EPIDEMIOLOGY OF ELECTRICAL BURNS IN OUR CENTRE

Haberal M., Kaynaroglu V., Oner 1, G0lay K, Bayraktar U., Bilgin N.

Hacettepe University Hospital Burn Center-Turkish Transplantation and Burn Foundation Hospital, Ankara, Turkey.

SUMMARY. Of the 811 patients who were admitted to our Bum Centre from January 1, 1980 to January 1, 1988, 137 (16.90%) had electrical bums, not including 7 flash bums, 2 lightning and 1 bum from electrical stove. Of these 137 patients, 94 (68.60%) were over 15 years old with mean age 26.8 years (16 to 48 years). 84 (89.36%) were males and 10 (10.64%) were females. 43 (31.40%) patients were under 15 years old with mean age 11.2 (1 to 15), 39 (90.70%) were males and 4 (9.30%) were females, the majority being 11 to 15 years old. 53 (38.69%) of the patients were injured with house current (220-400 volts) and 84 (61.31%) with high tension (100-134,000 volts). The occupations of the patients over 15 years old could be classified as follows: 40 (42.35%) electricians, 23 (23.5%) blue collar workers, 9 (10.58%) farmers, 7 (7.44%) housewives, 7 (7.44%) teachers and 8 (8.56%) others including 2 students, 2 chafreurs, 1 pharmacist, 1 pensioner, 1 engineer and 1 shoemaker. All of these patients came from throughout the country. Following routine resuscitation and local wound care, including fasciotomy and debridement, the patients were observed closely.

The evidence we have obtained from this experience reveals that electricity is one of the major causes of bums; another derivation is that electrical burns are mostly encountered among electricians. This is mostly owing to the lack of knowledge and education among this group of people. We can therefore say that enhancing the level of education is a necessity with potential value.

Electricity is one of the necessary requirements for human survival. However, when misused, it can lead to a life spent as a cripple or cause a fatal injury. In the developing countries, electrical energy is used widely but sometimes inappropriately. For this reason, the incidence of electrical injury causing severe complications or death is high. In order to prevent this life-threatening event, measures should be taken by health-care officials and physicians to educate the public on bum prevention through every available means of communication (1,2). In this paper, we present our 8 years' experience with electrical burns in Turkey.

From January 1, 1980 to January 1, 1988, 811 patients were admitted to our Burn Centre. Of these, 137 (16.90%) had electrical burns, not including seven flash burns, two lightning and one burn injury from an electrical stove. Ninety-four (68.60%) of the 137 patients were over 15 years old, with the age 26.8 years (16 to 48 years). Eighty-four (89.36%) were males and 10 (10.64%) were females. Forty-three (31.40%) patients were under 15 years old with the mean age 11.2 (1 to 15); 39 (90.69%) were males and four (9.30%) females, the majority being 11 to 15 years old (Fig. 1). Fifty-three (38.69%) of the patients were injured with house current (220-400 volts) and 84 (61.31%) with high tension (100-134.000 volts). The occupations of the patients over 15 years were as follows: 40 (42.35%) electricians, 23 (23.5%) blue collar workers, 9 (10.58%) farmers, 7 (7.44%) housewives, 7 (7.44%) teachers and 8 (8.56%) others, including 2 students, 2 chauffeurs, 1 pharmacist, 1 pensioner, 1 engineer and 1 shoemaker (Fig. 2).

All of our patients came to our Centre from throughout the country. The treatment of all patients began at the time of hospitalization. Following routine examinations, 1.v. fluid (saline or saline with dextrose) was administered and following the results of the electrolyte measurements, provided potassium levels were normal, the solution was changed to Ringer's lactate. The rate of fluid administration was adjusted until the urine volume was at least 50 ml. per hour. If the patient was oliguric and acidotic, sodium bicarbonate, 20-40 gm of mannitol and 40-100 ing furosemide were given. If the patient still remained oliguric, and potassium, BUN, and creatinine levels were rising, peritoneal or haemodialysis was carried out using a double-lumen subclavian catheter (Gambro SCK-102 20-cm, Lund, Sweden). We found that this system was very easy to use for both haemodialysis and parenteral alimentation. A urinary catheter and a central venous pressure catheter were used only in severe cases or if clinical evaluation so indicated.

Following initial stabilization, the patients were taken to the dressing room for re-evaluation and, if necessary, debridement, escharotomy and fasciotomy. After premedication, wounds were cleansed and closed using one of the local chemotherapeutic agents, such as silver sulphadiazine, mafedine acetate, or silver-incorporated amniotic membrane (4). This procedure was repeated until all nonviable tissue was removed. In patients where amputation was required the wounds were then closed with skin grafts or flaps. Rehabilitation such as physical therapy was started while patients were hospitalized and continued after discharge if necessary.

