|Year : 2014 | Volume
| Issue : 1 | Page : 104-108
A review of 5 years experience in management of electrical injuries
Smitha S Segu, Vijay Jaganathan, Amaresh V Biradar, Shankarappa Mudukappa
Department of Plastic Surgery and Burns, Bangalore Medical College and Research Institute, Victoria Hospital, Bengaluru, Karnataka, India
|Date of Web Publication||15-Dec-2014|
Smitha S Segu
Department of Plastic Surgery, MBCC, 1st Floor, Victoria Hospital, Bengaluru - 560 002, Karnataka
Source of Support: None, Conflict of Interest: None
Introduction: Electrical injuries represent a special type of thermal injury, with a patho physiology depending on the voltage, current flow and resistance of the skin. Electrical injuries can produce significant morbidity and long-term sequelae. Aims and Objectives: This study is a comprehensive institutional review of database of patients with electrical injuries, from initial resuscitation through final impairment ratings. Materials and Methods: The study period was for 5 years from January 2008 to December 2012. All Patients admitted in burns ward with electrical injury are included in the study. A proforma was used to collect details. Procedures needed, their timing, final impairment ratings, and return to work were recorded. The results are quantified in terms of incidence of various complications incidence of amputations, mortality rate, disability incidence, etc. Result and Analysis: Electrical injuries can produce significant morbidity despite relatively small burn sizes. Electrical injuries occur in young males and leads to high incidence of upper extremity amputations, resulting in long period of unemployment and extensive new job training and rehabilitation. Patients require early operative procedures for prevention of further injury. Timely reconstructive surgery may improve final function and return to productivity. Work site accident, which is an important cause is largely preventable.
Keywords: Amputation, electrical injuries, prevention, resuscitation, rehabilitation
|How to cite this article:|
Segu SS, Jaganathan V, Biradar AV, Mudukappa S. A review of 5 years experience in management of electrical injuries. Indian J Burns 2014;22:104-8
|How to cite this URL:|
Segu SS, Jaganathan V, Biradar AV, Mudukappa S. A review of 5 years experience in management of electrical injuries. Indian J Burns [serial online] 2014 [cited 2019 Nov 21];22:104-8. Available from: http://www.ijburns.com/text.asp?2014/22/1/104/147018
| Introduction|| |
Electricity as a flow of electrons constitutes current, which depends on the voltage and amperage.  The effect of the electric current on the body is determined by the following seven factors:
- Type of current
- Amount of current
- Pathway of current
- Duration of contact
- Area of contact
- Resistance of the body
Since 1849, when commercial electricity became available, the potential danger of injury has continued to increase.  According to statistical data, all over the world electrical injuries are second most important cause for admission to a burns unit (US - 60%, Asia and Africa - 20%).  In US one person dies per day due to electrical injuries at his work place, 0.8-1% accidental deaths are caused by electricity and 13 days of work lost per electrical injury. No such detailed data is available from Europe, Asia, Africa or Indian subcontinent. 
Electrical injuries can be true electric (definite passage of current through body) and false electric injuries (no passage of current through body). Direct contact and arc burns are true electrical injuries, whereas flash and flame burns are false electrical injuries. Direct contact is divided into high voltage (>1000 volts) and low voltage (>1000 volts) injuries.
High-voltage electric current has irreversible localized and systemic consequences, with a high percent of disability. Electrical injuries are potentially devastating events that result in damage to the skin as well as other tissues, including nerve, tendons, and bone. There are several long-term sequel of electrical burns. 
| Materials and methods|| |
This descriptive prospective study was conducted in Department of Plastic Surgery and Burns, Victoria Hospital, Bangalore Medical College and Research Institute for a period of 5 years. All patients admitted to the burns unit from January 2008 to December 2012 with electrical injuries were included in the study.
A proforma was used to collect details. Total number of patients included in our study was 326. Patients were treated by standard care of treatment described below in treatment. Results are quantified in terms of various complications, amputations, and disability and mortality rates.
| Treatment|| |
The treatment of electric injuries has to be intensive because of the specific effect on nonviable tissue covered by healthy uninjured skin. Considerable alterations occur in the microcirculation, with the loss of endothelial integrity and the trapping of large volumes of fluid in the extra vascular space, leading to massive edema and decreased circulation in the injured limb. Immediate and adequate fluid resuscitation is therefore essential.
On admission patient were resuscitated by Advanced Trauma Life Support protocol. Initial fluid management with Ringer's lactate was administered in sufficient amounts to maintain a urine output of at least 2 ml/kg/h. Myoglobinuria when present was treated with mannitol and sodium bicarbonate. 
