Escudero-Nafs F.J., Leiva-Oiiva R.M., Collado-Aromir F, Rabanal-Suirez F, De Molina-NOfiez 1M.

Department of Plastic Surgery and Burns, Valle de Hebron. General Hospital, Barcelona, Spain

SUMMARY. Seventy patients with high-tension bums, admitted to the <<Valle de Hebron>> General Hospital Burn Unit, during a period of 9 years (1980-1988), were evaluated retrospectively. Only victims with documented passage of high-tension electrical current ( > 1,000 volts) through the body were reviewed. Patients with only flash or flame bums from electrical accidents were excluded. There were 69 males and I female, with an average age of 31.3 years. Thirty-nine accidents (55.7%) occurred at work, and 31 (44.3%) occurred in leisure time. All the patients, with one exception, were admitted within 5 hours of injury. The extremities were the most frequent site of injury. In 54 cases (77%), two or more extremities were burned. Thirty patients (43%) sustained additional flash and/or flame bums. The mean total body surface area of the burns was 12%, with a mean full-thickness bum area of 7%.

Twelve patients (17%) required cardiopulmonary resuscitation at the scene of the accident or following admission. Fluid resuscitation was carried out using Ringer's lactate at a vigorous rate. Acidotic patients, or with marked myoglobinuria, were additionally treated with intravenous sodium bicarbonate, mannitol or both. A total of 179 operations were performed, for exploration, debridement and closure of the injuries. Thirty-six cases'(51.4%) underwent a total of 56 amputations; 14 patients suffered multiple amputations.
Acute renal failure developed in two cases (2.8%), and both died. No cases of clostridial infection occurred. Sixty-seven patients (95.7%) were discharged, with an average stay of 50 days. Three deaths occurred among the reviewed cases (4.3%). We attribute this low mortality to early transfer of patients to our Burn Unit, aggressive fluid resuscitation, and early aggressive debridement.

Electricity in its unprotected, naked form may produce both death and devastating injuries (1). Electrical burns account for 3 to 17 per cent of all admissions to Burn Centres (2, 3).
Although there are several factors that decide the severity of the traumatism, the principal determinant of tissue damage is the voltage of the current (4). Traditionally, injuries caused by exposure to 1,000 volts or greater are considered high-tension electrical bums (1, 2). Luce and Gottlieb (5) have divided these injuries into flash and "true" high-tension electrical burns. The former are caused by a flame of very high temperature and short duration, due to the conversion of electrical energy to heat outside the body (6). These burns are typically mixed full- and part ial-thickness burns, without characteristic entry and exit wounds. "True" electrical injuries are caused by the passage of an electrical current through the body, between entrance and exit points, with significant destruction in these areas. Both flash and "true" electrical burns may occur in the same patient. Secondary burns can be inflicted by ignition of clothing or environmental objects.
High-tension electricity may produce massive tissue loss. In addition to cutaneous injuries, there is severe damage to underlying muscles, nerves, blood vessels and bones, which frequently results in amputations, renal failure and other complications. Every organ system can be injured by the passage of current. Vigorous resuscitation, with early wound exploration and debridement, may prevent some of the devastating disabilities and systemic complications of these burns. In this paper, we present a review of the treatment of high-tension electrical burns in our Department.

Seventy patients with high-tension electrical burns, admitted during a period of 9 years (1980-1988), were evaluated retrospectively. Only victims with documented passage of high-tension electrical current (>1.000 volts) through the body were included in this review. Patients with only flash or flame burns from electrical accidents were excluded.
There were 69 males and 1 female, with an average age of 3 1.3 years (range: 8 to 75).
Thirty-nine patients (55.7%) were injured at work; 23 of these cases were electricians and 6 were construction workers. Thirty-one accidents (44.3%) occurred in leisure time. The majority of accidents were caused by grasping or touching high-voltage lines, or happened in transformers or electrical substations. Lightning produced injuries to one patient.
The mean voltage involved was 15,000 volts (range: 8,000 to 25,000); the voltage of the lightning was unknown.
All the patients, with one exception, were admitted within 5 hours of injury.
All the patients sustained entrance and exit wounds (Figs. I and 2). The extremities were the most frequent site of injury (Tab. l). In 54 cases (77%), two or more extremities were burned (Tab. 2). In addition to the "true" electrical injuries, 30 patients (43%) sustained flash and/or flame bums. The mean total body surface area of the bums was 12% (range: 2 to 45), with a mean full-thickness bum area of 7% (range: I to 40). Five cases had fractures with soft tissue wounds.
Treatment. Twelve patients (17%) required cardiopulmonary resuscitation at the scene of the accident or following admission; all these victims survived. Electrocardiographic monitoring was performed if clinical evaluation so indicated.
Fluid resuscitation was carried out using Ringer's lactate. The rate of fluid adminstration was adjusted to keep a urine output of I to 1.5 ml/kg body weight per hour. Acidotic patients, or with marked myoglobinuria (41 cases, 58,5%), were additionally treated with intravenous sodium bicarbonate, mannitol, or both. Ringer's lactate was continued at a vigorous rate to grossly clear the pigments.
After initial stabilization, patients with signs of increasing compartment pressures or myonecrosis were taken to the operating room (usually within 4 hours after admission), for fasciotomies and tissue exploration. All potentially involved muscle compartments were explored, including deep muscle groups adjacent to bone (Fig. 3). Obviously nonviable tissues were debrided initially; amputations were performed only in clearly necrotic extremities. Amputation sites were left open unless obviously viable tissue was present at the level of amputation. Following initial exploration and debridement, exposed tissues were covered with skin homografts, topical agents, or dressings soaked in physiological serum. Silver sulphadiazine was used on the associated flash and flame bums. Wounds were explored and debrided at 48 to 72 hour intervals, until all nonviable tissues were removed or amputation was necessary. Wounds were then closed with skin autografts, flaps or both. Associated full-thickness flash and flame bums were treated through early excision and grafting.
Rehabilitation was started during the hospital stay and continued after discharge.

