Annals of Burns and Fire Disasters - vol. XI - n. 3 - September 1998

ELECTRICAL BURN INJURIES

Babik J., Sandor, Sopko

Kosice Saca Burns Centre, Slovakia

SUMMARY. The distribution of burn injuries treated in the Saca Burns Centre in Kosice (Slovakia) is documented. During the period considered (1971 -present day), electrical burns constituted 2.7% of all burn cases treated. With regard to the period between 1987 and 1994, a more detailed study describes 96 patients treated for burns caused by electricity. The causes of the burns and typology are described. The methods of treatment are also considered.

Introduction

Electrical injuries represent a special type of thermal injury, with a pathophysiology depending on the voltage, current flow and resistance of the skin. High-voltage electric current has irreversible localized and systemic consequences, with a high percentage of disability.
Electrical injuries represent 2.7% of all burn admissions (12,930 patients since 1971) to the Kosice Burn Centre. The pathological effects, the complications and the treatment are discussed.
Since 1849, when commercial electricity became available, the potential danger of injury has continued to increase.' According to statistical data, about 1% of accidental deaths are caused by electric current. Electrical burns represent 2.7 % of all admissions to our burns centre and the incidence is growing as the sources and use of electric power continue to increase. Injuries due to contact with electricity most commonly involve utility workers, and there is also a high incidence among children because of uncovered electric lines. Household injuries from homemade equipment and repairs are very frequent. The victims of electrical burns show certain specific features with regard to therapy and the evolution of the pathology.
Electricity - as a flow of electrons - constitutes current, which depends on voltage and amperage. The effect of the electric current on the body is determined by the following seven factors: 1. type of current; 2. amount of current; 3. pathway of current; 4. duration of contact; 5. area of contact; 6. resistance of the body; 7. voltage.
Flash or arc burns are usually superficial despite the fact that the arc generates temperatures of over 10,000 °C.
Flash or are burns causing the ignition of clothing produce similar effects to those of ordinary burns, with serious damage depending on the percentage of TBSA. Direct electrical injury is due to the passage of current through skin, which is damaged either by the heat generated or by a specific but as yet not well-defined effect on the body. It is generally accepted that the severity of an injury is proportional to the intensity of current that flows through the tissue.

Results

The distribution of burn injuries in our Centre since 1971 is documented (Fig. 1).

Electrical burn injuries represented 2.7% of the total number of 12,355 admissions over this period, corresponding to 347 patients. The total body surface area burned (TBSA) ranged from 1 to 91% (mean area, 17.5%), but in electrical burns the mean TBSA was 5% and the range was from 1 to 8 1 %. Infection, one of the most important cause of complications, does not differ from that found in non-electrical burns, with an incidence of 21.3% for Staphylococcus aureus and a slight prevalence of gramnegative bacteria (Fig. 2).

A more detailed study was carried during the period 1987 - 1994. Ninety-six patients were treated for electricityrelated burns. Of these, 24 (24.4%) were victims of highvoltage electric current. Apart from three children, they were all linemen involved in various types of working accidents. The voltage range was from 1000 V to 200 kV. One patient with high-voltage injury (81% TBSA) died as a result of septic complications. All the patients with highvoltage injuries sustained serious burns (TBSA 11-81%, mean 21%), with high levels of morbidity and disability. Over a hundred operations were performed, including nine amputations of the upper right arm and one shoulder disarticulation. Seven amputations of the left arm were performed, with the seven forearms, and two finger-andhand amputations. One patient with abdominal injuries underwent laparotomy with reconstruction of a large defect of the peritoneum and abdominal wall. One complication of high-voltage injuries was delayed healing due to impaired circulation, even in uninjured parts of the extremities. In extensive electric burns the incidence of septic complications was comparable with that of nonelectric burns. In the group of high-voltage injuries, haemorrhage was accompanied by massive blood loss in 1% of cases.
One-quarter of fatalities due to electric power are caused by natural lightning energy. In our area of the Tatry Mountains there is at least one case of this type of injury every year. In the period of study, three patients were simultaneously injured by lightning. A mother and her two children were struck by a bolt of lightning while sitting under an umbrella in a mountain area. All three sustained Ill-degree burns to the head, buttocks and feet, with 5% TBSA burns in one child and only puncture burns in the other two victims. There was no effect of seizure or as regards breathing. The treatment was complicated in one of the children, who presented slight epileptic activities documented by EEG for six months post-injury.