Incision and fasciotomy were performed on suspicion of compartment syndrome. Early necrectomy, extensive debridement and amputations were done when indicated. Fasciotomy and neural decompression were necessary on the dorsal and volar aspects of the arm or lateral aspects of the leg. The hand and wrist were observed and decompression of the carpal tunnel was performed as required.
Full-thickness injury over major vessels was debrided promptly and definitive coverage provided as soon as possible. Small deep injuries have a slow spontaneous healing and excision was of great help. Rotation or pedicle flaps and musculocutaneous flaps were used. Coverage of the wounds by skin grafts was delayed because of the high frequency of progressive necrosis of injured tissue. We performed surgical excision on day 5 postburn with re-excision and coverage after 48 h. Silver sulfadiazine was used for topical application. 
Renal failure and sepsis were treated appropriately. Other traumatic injuries were noted and treated. Hand elevation, splinting in position of immobilization and physiotherapy to hand was provided in acute stage. After flap cover, patients were provided with physiotherapy of the joints to keep it supple until tendon and nerve reconstruction is done. Limb prosthesis was provided for amputees. Psychiatric counseling was given to overcome stress and depression.
| Results|| |
We had 326 patients in our study out of which 284 were males and 42 were females. A total of 7984 burns patients were admitted during the study period.
Age distribution was as shown in [Table 1]. Patients between 15 and 40 years of age were most affected. Mode of injury is shown in [Table 2]. Most of them sustained direct contact injury.
High tension injuries were found to be more (234 patients) compared to low tension injuries (92 patients) in our study.
We found that the total body surface area burnt due to electrical injuries was <15% in 74.11% (241) of the patients. 49 (15.03) patients suffered 15-30% total body surface area burns and 36 (10.85) patients suffered more than 30% total body surface area burns.
More than half of the patients" sustained 4 th degree burns. 54% (176) patients had 4 th degree burns and 46% (150) of patients had <4 th degree burns.
Of 326 patients, 176 patients (54.11%) underwent amputation of a part.148 patients who underwent major limb amputation were due to high tension electrical burns. 24 patients had low tension electrical injuries involving toes and fingers. The various amputations performed in our study are shown in Chart 1. [Additional file 1] The most common amputation performed in our study was a below elbow amputation.
Forty-six percent of patient's sustained injuries at the work site. Building construction laborers, electrician, and cable television operators were the most commonly affected professionals. Twenty percent of victims of electrical injuries sustained associated injuries due to fall off objects or fall from height etc., in our study. Associated injuries included seven patients of colle's fracture, brachial plexus injury in two patients (one patient had neuropraxia, which recovered completely, one patient did not follow-up), 13 patients had head injury, eight had clavicle fracture, five had femur fracture and 29 patients had abrasions and lacerations over different body parts.
Other complications and their incidence are shown in [Table 3]. In our study, there were no patients with any cardiac arrhythmias or neurological sequelae. Twenty-six patients with rhabdomyolysis were treated successfully and six patients with renal failure underwent hemodialysis.
In our study, we found 51.76% of the patients had upper limb involvement and needed procedures such as amputation, flap reconstruction [Figure 1], later tendon and nerve reconstructions. Two hundred and ninety patients of 326 patients underwent fasciotomy.
|Figure 1: High tension injury of right hand, under went fasciotomy and then defect covered by abdominal flap — secondary tendon reconstruction done|
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Most commonly used flaps for upper extremity reconstructions were groin flap (60 patients), random abdominal flap (28 patients), paraumbilical perforator flap (15 patients) Transposition flap (4) [Figure 2], philleting flap (1) [Figure 3] and pedicled Latissmus dorsi flap (2). 96 patients underwent split skin graft. We have not done free flaps for electrical injury reconstruction as literature doesn't favor its use due to the high rate of failure. Nerve repair done in 30 patients and tendon repair done in 94 patients. We noticed premature cataract formation in two patients within 6 months of electrical injury. Two patients had contact injury of the chest with pleura exposed and later on had open pneumothorax, they underwent intercoastal tube drainage and later settled after latissimus dorsi flap reconstruction and closure of the defect.
|Figure 2: An electrician with scalp entry wound covered by a transposition flap|
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|Figure 3: An exit wound with exposure of fifth metacarpal head with a dangling toe. It was covered with a toe fillet flap|
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Psychiatric illness like anxiety was seen in 70 patients, depression in 50 patients, emotional distress 38 patients, nightmares in 27 patients, insomnia in 40 patients, flashbacks in 36 patients.
Range of hospital stay was 7-82 days. Mean hospital stay was 24 days.
The mortality rate in our study was 10.58%. Most of them died of septicemia. The culture yielded pseudomonas and Klebsiella in all these patients.
| Discussion|| |
Electricity, although an important commodity, has become a significant cause of injury in our society. Both high and low-voltage electrical injuries may produce muscle damage (myonecrosis) with myoglobinemia and myoglobinuria. High voltage exhibits a greater current flow and hence causes more severe tissue damage.
