ELECTRICAL BURNS IN THE BENGHAZI URBAN AREA

EI-Gallal A.R.S., Yousef S.M.

Plastic and Burn Unit, Al-Jala Hospital, El-Arab Medical University, Benghazi, Libya

SUMMARY. Between January 1988 and December 1997, a total number of 389 patients aged between 2 and 58 years with true electrical burns were treated in the Burn Unit of Aljala Hospital in Benghazi, Libya. Benghazi is a growing city that has upcoming industrial units in the suburbs, and the hospital serves not only the city but also the surrounding villages and receives all referral cases from the eastern part of Libya. Thirty-eight patients sustained high-voltage electrical injuries while in the other 351 the burns were low-voltage. Initial resuscitation was employed in most of the patients; we also carried out appropriate urgent surgery whenever required. Despite the medical and surgical management, nine patients with high-voltage and seven with low-voltage injury succumbed to their injuries. Our study showed that electrical injury remains a formidable problem with significant morbidity. It is therefore advocated that an appropriate preventive plan should be drawn up and applied.

Introduction

A true electrical burn is one of the most devastating injuries to be seen in emergency departments, and is attended by high morbidity and mortality rates. We report here on aspects of true electrical burns seen in A1jala Hospital, which serves the population of the Benghazi urban area, Eastern zone, Libya. Over a period of ten years (19881997), electrical burned patients constituted 7.4% of all admissions to our Burn Unit. Only 4.4% of the patients had sustained true electrical burns with actual contact with live electric wire (flash and heat burns were excluded). This paper reviews these cases. The emphasis is on the pattern and outcome of the injuries with reference to our management.

Patients and methods

The medical records of all the patients admitted to our Burn Unit with true electrical burns between January 1988 and December 1997 were thoroughly reviewed with reference to the following variables: age, sex, occupation, site of accident, tension of the current (voltage), clinical presentations, surgical procedures, and outcome. Our specific management for electrical injury includes immediate cardiorespiratory resuscitation and administration of intravenous fluids (plasma and Hartmann's solution). In the presence of myoglobinuria, we encouraged osmotic diuresis by infusing an adequate amount of Ringer's lactate (Hartmann's) solution and mannitol 20% (I g/kg), in addition to sodium bicarbonate solution, with the aim of obtaining an alkaline-urine output of 1.5-2 ml/kg/h. Povidone-iodine (Betadinel) and silver sulphadiazine (Flamazinel) were the main items used locally for dressing the burn wounds. Required surgical procedures were usually carried out urgently after being appropriately selected for given patients.

Results

Out of 8851 burned patients, 655 (7.4%) presented with electrical burns during the 10-year period. 389 patients (4.4%) - 149 of whom had been referred from other peripheral hospitals - had sustained real electrical burns. The pattern of annual admission is shown in Fig. 1. The annual male to female ratio was variable but it was always greater than 2 to 1. Thirty-eight patients (9.8%), one of them a 26-year-old female, were electrocuted by high-voltage line (> 1000 V); the majority were electricians who had ignored safety precautions. With regard to the other 351 patients (90.2%), of whom 248 were male and 103 female, the injuries were due to low-voltage current. Two hundred and two patients (51.9%), including 125 pre-school children, suffered their injuries at home (102 males and 100 females) (Table I).

The annual frequencies of high- and low-voltage injuries are shown in Fig. 2, and distribution by age in Fig. 3. The high-voltage injuries all occurred in adult patients, while low-voltage injuries predominated in the younger age groups.
The mean age (± SD) of patients with low-voltage injuries was 16.4 yr (± 13.8) (range 2-58 yr), and with high-voltage injuries 34.5 yr (± 5.8) (range 2247 yr). Further analysis of the annual frequency of low-voltage injury in relation to the place of accident (at home or outdoors) is shown in Fig. 4.

Fig. 1 - Annual admission. Fig. 2 - Annual frequency of low- and high-voltage injuries. Fig. 3 - Distribution of low- and high-voltage injuries by age. Fig. 4 - Annual frequency of low-voltage injuries by place of accident.

