|Year : 2012 | Volume
| Issue : 1 | Page : 30-35
Electrical burns in children: An experience
Imran Ahmad, Sohaib Akhtar, Ehsan Rashidi, M Fahud Khurram, Rabeya Basari
Department of Plastic and Reconstructive Surgery, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
|Date of Web Publication||13-May-2013|
Department of Plastic and Reconstructive Surgery, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, UP
Source of Support: None, Conflict of Interest: None
Objective: The objective of this study was to evaluate the etiological factors, nature and pattern of injuries, early and late morbidities of injuries, corrective surgeries, and final outcome and rehabilitation in pediatric electrical burns. Materials and Methods: This study includes 53 children, below 14 years of age. All children, irrespective of severity of injuries, were admitted, assessed, and treated. The charts of pediatric patients who had been admitted to the authors' Centre with electrical burn injuries from January 2006 to December 2011 were reviewed retrospectively. Etiological factors, nature and pattern of injuries, early and late morbidities of injuries, corrective surgeries, and final outcome and rehabilitation were evaluated. Results: Injuries resulted from biting an electrical cord (n = 8), placing an object into an electrical socket (n = 7), coming in contact with a low-voltage wire or appliance indoor (n = 18), coming in contact with a high-voltage wire outdoors (n = 17), e.g., while flying a kite (n = 3). Most of the injuries occurred at the age between 4 and 7 years. Sixty-seven percent of the patients having electrical burns were boys and 33% were girls (M:F, 2.1:1). Most of the injuries occurred between 12:00 and 6:00 PM (51%) and most common organs involved were trunk and upper limb (30%). A 100% skin graft take was recorded in 14 patients (78%) on day 4 postoperatively. Three patients (17%) required partial regrafting and one (5%) experienced a complete loss, which was resolved with regrafting. There were no flap losses. Four amputations were performed and three patients did not survive. Conclusion: The study revealed that if the basic principles of early and adequate resuscitation, proper wound care, maximum tissue preservation, early wound coverage by proper reconstructive procedures, and appropriate rehabilitation are adhered to, there will be a successful outcome for patients with these injuries. Almost every child with high-voltage current injury had a bad prognosis due to the severity of the injury.
Keywords: Children, electrical burn, reconstruction
|How to cite this article:|
Ahmad I, Akhtar S, Rashidi E, Khurram M F, Basari R. Electrical burns in children: An experience. Indian J Burns 2012;20:30-5
| Introduction|| |
Electrical injuries are associated with significant impact on morbidity and mortality in children. Annually, thousands of patients require emergency treatment for an electrical injury; however, the percentage of all burn admissions secondary to electrical injury is usually low, ranging from 2% to 4%. ,, Children are generally at high risk because of their natural curiosity and having thin skin to offer low resistance. Saliva is often present in children, which again promotes conductivity.
Many a times in electrical injuries the wounds may appear benign but they may be associated with life-threatening cardiac arrhythmias, limb-threatening vascular compromise, and acute renal failure secondary to myoglobinuria. Due to these concerns, it is recommended that all electrical burns should be admitted for observation for 24-48 hours. Cardiac monitoring and laboratory evaluation are also performed without distinction whether patients are injured by low voltage or high voltage current. ,,,
| Materials and Methods|| |
This study includes 53 children, below 14 years of age. All children, irrespective of the severity of their injuries, were admitted, assessed, and treated. All the patients were adequately resuscitated following advanced trauma life support principles. The charts of pediatric patients who had been admitted to the authors' Centre with electrical burn injuries, between January 2006 and December 2011, were reviewed retrospectively. The recorded information includes etiological factors, nature and pattern of injuries, early and late morbidities of injuries, corrective surgeries, final outcome, and rehabilitation. On the basis of pattern and nature of injuries the patients were divided into two groups: High-voltage and low-voltage electrical injuries [Table 1]. High voltage was defined as greater than 1000 V and low voltage as less than 1000 V. Thirty patients sustained injury over the trunk and upper limb, 15 over the scalp, hand, and face, 16 over hand only, 11 over lower limb only, 3 over genitals, 16 over lower limb, face, and trunk, and 8 patients involved more than 70% of body parts [Table 2].
Surgical preparation of the wound was achieved by aggressive debridement of all nonviable and necrotic tissue from the wound bed and wound edges, in a sterile environment.
