Subrahmanyam M.

Department of Surgery, Government Medical College, Miraj and General Hospital, Sangli, Maharashtra, India

SUMMARY. Between January 1999 and December 2000, a total number of 40 patients with electrical burns treated at General Hospital, Sangli, India, were studied. Electrical burns were responsible for 2% of all burn admissions; 67.5% of the burns were due to low voltage and 32.5% to high voltage. The extremities were involved in 52.5% of the patients, and 55% underwent surgery. Debridement was the commonest procedure, followed by escharotomy. The mortality rate was 25%. The commonest cause of death was cardiac arrest, followed by septicaemia and renal failure. Congestion of the brain and oedematous lungs were frequent findings post mortem.

Introduction

Electrical burn injuries represent a special type of lesion, in which disability is high and functional and aesthetic sequelae are significant. They occur less frequently than flame or liquid burns, and account for 3-9% of all patients treated in burns centres. The damage due to electrical current is caused by two mechanisms - heating and the passage of electric current itself through tissues. Heating causes coagulative necrosis, and the passage of electrical current through tissues causes the disruption of cell membranes. The effects of electric current depend on the type of current, its voltage, the resistance of the tissues, the strength of the current, the pathway taken by the current through the body, the duration of contact, and individual susceptibility.1

Patients and methods

A study was made of 40 patients with electrical burns treated in the burns ward at District General Hospital, Sangli, India, during the period from January 1999 to December 2000. The following variables were considered: age, sex, occupation, site of accident, tension of current (voltage), clinical presentations, surgical procedures, and outcome. Management for electrical injuries included immediate cardiopulmonary resuscitation and the administration of intravenous fluids. In the presence of myoglobinuria, diuresis was induced by infusing an adequate amount of Ringer’s lactate solution and mannitol 20% (1 g/kg), in addition to sodium bicarbonate solution in order to obtain an alkaline urine output. Silver sulphadiazine 1% was used locally to dress the wounds. The required surgical procedures were carried out urgently, after assessing each patient and selecting the appropriate procedure.

Results

The incidence of electrical burns has been increasing over the last five years. In the year 1996, the incidence was 0.7%, while in 2000 it was 4.7%. The overall number of 643 admissions to our burns ward in 1999 included 18 patients with electrical burns (2.8%), while in the year 2000 22 patients (4.7%) out of the total number of 461 burn patients had electrical burns. The pattern of annual admissions is shown in Table I.

Among all these patients, 40 with electrical burns admitted during the period 1999-2000 were studied in detail. The youngest of these was 3 years old and the oldest 60 (mean, 26 yr).

Thirty-four were males and six females. Of the 40 patients, 14 were farmers (35%); one was an electrician, seven were labourers, ten were students, four were housewives, and four were children.

The causes of electrical burns were the touching or grasping of electrically live objects (24), short-circuiting (6), inserting fingers into electric sockets (1), falling into electrified water (1), lightning (1), and contact with an overhead electric line (7). Low-voltage electrical burns occurred in 27 patients (67.5%) and high-voltage burns in 13 (32.5%). Contact burns occurred in 21 patients (52.5%) and mixed burns in 19 (47.5%), involving a combination of contact burns, flame burns, and arc burns. The extremities were affected in 21 patients (52.5%), the head, neck, and face in one (2.5%), the trunk in one (2.5%), and a combination of these sites in 17 patients (42.5%).

The associated injuries were head injury in 7 patients, fracture of long bones in one patient, and fracture of vertebrae in 2 patients. The extent of burns (total body surface area percentage) was 0-10% in 31 patients (77.5%), 11-20% in 3 patients (7.5%), 31-40% in 3 patients (7.5%), and more than 60% in 3 patients (7.5%) (mean, 15%). Electrocardiogram records were normal in 22 patients (67%) and showed ST-T changes in 2 patients (6%), tachycardia in 7 patients (21%), and bradycardia in 2 patients (6%). No electrocardiogram could be performed in 7 patients who died immediately after admission.

Thirty-five patients developed complications: sepsis in 18, cardiac complications in 17, acute renal failure in 3, contractures in 2, paralytic ileus in 2, and gangrene of the right upper limb in 2.

The organisms isolated from the wounds were Staphylococcus aureus (13), Pseudomonas (2), Klebsiella (2), and Proteus (1). No wound had Clostridial infection. Twenty-one wounds had no organisms grown on culture.

A total number of 22 patients (55%) had 31 surgical procedures, with an average number of 1.4 procedures per patient (Table II). Two patients underwent amputation of the right upper limb (6.5%) (one forequarter amputation and one above-elbow amputation).

Ten of the 40 patients (25%) died. Septicaemia with acute renal failure was the cause of death in 3 patients, cardiac arrest in 5, myocardial infarction in one, and associated injury in one. The post-mortem findings in these patients are shown in Table III.

The remaining 30 patients had a hospital stay ranging from a minimum of 2 days to a maximum of 100 days (mean, 12.5) and were discharged after recovery.

Discussion and conclusions

In this study, electrical burns constituted 2% of all admissions to the burns ward.

The increasing incidence of electrical burns is due to the increasing use of electricity in day-to-day life and an increasing population. In our study, young persons were mostly affected and there was a male preponderance. Distribution by age and sex, clinical presentation, and complications was consistent with the findings of other researchers.2-4 Low-voltage injuries were more frequent in our study than in other studies.2,5 A considerable number of patients were farmers who sustained injuries due to touching or grasping live electric objects. These accidents were caused by ignorance, non-compliance with rules and regulations, and the lack of safe work practices.

The mortality rate of 25% was higher than in other reports, but the causes of death were similar.3,5 The post-mortem findings revealed brain and lung congestion and blood clots in the great vessels, which correlated with the clinical causes of death. We are not aware of any similar report on post-mortem findings in electrical burns.

Most of the electrical burns in this study were due to low voltage. This indicates that also low-voltage current is dangerous. Low voltage does not mean low hazard, but it is not always possible to know the exact voltage to which a person was exposed. Household injuries are due to low voltage, while contact with overhead lines causes high-voltage lesions. The two types of electrical burns have a different epidemiology and vary considerably in their clinical presentation and outcome, but it is reasonable to treat both types of injuries on the basis of the same management principles.

The care of each patient has to be individualized. Immediate adequate resuscitation, surgical decompression, and appropriate debridement will have a favourable effect on morbidity and mortality.6,7 Although electrical burns represent only a small proportion of burn injuries, the incidence of complications, mortality and morbidity, and disability is high. Such injuries can be prevented with proper educational programmes designed to suit the community.

RESUME. Les lésions chroniques et le tissu cicatriciel sont exposés à un risque augmenté de cancer de la peau. En 1828 Jean-Nicholas Marjolin a décrit la manifestation de tumeurs dans le tissu cicatriciel posttraumatique. Le type le plus commun de carcinome qui dérive de l’ulcère de Marjolin est l’épithélioma spinocellulaire. La période de latence entre la lésion et la manifestation du cancer varie entre 25 et 40 ans. L’ulcère de Marjolin qui se présente en manière précoce a été rarement décrite dans la littérature. Les Auteurs présentent ici un cas de cette sorte de la manifestation précoce de l’ulcère de Marjolin.

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