The clinical presentation of our patients was variable. Most of those with high-voltage injuries presented with shock and loss of consciousness. One patient sustained spinal fracture, while another one had shoulder dislocation. Six patients developed acute renal failure around the third day post-injury. Confusion, dizziness and various types of cardiac arrhythmia other than conduction disorders were frequently recorded in low-voltage injuries.
The extremities were most commonly affected in both types of injury, the upper limbs being more frequently involved (Table II). The mean (± SD) total burned surface area was 9.7% (± 9.2) and ranged between 0.25 and 55%.

Overall, high-voltage current caused very deep and extensive tissue damage (Fig. 5), while low-voltage current resulted mainly in full-thickness and deep dermal burns, although significant tissue damage was occasionally observed (Figs. 6, 7). In addition, some patients whose clothes caught fire suffered extensive flame burns.

Fig. 5 - Very extensive tissue damage seen in a high-voltage injury. Fig. 6 - Severe hand injury in child caused by a low-voltage current. Fig. 7 - Multiple deep burns and below-elbow amputation after lowvoltage injury.

Considering all admissions, there were 16 deaths (4.1%). Nine of these occurred among patients with highvoltage injuries (23.7%): four deaths within a few hours of admission were due to persistent serious arrhythmia and cardiac arrest, three to septicaemia, DIC and multisystem failure, and two to acute renal failure. There were seven deaths among the 351 patients with low-voltage injury (2%); six of these were children aged under 12 yr, while the seventh was a 56-year-old female. Five patients sustained extensive flame burns; their deaths were due to the consequences of burn sepsis. Three of the five were referred to our hospital some days after injury, of whom two presented established acute renal failure and one mental retardation (Down syndrome). Of the remaining two deaths the 56-year-old diabetic female developed severe respiratory complications, while the other patient developed gramnegative septicaemia and multisystem failure.
Twenty-three patients with high-voltage injuries and 273 with low-voltage injuries were operated upon. Seventyone patients with low-voltage injuries were treated conservatively.
The surgical procedures and their frequencies are shown in Table III, together with an analysis of the group subjected to amputation.

The most significant complications were septicaemia in 48 patients, myoglobinuria in 13, acute renal failure in 8, DIC in 7, multisystem failure in 4, respiratory complications in 3, wound infection in 124, delayed healing in 42 (wound not dry by day 14 post-operation or subsequent breakdown), spinal neuropathy (motor) in 2, and peripheral main nerve injury in 56. One patient developed bilateral cataract 6 months post-injury.
Six of our high-voltage group, of whom four were nonLibyan expatriates, discharged themselves against medical advice in order to be treated elsewhere.

Discussion

The trends of both types of injury in our region differ from those reported elsewhere in the literature.` This could be due to many factors, such as progress in the country's industrial and agricultural development, lack of attention because of crowded living condition (large families living in flats), rapid urbanization, and the community's sociocultural transformation.
It is clear that the incidence of both high- and lowvoltage injuries increased over the years. Low-voltage injuries outnumbered high-voltage injuries, in contrast with other findings."` This is evidently due to the considerable number of domestic accidents and paediatric involvement.
In our study, the incidence of low-voltage domestic injuries (57.55% = 202/351) and of industrial injuries (42.45% = 149/351) was consistent with other results.' In our series, however, children were involved more frequently.
While neglect of industrial safety precautions was the principal cause for high-voltage injuries in most of our cases, the main causes of low-voltage injuries were carelessness, improper use and negligence. Other causes were occasionally recognised.
Regarding factors modulating the severity of injuries, such as type and strength of current, and time and nature (resistance) of contact, the clinical presentations of our patients differed little from those reported elsewhere. " None of our patients suffered any involvement of internal organs.
The two types of true electrical burns have a different epidemiology and vary considerably in their clinical presentation and outcome, while instead electrical injury mechanisms` ` remain the same and are applicable for both types. It is therefore reasonable to treat both types of injuries on the basis of the same management principles, although care must of course be individualized.
In severe injuries, it is well established that any reduction in time lost before starting adequate resuscitation, surgical decompression and appropriate debridement will have a favourable effect on morbidity and mortality." 12,13 Hence our management is based upon instant cardiovascular resuscitation and renal support, in addition to the application of what we would prefer to call an 11 urgent appropriate surgical approach" rather than an aggressive surgical approach,' whenever it is required. The outcome of delay in treatment can be lethal, as was seen in three of our paediatric patients who succumbed to their injuries.
Finally, we believe that the results of this study, including the epidemiological trends, are not unique to our community, and could be expected in other similarly developing societies. Moreover, the complexity of the injuries, the urgent need for versatile management, and the potentially catastrophic complications make such injuries a genuine health hazard. Proper educational programmes must therefore be designed and implemented in order to reduce the frequency of this devastating form of injury in our developing societies.