Surgical procedures. The patients reviewed required a total or 179 operations, ranging from one to six surgical procedures per patient (mean number 2.5), for exploration, debridement and closure of the injuries. Thirty-six cases (51.4%) underwent a total of 56 amputations; removal of multiple fingers or toes form the same extremity counted as one amputation. Almost two thirds of the amputations involved the upper limbs. Fourteen patients had multiple amputations (Figs. 4 and 5). One bilateral shoulder disarticulation and two unilateral shoulder disarticulations were performed (Tab. 3).

Fig. 1 A 25-year-old man with entrance injuries of a high-tension electrical bum. The current vaporized the soft tissues in the wrist and distal forearm. Shoulder disarticulation was performed. Fig. 2 Exit wounds of a high-tension electrical bum, involving the left thigh, penis and scrotum.

A right fourth rib excision was necessary in one case with electrical burns on the chest wall. One patient sustained a full-thickness loss of the abdominal wall, with prolapse of perforated intestinal loops through the wound; in addition to debridement of the burns, the necrotic intestine was resected, and intestinal anastomosis was performed (Fig. 6).
Surgical procedures used for closure of the electrical injuries are shown in Tab. 4.

Complications and mortality. Two patients developed acute pulmonary oedema from fluid overload. One of these sustained an acute gastrointestinal haemorrhage, as a result of stress ulcers. Acute renal failure developed in only two patients (2.8%), both of whom died. No instances of infection with clostridial organisms occurred.
There were three deaths (4,3%). The mean age of the deceased patients was 40 years, and the mean total body surface area of the burns was 20%. One victim suffered a deep electrical bum on his scalp and skull (Fig. 7). He died nine days after injury with severe cerebral oedema and acute respiratory insufficiency.

Fig. 3 High-tension electrical bum of the right upper extremity: Decompressive fasciotorny of forearm, with extension of surgical incision through the carpal tunnel space of the hand. Fig. 4 An 18-year-old boy with high-tension electrical burns involving upper extremities. Fig. 5 Patient of figure 4. Bilateral amputation of upper extremities following high-tension electrical bums. Fig. 6 A 45-year-old man with extensive destruction of the abdominal wall by high-tension electrical current. The patient died three days after injury.

Fig. 7 High-tension electrical bum of the scalp, skull and neck. The patient died nine days after injury.

The patient with destruction of the abdominal wall and intestinal necrosis had severe electrical bums on his left leg. An above-knee amputation was performed. He died three days after injury, as a result of peritonitis, generalized sepsis and acute renal failure. A 50-year-old man had an associated ,skull fracture. Following exploration and debridement of the bums, the patient died ten days after injury. He developed multiple organ failure, including acute renal failure.
Length of hospitalization. Sixty-seven patients (95.7%) were discharged from the 13th to the 112th days following admission (average stay, 50 days).

