EARLY NEUROLOGICAL COMPLICATIONS IN ELECTRICAL BURNS

Haberal M., Bayraktar U., OztOrk S., Oner 1, Bilgin N.

Hacettepe University Hospital, Ankara, Turkey

SUMMARY. It was observed that high-tension electrical burns rnay cause major damage to the neural system, even in the absence of severe tissue injury. A description is given of three such patients, who suffered variously from loss of sensation, myelopathy, a paraplegia-like syndrome and neuropraxia. It is therefore advisable to perform a thorough neurological examination in patients with electrical burns, even if they do not present severe tissue injury, in order to prevent later complications.

Burn therapy has long been a major problem in Turkey and the therapy of electrical bums in particular requires special attention.
In our country, electrical energy is used widely but sometimes inappropriately. For this reason, the incidence of this type of bum, which causes severe complications or death, is considerably high. On average, 15% of the patients admitted to our Burn Unit are diagnosed as having electrical bums (1).
In this series we have observed that the high tension of electrical burns can cause major damage to the neural system, though not causing any severe tissue injury.

From Ist January 1988 to 31st December 1988 61 burned patients were admitted to our Burn Centre. 15 (24.5%) presented electrical burns (Fig. 1). Three of the adult patients had early neurological complications without displaying any severe tissue damage. All three patients were hospitalized in our hospital or another centre following the injury.
Case 1: A 40-year-old male electrician came into contact with a high-voltage electricity supply (30,000 volts) while working. Electrical current entered through his neck and exited from the bilateral hands. On admission, physical examination showed 25% TI1SA burns (23% second-degree and only 2% third-degree).
The burns area included: back of body (superficial second-degree) 14%, front of the body 3%, left hand 1%, right hand 1%, left leg 2%, neck 2%. The patient was treated with our routine protocol. He did not show any problem with the related kidney but presented imbalance and there was loss of sensation in the lower part of the back of the body and the bilateral lower extremities. The neurological examination myelopathy. In exercise was complications. after admission
Case 2: A 37-year-old male electrician came into contact with a high-voltage electricity supply (15,000 volts). On admission, physical examination showed 12% T13SA burn (10% second-degree and 2% third-degree) without revealing any severe tissue damage, together with 10% burn in the right hand and 11% in the left lower extremity. Electrical current entered through the right hand and exited from the left lower extremity. Following the injury, the patient was treated in one of the Community Hospitals and 15 days later he was transferred to our Centre with a paraplegia-like syndrome. Neurological examination and EMG showed myelopathy, and vascular damage was diagnosed in the spinal cord. Besides the burn treatment, physical therapy was applied and the patient was discharged 90 days after admission, having been advised to continue the physical exercise.
Case 3: A 33-year-old male electrician came into contact with a high-tension electrical supply (30,000 volts). On examination the patient showed 2 1 % T13SA (18% second-degree and 3% third-degree), without displaying any severe tissue damage. The entry point of the electrical current was the left hand and exit was from the left lower extremity. The burn area was 6% front of body, 2% left arm and 13% left lower extremity. Following the injury, the patient was treated in one of the Community Hospitals and 48 hours later he was transferred to our Centre. During the treatment he presented loss of sensation in the bilateral upper extremities. The neurological and EMG examinations showed bilateral ulnar and median nerve neuropraxia. The patient started physical therapy besides the bum treatment and he and electromyelography showed addition to the burn treatment, recommended for neurological The patient was discharged 55 days was discharged on the 7 1 st day following hospitalization, having been advised to continue the physical exercise.

Electrical injury is still one of the main problems in our society in spite of training and prevention activities. Approximately 15% of hospitalized burn patients still present electrical burns (1). Electrical current mainly travels along the path of the least resistant tissue, such as nerve, vessels, muscles etc. Electricity can cause injury to the body in three ways. First, electrical energy can be converted into light, which can damage the eye. Second, the passage of electrical current through the body can produce effects particularly on the heart and brain, as a result of which electrical shock occurs. Third, injury May occur by the conversion of electrical energy into heat. If this occurs outside the body, it causes a flash burn. If this conversion takes place within the body, a great amount of heat is produced in the bone where electrical resistance is high (2). The tissue damage will be high, for the extent of damage is related to the sensitivity of the tissue to heating: in other words, the least resistant tissue suffers the least severe tissue damage. In contrast, highly resistant tissue suffers severe tissue damage. Therefore, following severe electrical injury, approximately 35% of patients have severe musculo-skeletal complications (3). In spite of severe musculo-skeletal complications, neurological complications were not a severe problem either in our series or in the literature, in which very few cases have been reported (4, 5). Most relate to spinal cord injury.
The pathophysiology of electrical spinal injury is as yet unclear and various possible modes are reported in the literature, such as thermal injury occurring because of heat production by an electrical current, vascular damage causing thrombosis or haemorrhage, direct mechanical trauma from fracture or dislocation resulting from intense muscle spasm, and radiation light effect caused by changes in tissue protein which may lead to secondary vascular changes (4). In our four cases, we were not able to find out which of the above-mentioned path ophysiological changes was the cause of the pathology. But this patient did have a spinal cord injury. Diagnosis was very important for him. Accordingly, whenever electrical injury patients are admitted to hospital, besides the routine examination, a neurological examination should also be performed, including ENIG. In addition to the burn treatment, physical therapy was applied to prevent later complications.
The evidence obtained from this study supports the view that high-tension electrical burns can damage the neural system without causing any severe tissue injury. Therefore, electrical burn patients require close monitoring also of the neurological aspect.

RÉSUMÉ. Les Auteurs ont observé que les brûlures électriques à haute tension peuvent produire des dégâts tissulaires. Ils décrivent trois de ces patients, qui ont manifesté différemment la perte de sensibilité, la myélopathie, un syndrome qui ressemble à la paraplégie, et la neuropraxie. Il est donc conseillable de faire un examen neurologique exhaustif chez les patients avec brûlures électriques, même s'ils ne présentent pas de dégâts tissulaires graves, afin de prévenir les complications successives.