RESUME. Entre janvier 1988 et décembre 1997 les Auteurs ont traité 389 patients atteints de brûlures électriques véritables âgés de 2 à 58 ans chez l'unité des Brûlures de l'Hôpital AI-jala à Benghazi, Libye. Benghazi est une cité croissante avec de nouvelles zones industrielles en banlieue. L'Hôpital AI-jala sert non seulement la cité mais aussi les villages voisins et reçoit tous les cas provenant de la région orientale de la Libye. Trente-huit patients ont été atteints de brûlures électriques à haute tension et les autres 351 patients ont subi des brûlures à basse tension. La plupart des patients ont reçu la réanimation immédiate et les Auteurs ont effectué une "chirurgie appropriée urgente", selon les nécessités. Malgré la gestion médicale et chirurgicale les Auteurs ont constaté le décès de neuf patients atteints de lésions à haute tension et sept à basse tension. L'étude a démontré que les lésions électriques restent un grave problème accompagné d'une morbidité significative. Les Auteurs soulignent l'importance de la préparation d'un projet préventif approprié qu'il faut appliquer avec soin.

BIBLIOGRAPHY

1. Napoli B., D'Arpa N., Gullo S., Masellis M.: Epidemiology, clinical treatment and therapy in electrically burned children. Ann. Medit. Burns Club, 7: 188-93, 1994.
2. Hadjiiski 0., Argirova M.: Observation clinique des brûlures à haut voltage. Ann. Burns and Fire Disasters, 9: 13-17, 1996.
3. Lochaitis A., fliopoulou E., Poulikakos L.G., Asfour S.: Electrical burns: A survey of 24 cases. Ann. Medit. Burns Club, 5: 75-7, 1992.
4. Haberal M.: Electrical burns: A five-year experience. J. Trauma, 26: 103-9, (year not provided).
5. Moran K.T., Munster A.M.: Low voltage electrical injuries: The hidden morbidity. J. Royal Coll. Surg. Edinburgh, 31: 227-8, 1989.
6. Holliman CT, Saffle J.R., Kravitz M., Warden G.D. et al.: Early surgical decompression in the management of electrical injuries. Am, J. Surg., 144: 733-9, 1982.
7. Parshley P.F., Kilgore J., Pulito J.F. et al.: Aggressive approach to the extremity damaged by electric current. Am. J. Surg., 150: 7882, 1985.
8. Christoforou M., Antonopoulos D., Danikas D. et al.: Electrical burns in south-east Greece - Experience in the last three years, Ann. Medit. Burns Club, 5: 31-2, 1992.
9. Gordon M.W. G., Reid W.H. et al.: Electrical burns incidence and prognosis in western Scotland. Burns, 12: 254-9, 1986.
10. Lee R.C., Kolodney M.S.: Electrical injury mechanisms: Dynamics of the thermal response. Plast. Reconstr. Surg., SO: 663-71, 1987.
11. Lee R.C., Kolodney M.S.: Electrical injury mechanisms: Electrical breakdown of cell membranes. Plast. Reconstr. Surg., 80: 672-9, t987.
12. Govila A.: Early excision and primary resurfacing of wounds following high voltage electrical burns. Eur. J. Plast. Surg., 12: 14754, 1989.
13. Arturson G., fledlund A.: Primary treatment of 50 patients with high tension electrical injuries. Scand. J. Plast. Surg., IS: 111-8, 1984.