Patterns of high-tension injuries include instant death, massive tissue loss, secondary ignition burns, and associated traumatisms. The victims are almost exclusively young men, with an average age of 30 years. Approximately one third of these injuries occur in electrical workers (1, 4).
Resuscitation following electrical accidents must be directed immediately to the cardiorespiratory systems, because respiratory paralysis and ventricular fibrillation are the principal causes of death (4). Because the victims tend to be young and in good health, prolonged efforts at cardiopulmonary resuscitation are warranted (7).
One of the major complications of high-tension electrical bums is acute renal failure. Circulating muscles and red blood cells may lead to acute tubular nephropathy, in the presence of low renal blood flow and low urine volumes. Prompt fluid resuscitation is the key to the prevention of this complication. myoglobin and haemoglobin from damaged Because of the iceberg effect of the cutaneous injury, coupled with the extensive destruction of all underlying structures, the fluid requirements are much greater than in a comparable thermal bum (1, 4, 8). Large infusions of Ringer's lactate should be administered, at a rate that maintains a urine output of approximately I to 1.5 ml/kg body weight per hour. The use of mannitol to increase renal perfusion and sodium bicarbonate to achieve urine alkalinity has been an integral part of the resuscitation programme for electrical bums (1, 2, 3, 9, 10).
Sometimes it is impossibile to resuscitate a patient with a large amount of dead muscle, and an emergency operation to amputate the injured extremity or remove the destroyed tissues may be necessary (11).
The incidence of acute renal failure in most series has been reported to be 1.5 to 7.5 (2, 12). Two cases (2.8%) of this complication occurred in our series.
After the cardiopulmonary and renal situations have stabilized, attention must be directed to the injured tissues. We agree with Holliman et al. (13) that early and repeated direct inspection of all damaged muscle groups seems to be the most reliable method of assessing vaibility. Parshley et al. (14) have emphasized the importance of immediate decompression of tight muscle compartments, by early and radical fasciotomy, to prevent further damage to the tissues, and simultaneous and often radical removal of obviously nonviable muscles, including immediate amputation of extremities that are clearly not salvageable. Care must be taken to investigate not only the superficial muscle layers, but also the deep muscle adjacent to the bone (4). Muscles with questionable viability should be left for re-exploration and re-evaluation at 48 to 72 hour intervals (13, 14). Nerves and tendons should be preserved even if they appear devitalized (2). Luce et al. (15) have observed regeneration and return of function in apparently nonviable nerves. Preservation of flexor tendons can facilitate later tendon transfer during the process of reconstruction.
Repeated debridements are usually necessary in order to excise all devitalized tissues. Definitive coverage is provided when no further nonvital tissue surgeons (16, 17) believe that tissue can be salvaged by early coverage with a flap that brings new blood supply, but others feel that flaps covering nonviable tissue may become necrotic, and serve as a source of severe clostridial infection (4). Coverage may be achieved by means of autogenous split-thickness skin grafts, but they do not provide the stability often required (2). If a substantial number of exposed muscles, tendons, and nerves are deemed viable at the initial or subsequent procedures, coverage within the first few days by a pedicle or free flap may preserve essential function in a way that no other method can achieve (1, 15, 18).
Wang et al. (19) have obtained satisfactory results in the prevention of limb necrosis using early vein grafts for re-establishing blood circulation in wrists showing impaired blood flow, as a result of electrical injury.
Amputation should be carried out as soon as it becomes clearly necessary, both to lessen the risk of later invasive infection, and to lessen the load of myoglobin and tissue toxins that could be absorbed by the bloodstream (14). Remensnyder (1) has summarized some of the reported experience with major amputations in high-tension electrical injury. Of the 598 patients reported, 37% underwent one or more major amputations. A total of 56 amputations were performed in 36 cases (51.4%) of our review; 36 were major amputations.
The overall mortality rate from electrical bums has been reported to be between 3 and 14% (2, 6, 9). Our mortality rate was 4.3%. We attribute this low incidence to early transfer of patients to our Bum Unit, aggressive fluid resuscitation and early aggressive debridement.

RÉSUMÉ. Les Auteurs ont exécuté une analyse rétrospective de 70 patients (69 mâles, 1 féminin, âge moyen 31,3 ans) qui ont subi des brûlures électriques de haute tension (--1000 V) hospitalisés pendant la période 1980-89 chez l'Unité des Brûlures de l'Hôpital Général "Valle de Hebron". Pour ce qui concerne le lieu des accidents, 39 (55,7%) se sont produits à la maison et 31 (44,3%) au travail. Tous les patients, sauf un, ont été hospitalisés dans les premières 5 heures après l'accident. Les extrémités ont été la partie du corps plus fréquemment atteinte (deux ou plus de deux extrémités en 54 cas (77%". Les Auteurs décrivent les thérapies employées et les interventions chirurgicales effectuées. Ils attribuent le taux de mortalité très limité (seulement trois patients sont décédés, c'est-à-dire 4,3% des cas) à l'hospitalisation précoce chez leur Unité des Brûlures, à la réanimation agressive avec l'emploi des liquides, et au débridement précoce et agressif

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