Ann. Medit. Burns Club - vol. V11 - n. 4 - December 1994

EPIDEMIOLOGY, CLINICAL TREATMENT AND THERAPY IN ELECTRICALLY BURNED CHILDREN

Napoli B., D'Arpa N., Gullo S., Masellis M.

Divisione di Chirurgia Plastica. e Terapia delle Ustioni, Ospeclale Civico e Benfratelli, USL 58, Palermo, Italy

SUMMARY. This research reviews electrically burned children aged 0-12 years admitted to the Palermo Bums Centre in the period 19751991. As regards the epidemiological aspects, apart from sex and age distribution, particular attention is paid to the lesive agents and mechanisms responsible for the burns and to the voltage of the electric current. From the clinical point of view an account is given of the distribution of the burns according to the most frequently involved sites (hand, mouth, forearm, wrist), followed by a discussion of the influence of the localization of the lesion on the course of the disease and its treatment. The distribution of patients is given on the basis of treatment (either exclusively medical or medical and surgical). For the surgically treated cases the more significant procedures for the functional recovery of the electrocuted upper limb are described.

In the period 1975-1991 we admitted to our Burns Centre 132 children suffering from electrical burns. Boys (73.5%) outnumbered girls (26.5%) with a male/female ratio of 2.7 to 1. The highest concentration of cases (82, i.e. 62.1 %) was in the 0-3 year age group (Table I).
Burns caused by low voltage in the home environment were the most frequent (93.3%). Play activities, such as the recovery of kites or birds' nests on power pylons, caused some high-voltage bums in older children (3.5%) (Table II).
The list of causative agents, mainly exposed electric wires (36.3%), power points (33.9%) and electric plugs (8.9%) - all in the home environment - indicates the lesive mechanism of the electric arc by contact with these agents (Table III).
Contact generally occurs by direct handling: when electrified objects come into contact with the mouth, the saliva, which is rich in electrolytes, completes the circuit, transmitting the current through body tissues where resistance is lower.

Table 1 - Distribution by age and sex

In 103 cases (78%) the lesion was in the hands, in 15 cases (I I%) in the mouth, in six cases (5 %) in the forearm and wrist, and in eight cases (6%) in other parts of the body (Table IV). Hand burns involved the first and second fingers in 55 cases (53.4%).
The percentage of body surface area burned was very limited in all patients but two (1.5%), in whom contact with high-voltage cables caused the ignition of clothing, resulting not only in electrocution of the forearm and wrist but also an extensive fire burn in 20% BSA in one case and 15% in the other. In all cases burns were third degree or associated second and third degree.
Altogether 7 8 (59. 1 %) patients were cured with exclusively medical treatment, while 54 (40.9%) were treated surgically (Table V). Of the surgically treated patients, forty (74.1%) were subjected to early surgery (within 20 days post-burn) while the other fourteen (25.9%) had late surgical treatment.
As regards non-definitive surgical procedures (escharectorny, escharectomy and temporary coverage with free skin graft) and multiple stage operations (flaps), the number of operations performed was 78, equivalent to 1.4 per patient.
Case 1. G.G., age 1, girl

Table II - Distribution by current voltage Table III - Distribution by causes Table IV - Distribution by site of lesion Table V - Distribution by site and therapy

Fig. la - Necrosis due to electrocufion of tongue and left labial commissure. Fig. 1b - Lesion in advanced state of cure after conservative treatment.

Fig. 2a - Necrosis due to electrocution of scalp. Fig. 2b - Exposure, after escharectomy, of cranium; design of rotation flap performed on day 15.

Fig.3a - Electrocution of first finger of left hand with exposure of long flexor tendon. Fig. 3b - Cross-finger with second finger performed on day 22 Fig. 3c - Long-term functional recovery.

Fig. 4a - Destruction of extensor apparatus and articular capsule of proximal interphalangeal articulation of second finger of left hand recostructed with skin graft from ipsilateral forearm. Fig. 4b - Abdominal pouching on day 12. Fig. 4c - Long-term functional recovery.

Fig. 5a - Serious electrocution of first and second finger of right hand with complete destruction of soft tissues subjected to surgical debridernent on day 11. Fig. 5b - Coverage with groin flap on day 16 after further debridement. Fig. 5c - Functional recovery.

Fig 6a - High voltage double electric arch in right wrist Fig. 6b - Exposure of ulnar vasculonervous bundle after escharectomy on day 15. Temporary coverage with skin graft. Fig. 6c - Exposure of uIna after further escharectomy. Fig. 6d - After reconstruction with abdominal flap performed on day 30.