Among the patients sustaining scalp burns, two patients with a scalp defect with exposed bone resulting from high-tension electrical burns were treated by local scalp flaps [Figure 1]. One patient without exposed bone required excision of wound and primary closure. Among those who sustained upper limb burn, 10 patients required skin grafting, 2 required amputations at wrist level, 1 needed an amputation at below elbow level, and remaining were managed conservatively [Table 3]. One patient with forearm stump required local flap. Three male patients sustained injury over genitals; [Figure 2] and [Figure 3] among them one had near-total penile amputation in which penile reconstruction was performed with groin flap and a neourethra was reconstructed by tensor fascia lata [Figure 4]. Among those who sustained injury over the lower limbs, five patients required skin grafting, one needed a local flap, and one required a below knee amputation. Three patients required skin grafting over the trunk. One patient with facial burn required skin grafting over the eyelid [Table 3].
|Figure 1: (a) Preoperative photo of high voltage scalp burn injury in 5 y old child (b) intra-operative photo of local flap covering the defect|
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|Figure 2a: High voltage genital injury (b) High voltage healed genital injury with UCF fistula in same patient|
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|Figure 3: Penile burn following micturiting over high voltage live wire in field leading to near total penile loss|
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|Figure 4: Postop view of above patient after penile reconstruction with groin flap and neourethra by tensor fascia lata|
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One patient developed contracture of axilla and one contracture of hand which was released and skin grafted at a later date [Table 3]. One patient with oral burn required delayed reconstructive surgery of oral commisure [Table 3] [Figure 5] [Table 7].
|Figure 5: (a) Preoperative photo of low voltage wire biting injury in 7 y old child (b) Postoperative photo after release|
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Rehabilitation was started immediately after the injury by a team approach including psychologist, physiotherapist, and reconstructive surgeons and continued well beyond the wound coverage.
All of the patients, who were admitted, underwent close cardiac monitoring.
Statistical analysis was performed using Student's t-test. 
| Results|| |
Fifty-three patients were identified with electrical injuries. Injuries resulted from biting an electrical cord (n = 8), placing an object into an electrical socket (n = 7), coming in contact with a low-voltage wire or indoor appliance (n = 18), coming in contact with a high-voltage outdoor wire (n = 17), e.g., while flying a kite (n = 3) [Table 4].
Most of the injuries occurred at the age between 4 and 7 years [Table 5]. Sixty-seven percent of the patients with electrical burn were boys and 33% were girls (M:F, 2.1:1). Most of the injuries occurred between 12:00 and 6:00 PM (51%) because children are least attended in this period [Table 6]. The most common organs involved were trunk and upper limb (30%).
Seventeen patients sustained high-voltage electrical injuries and thirty-six patients had low-voltage current injuries. Of the patients who received skin grafts, a 100% skin graft take was recorded in 14 patients (78%) on day 4 postoperatively. Three patients (17%) required partial regrafting and one (5%) experienced a complete loss, which was resolved with regrafting. In this series there were no flap losses. A total of four amputations were performed, two at wrist level, one at below elbow and one at below knee. Among eight patients having injury more than 70% of body parts five survived [Figure 6]. None of the patients had cardiac complications.
| Discussion|| |
Electrical burn injuries form less than 5% of admissions in the major burn centers. Nevertheless, an electrical injury has much more complexity than a skin burn and the rate of morbidity and mortality is significantly higher. Severity of tissue injury depends on the amperage (the actual amount of current that passes through the tissues). Though it is not possible to know the exact amperage because of the variability of tissue resistance and time of exposure at the time of accident, one can infer amperage (high or low) from the voltage of the source. Even a low-voltage source is capable of producing major cardiopulmonary complications and can cause death if sufficient current passes through the body.
A high-tension source generally produces severe tissue necrosis which is characteristically seen along the pathway of the current. Both heat production and direct current causes this damage. The initial resistance to flow of current, i.e., skin or clothing, is overcome by the heat generated from high voltage, and subsequent tissue necrosis takes place with constant contact. A dry hand may have sufficient resistance to avoid the passage of current from a low-voltage source with a short period of contact time. While high-voltage current injury is an uncommon pediatric injury, it produces devastating damage. Low-voltage current injuries rarely cause deep tissue destruction, but prolonged contact can cause sufficient injury to require amputation.  The criteria for admission of low-voltage current injuries are not uniform in the literature. , For high-voltage current injuries, admission is indicated in virtually all cases. 
The most common causes of electrical burns in children differ from those of adults. The present study shows that the most common types of electrical injuries in the pediatric population were due to either coming in contact with a low-voltage wire or appliance indoor or biting an electrical cord or placing an object into an electrical socket. As described by others, we found that these injuries occur typically in poorly supervised or unattended children.  Additionally, we found that the number of admissions for electrically injured patients is increasing.  Previous recommendations were to admit all electrically injured children to the hospital. But as per the study of Wallace et al.,  healthy children with household current injuries which are small partial-thickness burn, and who have no evidence (over the first few hours) of cardiac or neurovascular injury, do not appear to need hospital admission.
