, “segmental” and “jumping” injuries, as well as “pinch-like” necrosis of muscles and “sleeve-like” necrosis around bones. After years of clinical research and practice, a consensus has been reached on the early flap repair of deep electrical burn wounds. The use of an abdominal flap to repair the trauma of both hands, wrist, and forearm in this patient’s relatively stable systemic condition was consistent with clinical practice. The difficulty in treatment was the combination of extensive scalp and cranial electrical burns with an epidural hematoma and cerebral contusion at the same site. Generally, if the whole skull is burned, early treatment is more difficult and the course of treatment is longer, and it is also easy to cause serious infection and other comorbidities when it is not treated properly. The traditional treatment methods are: ① wait for the dead bone to be separated and removed, and then implant skin on the granulation wound. For small-scale cranial osteonecrosis, early crusting and craniectomy are feasible, and local flap repair is performed. ③For large cranial osteonecrosis, bone drill multiple holes with 0.5cm distance between holes, drill to the bleeding bone or plate barrier, and then implant the skin after the granulation tissue grows. The traditional method of treatment requires multiple surgeries and a long course of treatment, which is still effective for small and non-whole-layer cranial electrical burns. However, it often leads to serious intracranial infections and other complications in patients with large full-layered cranial burns, which can sometimes cause death. In the 1980s, Beijing Jishuitan Hospital proposed that early admissions and patients with relatively late local infection should be designed to apply local scalp flaps or axial flaps and myocutaneous flaps or anastomotic free flaps and large omentum to repair the trauma according to the size of the trauma. The necrotic skull does not need to be removed, but only the surface is slightly chiseled away to obtain a one-stage healing. The necrotic skull bone can be gradually absorbed under the coverage of tissue flaps with good blood circulation. If the burn is only on the outer plate, it can be repaired by peripheral and basal healthy cranial bone growth. Even if there is total cranial necrosis, it can still be repaired by the osteogenic action of the epidural connective tissue. Since then, a large number of patients with electrical burns of the skull have been cured with appropriate treatment. In this case, the patient came late to the hospital with both traumatic brain injury and headache and blurred vision, and early surgery was no longer possible, but the use of scab and homograft gained time for neurosurgical treatment and control of local infection, and also avoided the risk of hemorrhage during early surgery. Four weeks after admission in a stable neurosurgical situation, instead of continuing to wait blindly, decisive surgery was performed and a scalp flap containing the parietal branch of the superficial temporal vein was used to cover the wound with good blood flow, thus healing in one stage. Third, expert comments Because electrical operations are often performed at high altitude, it is not uncommon to see patients with severe electrical burns combined with cranio-cerebral trauma. The diagnosis and treatment of the latter should not be neglected in the emergency management, and cranial CT examination is feasible when necessary. This patient focuses on the treatment of extensive scalp and skull electrical burns combined with simultaneous epidural hematoma and cerebral contusion at the same site, and suggests an appropriate plan for the timing of surgery and the choice of surgical approach with good results, which can be used as a reference for the treatment of such patients. Choosing the optimal point of time between conservative and aggressive surgery is the art of the burn specialist. The application of allogeneic skin grafting in this patient is also characteristic, gaining time for further treatment and worthy of consideration by fellow surgeons.