Treatment

The treatment of electric injuries has to be very careful 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 in the extravascular space, leading to massive oedema and decreased circulation in the injured limb. Immediate and adequate fluid resuscitation is therefore essential. The volume of resuscitation fluid may be very large and unpredictable. In our study, the initial calculation of the fluid was underestimated in every second patient. Every patient was carefully monitored in order to avoid complications throughout treatment. Initial fluid management with Ringer's lactate was administered in sufficient amounts to maintain a urine output of at least 50 ml/h. When myoglobinuria was present mannitol was administered.
Incision and fasciotomy were performed as soon as possible post-injury, with prompt release of compression. Early necrectomy, extensive debridement and even amputation when the injury was massive were necessary (Fig. 3). Fasciotomy and neural decompression were necessary on the dorsal and volar aspects of the arm or lateral aspects of the leg. Exposed nerves and tendons were covered with allografts until flap coverage was provided. The hand and wrist were observed and decompression of the carpal tunnel was performed. Full-thickness injury over major vessels should be debrided promptly and definitive coverage provided as soon as possible. Small deep injuries have a slow spontaneous healing and excision may be Of great help. Rotation or pedicle flaps and musculocutaneous flaps were used. In some cases a free flap was the method of choice - this required a very precise estimation of healthy vascular tissue. Coverage of the wounds by skin grafts was delayed two or three days because of the high frequency of progressive necrosis of injured tissue. We normally perform surgical excision on day 5 post-burn with reexcision and coverage after 48 h. Extensive burns of the extremities and scalp pose a particularly difficult problem in the acute phase as well as during reconstruction. For topical therapy we used Sulfarnylon and silver nitrate.

In cases of deep tissue injuries, when for example tendons, bones and nerves are injured and necrotized, coverage by some type of skin flap is the best treatment. Treatment utilizing pedicle skin flaps usually gives good results but there may be major disadvantages such as discomfort and the necessity of repeated operations. The free flap can resolve those problems. There is however another problem in the use of the free flap - how to recognize which vessels in the injured area are normal. Our experience with this type of surgery is very limited.

Discussion

Electrical burn injuries represent a special type of lesion in which disability is high, and functional and aesthetic sequelae very important.
The strategic management of high-voltage electrical injury can both challenging and complex. The challenge begins at the moment of the injury and continues through the rehabilitation period.
The complex aspects of management are the complications that occur owing to systemic effects, mostly due to damaged arteries and veins, with the compression of oedema followed by obliteration because of coagulation in the microcirculation, with a final effect that may lead to amputation, usually of the upper extremities. In our series there was a disability rate of 25% due to amputation of the upper extremities. Distribution by age and sex was consistent with the findings of other researchers. Surgery was performed as soon as possible in order to prevent lifeendangering complications, of which the most important were infections and sepsis (46%), kidney failure (9%) and neurological complications (3%).
Cloud-to-ground lightning producing some hundreds of millions of volts, at a speed exceeding a hundred thousand km per see, causes one-quarter of deaths from electrical injuries.' Despite all preventive measures, we recorded every year one or more deaths and a number of injuries of this type. Electrical burns represents only a small percentage of burn injuries, but the incidence of complications, morbidity and disability, especially in high-voltage injury, is high. All of those injuries are preventable. 

RESUME. Les Auteurs décrivent la distribution des brûlures traitées dans le centre des brûlés à Ko~icc (Slovachie). Pendant la période considérée (197 1 -aujourd'hui) les brûlures électriques constituaient 2,7% de tous les cas de brûlures traités. Entre 1987 et 1994 une étude plus détaillée a considéré 96 patients traités pour des brûlures causées par l'électricité. Les Auteurs décrivent les causes des brûlures, leur typologie et les méthodes de traitement.

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