Electrical burn injuries represent a special type of lesion in which disability is high [Figure 4], and functional and esthetic sequelae very important. The strategic management of high-voltage electrical injury can be both challenging and complex. The challenge begins at the moment of the injury and continues through the rehabilitation period.
|Figure 4: High tension electrical injury with right shoulder disarticulated and penis amputated — wearing prosthesis and penis reconstructed with groin flap with urethral reconstruction|
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It has been reported that muscle damage due to electrical injury is associated with contraction of striated muscles. ,, It is a consequence of electrical nerve stimulation or the direct triggering of striated muscles and this condition can result in rupture, rhabdomyolysis, edema, and myonecrosis.
Compartment syndromes may also develop because of muscle swelling and necrosis. It has been noted that in the muscle cells, the primary pathology is membrane permeability or membrane rupture, and this condition results in the loss of cellular enzymes. As a result, the serum levels of the muscle enzymes elevate. Alternating current which is the most commonly distributed form of current, causes titanic muscle spasm and prolonged contact with the source.
The complex aspects of management are the complications that occur owing to systemic effects, mostly due to damaged arteries and veins, with compression by edema followed by obliteration because of coagulation in the microcirculation, with a final effect that may lead to amputation, usually of the upper extremities.
Surgery was performed as soon as possible in order to prevent life endangering complications, of which the most important were infections and sepsis, and kidney failure. Management of patients with high-voltage injuries is dictated by the extent of injury, the presence of cutaneous burns, and the presence of myoglobinuria. Patients who sustain high-voltage injuries are placed on a cardiac monitor for the first 24 h following admission. This has been the traditional practice regardless of whether or not a dysrhythmia is present at the time of admission. There is no data substantiating routine monitoring of high-voltage injuries, and this is a practice that may change over time.
Early surgical management of electrical injuries should focus on the need for fasciotomy or compartment release. Peripheral neurovascular examinations should be performed to monitor for signs of compartment syndrome. Some patients will present with a contracted upper limb and tight forearm compartments, and these patients should undergo immediate fasciotomy and carpal tunnel release. 
Many surgeons believe that all patients should undergo immediate surgery for nerve decompression and debridement of necrotic tissue. On one hand, carpal tunnel release and fasciotomy are relatively facile operations to perform and, if the patient derives even a small amount of benefit, the procedures may be worthwhile.  On the other hand, the risks of the procedures, particularly if not necessary, can be significant. Exposure of the median nerve and forearm musculature increases the risk of tissue desiccation and necrosis. It is often difficult to determine preoperatively who will benefit from the decompression procedures. The ideal timing for tissue debridement has similarly been controversial. The ideal time to determine the presence of myonecrosis is generally 3-5 days following injury. Therefore, early debridement might not be sufficient because irreversibly injured tissue may not have demarcated. At 3-5 days, all unhealthy tissue can be debrided and definitive wound closure can be achieved.
Majority of high-tension electrical injuries involve electricity workers. The involvement of dominant upper extremity in the working age group of patients makes it more worrisome.
There is a need to establish and enforce adequate safety regulations and enforcements. These include properly locating high-tension electrical cables to prevent accidental contact, prompt repair of fallen high-tension cables, and provision of specially designed wear and ladders for electricity workers.
Electrical burns affect only a small percentage of body burn injuries, but the incidence of complications, morbidity and disability, especially in high-voltage injury, is high. All of those injuries are preventable. These preventable injuries affect the physically active young and middle aged male member of a family who are the sole earning members most often and thus have a direct effect in increasing financial burden of the affected family members and community as a whole. These injuries also pave way for companies and government to give compensation for the affected workers and thus put a strain in the economy of the country also.
| Conclusion|| |
Electrical injuries occur mostly in males and in the age group of 15-40 years. Electrical injuries occur mostly in males and in the age group of 15-40 years. Electrical injuries due to kite flying were common in kids. In adults 46% accidents were work site injuries, which are preventable. Cable connection operators and construction site laborers who don't follow any safety measures are more prone and worst affected. Strict measures should be taken and awareness created about safety with electricity among Cable operators and construction site laborers.
Most common type of injury is direct contact high-tension injuries. Percentage of total body surface area burnt was <15%, but the degree of burns was deep (4 th degree) in most. Disability rate due to amputation was 54.11% and associated injuries rate was 20% (further hinders recovery time). In our study, mortality rate was 10.58%. Permanent sequelae and disability was found in 60% of electrical injury population.
Treatment of electrical injuries is staged. It needs multidisciplinary team management.
Timely intervention by fasciotomies and escharotomy will have a very deep impact and decreases the disability due to electrical injuries.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3]