Annals of the MBC - vol. 5 - n' 2 - June 1992

ELECTRICAL BURNS: A SURVEY OF 24 CASES

Lochaitis A., Iliopoulou E., Poulikakos L.G., Asfour S.

Department of Plastic and Reconstructive Surgery and Burn Unit, General District Hospital K.A.T., Kifissia, Greece


SUMMARY. A study is made of a series of 24 patients who suffered low- and high-voltage electrical injuries during a 2-year period (1989-199 1). The complications and the methods of treatment are described. The strategy in the acute phase was that major traumas should never be closed or covered. Early coverage was feasible in minor injuries.

Introduction
We define true electrical injury as that caused by direct contact of the human body with electrical current, with typical points of entrance and exit.
The disease universally affects able young men, and its disastrous manifestations require drastic intervention.
The parameters involved in electrical tissue injury are those of the basic equations of Joule and Ohm, i.e., amperage, voltage, resistance and thermal energy produced, as well as the type and pathway of current, time of contact, and grounding (if any).
Tissue conductivity and resistance are variable through the body, and this led past authors to make misguided explanations of deep conduction injuries. However, recent investigations confirm that the thermal energy produced mainly depends on "current density". or "flow per unit cross-sectional area" (Remensnyder, 1990). There is no doubt that nerves, muscles and blood vessels are more prone to electrical damage than bones, tendons or adipose tissue.
Although the electrical path is usually the shortest one, multiple exit wounds are sometimes observed. Thus, virtually any structure in the body is at risk of electrical insult.
The area of electrical burn on the body surface may be small, but the extent of destruction of the deep tissues (especially the muscles) may be much greater (Liang, 1982).

Material and methods
Our series includes 24 patients (10 cases with low-voltage electrical injuries and 14 with high-voltage) hospitalized in our Department in the 2-year period 1989-1991. The male:female ratio was 23:1, and the majority belonged to the 40-50 years age-group (9 cases, 37.5%) and to the 20-30 years age-group (8 cases, 33.3%).
The real damage caused by electric current to the body is far more extensive that one would suspect on first inspection; complications involving deep-lying tissues and more than one system are most to be feared, and account for the very high mortality rates in this disease. The complications are:

  • cardiac manifestations, ranging from mild rhythm or ECG changes to standstill;
  • nervous system involvement, from dizziness to transient or permanent lesions of the CNS, spinal cord, or the peripheral nerves;
  • renal manifestations, sometimes climaxing in acute renal failure;
  • G.I. manifestations with perforation of bowels, ileus, etc.;
  • coagulopathy;
  • respiratory; and
  • psychiatric.

The majority of our patients had received a high-voltage shock of up to 1000 V (14 cases, 5 8.3 3 %).
In complete accordance with international data the area most commonly injured was- the upper extremity, followed by the lower limb or limbs, head, thorax, etc. (Table 1).
The manifestations were as follows:

  • neurological; these were the most common. Dizziness was universal and loss of conscience on admission was found in 5 (20.8%) cases, and reported in 4 others (16.6%). Hemiplegia and epidural haematoma during the acute phase were encountered in 2 (8.3%) cases;
  • cardiological manifestations were not heavy in this series. Surprisingly, they were encountered in comparatively lighter cases, and were always transient;
  • one patient who developed acute abdomen four days post-burn was operated on, and acute nonlithiasic cholecystitis was found;
  • there was one case of ARDS three days post

Head (cranium)

2 (8.33%)

Upper extremity

18 (75%)

Thorax

2 (8.33%)

Abdomen

2 (8.33%)

Lower extremity

6 (25%)

Joint area

1 (4.16%)

Table I Areas involved

 

Debridement

8 (33.33%)

Escharotomies

14 (58.33%)

Fasciotomies

11 (45.83%)

Amputations

9 (37.50%)

lower limb:

3

upper limb:

6

Early coverage

2 (8.33%)

Table 2 Acute phase treatment

 

Fatal1,

(4.1.6%)

Amputations

10 (41.66%)

Need for further reconstructions

21 (87.5%)

Table 3 Final outcome

Discussion
Our philosophy during the phase immediately post-injury has always been to preserve life, without any hesitation in the face of functional losses. Our goals in this phase are:

  • to provide accurate initial assessment and general resuscitative measures; and
  • to deal with the operative problems, which may imply multiple operations, before definitive closure is feasible.

Measures of resuscitation and support include:

  • establishment of airway patency and adequate respiration;
  • cardiac resuscitation if needed. Cardiac monitoring is of paramount importance;
  • vigorous handling of associated or concomitant injuries; and
  • monitoring of vital signs and urine secretion.

Regarding our operative technique during the acute phases, in 8 cases (33.3%) debridement was sufficient, while in the rest escharotormes, fasciotornies and/or amputations were performed soon after admission (Table 2).
Our strategy in the acute phase was that traumas should never be closed or covered, at least in major injuries. Early coverage (1-2 days post-burn) was feasible in minor burns and was achieved by raising distal flaps.
Of this series only one patient died. Ten underwent amputation, and while 21 required further reconstruction (Table 3).
To achieve this, our fluid administration formulae include about 8-12 ml/kg/TBSA/24 h and urine alkalinization. Factors that improve the microcirculation and antiplatelet agents (e.g. Buflomedile, aspirin) are normally used when there is no contraindication. Antithromboxane factors are not. readily available, and were not used in the patients in this series.
Low-molecular weight heparin derivates were administered to the older or immobilized patients. Since all these drugs were administered according to criteria other than the gravity of concrete conclusion can be driven.
Our operative approach to the injury is prompt and prudently aggressive. Removal of devitalized tissue and procedures of decongestion of limbs are performed on admission, or a few hours later. We do not proceed to reconstruction unless we are convinced that what remains is healthy. We never proceed to direct closure of the operative trauma.
The electrical burn is one of the most severe, catastrophic and challenging types of bum. The strategy and the methodology of a Burn Centre depend on the great variety of clinical and paraclinical features of each patient as a unique case (every patient may develop one or more complications). Highvoltage burns should be treated more aggressively. The surgeon's first responsibility should be to make sure that there is no underlying muscle damage (Artz, 1979). The applications of this approach, in relationship to adequate knowledge of the clinical signs, could provide better therapeutic results.

Conclusion

We believe that a careful understanding of the pathophysiology of electrical injury and meticulous initial assessment can lead to effective resuscitation and operative measures which, together with further reconstruction, will optimize results.
The results of this series do not differ greatly from those in the literature (Remensnyder, 1990; Liang, 1982~ Artz, 1979).

 

RESUME Les auteurs présentent une série de 24 patients atteints de 1ésions d'origine &Iectrique de basse et de haute tension, pendant une période de 2 ans (1989-1991). Ils décrivent les complications et les méthodes de traitement. Selon la stratégie suivie pendant la phase aig0 il ne faut pas ni couvrir ni fermer les traumatismes graves. La couverture est conseillée seulement pour les 1ésions mineures.


BIBLIOGRAPHY

  1. Ariz C.P.: Electrical injury. In: Ariz C.P., Moncrief J.A., Pruitt B.A., "Burns: A team approach", W.B. Saunders, Philadelphia, 1979.
  2. Chih-chun, Hsu Wei-shia, Shih Tsi-siang (Eds.), Shanghai Publishers, 1982.
  3. Remensnyder J.R.: Acute electrical injures. In: "Acute management of the burned patient". J.A.J. Martyn (Ed.), W.B. Saunders, Philadelphia, 1990.
  4. Liu Yue-Liang: Electrical burns. In: "Treatment of burns", Yang



 

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