The distribution by age and sex in our patients is consistent with that found by other authors (1). This is also true of the aetioPathogenetic aspects which - considering that we are dealing with children - may be considered typical (contact in the home with objects in a state of low voltage).
Also typical, in relation to the aetiopathogenetic aspects, are the site and the characteristics of the lesions, which are mainly in the hands and mouth and, although localized and limited in extension, generally deep (1, 2, 3).
Most of the burns were treated and cured medically, since in addition to non-serious lesions there are many others which due to their localization generally require conservative treatment.
This is the case of mouth electrocutions, especially at commissure level, which can if necessary be treated with secondary reconstructive procedures in the event of functional sequelae (2, 4).
We never carried out any surgical procedures in the first post-trauma hours, as is on the other hand recommended by some other authors (5, 6). However, compared to patients operated late, more patients were subjected to surgery before day 20, when the lesion was considered to be stable.
The definitive reconstructive techniques used are summarized in Table VL The procedures followed were debridement, d6collement and juxtaposition of the edges, and suturing in one case, and wedge excision and layered suturing in the other case, because of haernorrhagic complications secondary to electrocution of the lower lip. In accordance with the principle of greater simplicity we used dermoepidermal grafts whenever possible. We used flap coverage when structures such as nerves, tendons, vessels, articulations or bones were exposed. The demolition of nonviable segments of limbs was performed as soon as possible in order to prevent possibly life-endangering complications (sepsis, kidney failure) (6, 7,8)

The characteristics of the distribution by age and according to aetiopathogenesis of the lesions show that the prevention of electrical accidents in children is possible, and is based on:

1. careful surveillance of younger children by adults;
2. elimination of risk factors in the home environment;
3. preventive education in older children and the population as a whole (9).

Regarding the treatment of lesions caused by electric current we would recall that:

1. what may at first sight appear to be a serious and extensive injury will in some cases heal with minimal sequelae;
2. damage to the vessel intima may cause thrombosis even weeks after the trauma.

A lesion due to electric current is thus a lesion in evolution (4, 7); it is therefore of fundamental importance to make the right choice between conservative and aggressive treatment and, if surgery is necessary, to choose the right moment for reconstruction, i.e. either soon after the trauma or subsequently, when the lesion has stabilized. We have seen that the site of the trauma may determine the choice of the type of treatment; as to the choice of the right moment for surgical procedures, our previous considerations would recommend a prudent and watchful period of waiting. The reconstruction techniques are conditioned by clinical objectivity and by the normal functions performed by the affected area; in children, reconstruction using flaps involves an age-related risk factor due to their natural unawareness.and restlessness.

SUMMARY. Les auteurs dans cette étude considèrent les enfants atteints de brûlures électriques hospitalisés dans le Centre des Brûlés de Palerme pendant la période 1975-1991. Pour ce qui concerne les aspects épidémiologiques, ils ont analysé la distribution selon le sexe et l'âge et en particulier les agents et les mécanismes qui ont causé les lésions et la tension du courant électrique. Du point de vue clinique ils décrivent la distribution des brûlures selon les zones corporelles les plus fréquemment atteintes (main, bouche, avant-bras, pouls) et ils discutent l'influence de la localisation sur le cours de la maladie et son traitement. Les données sont fournies relativement à la distribution sur la base du traitement (soit exclusivement médical soit médical et chirurgical). Pour les cas traités chirurgicallement les auteurs décrivent enfin les procédures plus significatives pour la récupération fonctionelle du membre supérieur atteint de brûlure électrique.

1. Rodrigues Menes H., Rigo Aguada A., Del Pino Paredes V.: Epidentiologia, prevenci6n y tratarniento de las quemaduras electricas infantiles. Cit. Plast. lber. Latinoamer., 14: 265-71, 1988.
2. Kanzanjan, Converse: 11 trattamento chirurgico dei traumi facciali", vol. 2, chap. 29, Piccin, Padova, 1988.
3. Nahas L.F., Nahas R.A.; Quemaduras electricas de los labios y comisura bucal. Cit. Plast. lber. Latinoamer., 16: 129-34, 1990.
4. Feldman J.J.: Facial burns. In: McCarthy, "Plastic surgery", vol. 3, chap. 1, Saunders, Philadelphia, 1990.
5. Luce E.A.: Electrical injuries. In: McCarthy, "Plastic surgery", vol. 1, chap. 24, Saunders, Philadelphia, 1990.
6. Neale H.W.: Electrical injuries of the hand and upper extremity. In: McCarthy, "Plastic surgery", vol. 8, chap. 130, Saunders, Philadelphia, 1990.
7. Garriba R., Tanzarella M., Colesanto A.D., Pascone M.: Problemi di trattamento nelle gravi folgorazioni del polso. Riv. Ital. Chit. Plast., 15: 377-83, 1983.
8. Masellis M., Conte F., Fortezza G.S.: Use of dermis to reconstruct hand joint capsules. Ann. Plast. Surg., 9: 72-80, 1982.
9. Cabanes J.: Prevention des brOlures 6lectriques. Ann. Medit. Burns Club, 1: 38-40,1991.