A total of 152 surgical procedures were employed on 76 patients: 21 patients, one; 29 patients, two; 14 patients, three; four patients, four; and five patients five procedures. Forty-six (60.53%) had inuscoloskeletal complications; 32 (42. 11 %) patients required major amputations which included seven right arm disarticulations, four right arm amputations, five right forearm amputations, five right leg amputations (below the knee); six left arm amputations, two left forearm and three left leg amputations (below the knee); eight patients required multiple amputations; minor amputations consisted o17 various finger or toe amputations. In addition, there were one right mandible fracture, two compression fractures of lumbar vertebrae, three head traumas with craniectomies, and two costal fractures.
Six (13.04%) of the 46 patients died as a result of sepsis between the 10th and 44th days of hospitalization (average 17.8 days).
Forty patients were discharged from the 7th to the 159th days following hospitalization (average stay 4 5.7 days).
Twenty-two (16.05%) of the 137 patients had acute renal failure and 16 received peritoneal dialysis, 4 patients had haemodialysis and 2 patients both between the 2nd and 16th days after the injury (average 5.6 days). Thirteen (59.09%) of the patients died between the 4th and 21st days (average 8 days). Nine patients were discharged after 15 to,92 days of hospitalization (average 52.3 days). One patient in this group had g.i. bleeding 28 days after hospitalization; a duodenal ulcer was found on laparotomy and then vegatomy and pyeoroplasty were performed. Overall 101 (73.72%) patients were discharged between the 3rd and the 159th days (average 53.2 days) of hospitalization. Thirty-six (26.27%) patients died, 10 (7.30%) as a result of sepsis between the 10th and 44th days of hospitalization (average 22.3 days), and 26 (18.97%) wtih multiple organ damage between the 3rd and the 15th days (average 7.2 days).

Electrical burn injury is one of the severe problems in our society in Turkey. The main causes of injury in patients over 15 years of age are misuse, lack of attention and lack of knowledge, and the fact that utility poles and wiring are placed low and extremely close to buildings, so even installing a TV aerial can be life-threatening. In patients under 15 years of age, the injuries were mainly the result of mischievous activity that involved climbing, and lack of parental supervision. Another contributing factor is the lack of control of the systems by the electric companies.
One of the major complications of electrical injuries is musculoskeletal necrosis, which was seen in 60.53% of the cases which resulted in most of the major amputations (69.56%, about 2/3, involving the right upper and lower extremities and 1/3 left upper and lower extremities). This shows that in general, electrical injury involves the upper extremities and mostly on the right side. Most patients were right-handed.
We found that one of the reasons for the high rate of amputations could be that early surgical decompression with fasciotomy and subsequent wound debridement (5,6,7) were in many cases not accomplished as early as possible because the patients were transported to our Centre from non-specialized facilities.
Another important complication was acute renal failure in 22 (16.05%) patients. Quite a few factors are responsible for renal complications (7,8,9) and in addition to these we found that, in our series, acute renal failure could be attributed to the lack of early fluid resuscitation. Our current preference for acute renal failure is haemodialysis by using a double-lumen subclavian catheter, because it causes minimal discomfort for the patient and is easy for the medical personnel to perform. In spite of all the above treatments, the mortality rate in this group was quite high (59.09%).
Two types of neurologic complications were encountered in electrical injury patients, the first occurring immediately at the time of injury due to electrical shock or as a result of falling from a height (6,10). Eighteen patients in our series suffered from unconsciousness (eight as a result of a fall) at the time of injury and one patient became neurologically impaired.
The second type was peripheral nerve injury, which is often accompanied by vessel damage or, rarely, a vertebral fracture. We encountered nine patients with peripheral nerve injury in our study and one patient became a paraplegic as a result of a T 3 -T 4 fracture.
Although not often, it has been reported that after high-tension electrical injury intra-abdominal organ lesions as well as other tissue and organ damage can be encountered (5,11). Eight patients in these series suffered from multiple trauma.
This study reflects the importance of electrical burns in our country, where unfortunately their incidence is increasing rapidly, probably due to misuse, inattentiveness, lack of knowledge, and lack of parental supervision. Therefore, more concern is needed for the prevention of this life-threatening event, and the treatment of burns, if injuries are unavoidable.
Health-care officials and physicians must educate the public in the use and misuse of electricity, and we must continue our attempts in public education.

RESUME. Entre le premier janvier 1980 et le premier janvier 1988, 811 patients ont été hospitalisés dans le Centre des Brûlés de l'Hôpital Universitaire Hacettepe, dont 137 (16,90%) avec brûlures électriques, sans tenir compte de 7 brûlures par lueur, 2 par foudre et 1 par radiateur électrique. De ces 137 patients, 94 (68,60%) avaient plus de 15 ans, avec un âge moyen de 26,8 ans (de 16 à 48 ans); 84 (89,36%) étaient masculins et 10 (10,64%) féminins. 43 (31,40%) patients avaient moins de 15 ans, avec un âge moyen de 11,2 ans (d'un à 15 ans); 39 (90,70%) étaient masculins, et 4 (9,30%) féminins; la plupart avaient entre 11 et 15 ans. 53 (38,69%) des patients ont été blessés avec le courant domestique (220-400 v) et 84 (61,3 1 %) avec haute tension (100- 134.000 v). Les patients âgés de plus de 15 ans exerçaient les métiers suivants: 40 (42,35%) électriciens; 23 (23,50%) ouvriers, 9 (10,58%) agriculteurs, 7 (7,44%) ménagères, 7 (7,44%) professeurs et 8 (8,56%) métiers divers: 2 étudiants, 2 chauffeurs, 1 pharmacien, 1 retraité, 1 ingénieur et 1 cordonnier. Les patients provenaient de toutes les régions du pays. On a pratiqué la réanimation de routine et les soins locaux des brûlures, ce qui inclut la faisceautornie et la détersion, et les patients ont été suivis avec attention.
Les résultats de cette étude indiquent que l'électricité est une des causes principales des brûlures et en outre que les brûlures électriques affectent en particulier les électriciens, surtout à cause de l'ignorance et de l'inexpérience de ces personnes. Il faut donc conclure que l'amélioration du niveau d'instruction est une nécessité avec grande valeur potentielle.

BIBLIOGRAPHY

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