The admission requirements are variable in patients who sustain low-voltage household wire injuries. In general, the wounds themselves may be relatively benign, and easily cared for as an outpatient. As described by Zubair et al., significant cardiac complications can involve even this category. They also concluded that any patient in this category, having a history of cardiac dysfunction prior to arrival in the emergency room, needs to be admitted to hospital for cardiac monitoring. Those having abnormalities on EKG or cardiac monitoring also required the same. However, cardiac monitoring is not necessary and outpatient management is safe and cost effective in the absence of cardiac dysfunction, or without any history of loss of consciousness, tetany or wet skin during the accident. ,
As per the study of Zubair et al.,  it is recommended that children who have sustained high-voltage electrical injury be admitted to the hospital, whereas most children subjected to low-voltage electrical exposure who remain asymptomatic for 4 hours of observation in the emergency room can be safely treated in the outpatient setting. After adoption of these types of policies, not only the cost of medical care will be reduced, but also other benefits will be realized, including avoidance of the negative psychosocial issues and disruption of family dynamics associated with admission of a child to hospital. Lastly, it should be noted that a large number of electrical injuries, especially low-voltage electrical injuries in infants and toddlers, can be prevented by utilizing simple safety measures.
Currently there is little information on lightning injuries; however, it would appear that these patients can be treated much in the same way as those with a high-voltage current injury. One study found that if the lightning did not cause an immediate cardiac arrest at the time of the incident, then there was a very low risk of a death. 
The best method is prevention of electrical injuries. Rai et al., found that there was a decline in the number of patients admitted to their institution for injuries due to low-voltage current contact because of certain preventive measures including addition of ground fault circuit interrupters (GFCIs) to residential homes and the use of thicker insulation on appliance wires.  In 1987, the U.S. Consumer Product Safety Commission (CPSC) successfully incorporated the utilization of GFCIs into the National Electric Code (NEC). This made it mandatory for all newly built homes to have GFCIs installed in bathrooms, kitchens, basements, and near hot tubs or spas. 
George et al.,  describe three children who sustained high-voltage electrical current injuries. They concluded that patients who have sustained high-voltage electrical injuries need aggressive debridement. Early closure with temporary allograft should be undertaken before autografting, until the full extent of the wound is appreciated. A soft tissue cover with flaps for exposed bone, tendon, and joint is required with early postoperative mobilization.
Following adequate resuscitation and stabilization of the patients, operative procedures, including fasciostomy and esharotomy, may be required. Ferreiro et al.,  reported a decrease in amputation rate following fasciotomies. Proper operative assessment of the extent of injury and aggressive debridement should be undertaken with amputation of nonviable limbs if necessary. In our series we performed four amputations, all of them were of high-voltage current injuries and presented late.
There are various nonoperative techniques for assessing the extent of tissue damage in electrical burn. Xenon 133 and Tc99 scans have been shown to be accurate predictors of tissue viability, but Hammond in 1994 reported no decrease in length of hospital stay or number of operations overall with use of technetium-99 pyrophosphate scanning in management of high-voltage electrical injuries.  MRI scans alone have shown poor sensitivity. Gadolinium increases sensitivity of areas of tissue edema, but it is an expensive test, which may not provide overall benefit above surgical exploration. , Because of their limited availability, they are currently not a substitute for surgical management.
Allograft can be used for temporary cover and as a diagnostic tool for deeper tissue healing. 
As suggested in the treatment algorithm by George et al., within 24-48 hours a second look procedure should be undertaken and if no further debridement is needed robust soft tissue coverage can be undertaken. Where there is an uncertainty of tissue viability, further exploration and debridement and delayed autografting should be undertaken within 96 hours. Early release of contractures should be undertaken in order to aid physiotherapy and rehabilitation to improve long-term prognosis.
A coordinated burn center program that includes surgeons, pediatricians, occupational and physical therapists, vocational rehabilitation specialists, and psychologists is essential to successful rehabilitation. Perhaps because of their resilience and adaptive ability, children recover well even after major burn injury.  Sheridan and colleagues  reported that most children treated at Shriners Burn Institute (Boston) who survived massive burns (70% TBSA) became productive members of society. In their series however, 20% of patients had physical scores below norm, indicating that this subgroup had persistent sequel.
In our series rehabilitation was started immediately after the injury by a team approach including psychologist, physiotherapist, and reconstructive surgeons and continued well beyond the wound coverage.
| Conclusion|| |
The study revealed that almost every child with high-voltage current injury had a bad prognosis due to the severity of the injury. While smaller and more superficial burns can be adequately treated on an outpatient basis by conservative means, the successful management of severe larger burns requires a dedicated team approach. If the basic principles of early and adequate resuscitation, proper wound care, maximum tissue preservation, early wound coverage by proper reconstructive procedures, and appropriate rehabilitation are adhered to, there will be a successful outcome for patients with these injuries. Keeping in mind the common causes of electrical burn, pediatricians should teach the parents of children of this age group about electrical hazards and their preventive methods and the electricity department of the city/town/village should take care of live wires. These are some of the few injuries in children, which can be prevented by taking some simple measures.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]