Annals of Burns and Fire Disasters - vol. IX - n. 3 - September 1996

SEVERE COMPLICATIONS IN ELECTRICAL BURNS (INCLUDING VISCERAL COMPLICATIONS)

Haberal M.,(1,2) UQar K.(1), Bayraktar 0.(2), Oner R .(2).

(1)Baskent University, Ankara Hospital, Ankara, Turkey
(2)Burn Unit, Hacettepe University Hospital, Ankara

SUMMARY. Over a period of 13 years (1979-92), 1065 patients were admitted to the Bum Unit at the Hacettepe University Hospital, Ankara. Of these, 219 (20.1%) suffered from electrical injury. The patients were treated according to a routine protocol. The most important early complications were acute renal failure, sepsis, and associated skeletal and central nervous system injuries. The late complications were total or partial extremity amputation, scars and contractures, cataract, and epilepsy. The mortality rate was 21.5% (47 patients, of whom 26 died of multiple organ failure, 13 of sepsis, and 8 of severe cerebral trauma). The high overall incidence and rate of severe cornplications in electrical burns compared with those found in other reports show that electrical injury still constitutes a life-threatening problem in our country. The victims often suffer the physical and psychological consequences of late complications, such as amputation. To prevent these undesired effects, preventive measures are urgently required through a massive education campaign, together with the realization and maintenance of high industrial safety standards.

Electrical injuries constitute a relatively large proportion of burns in Turkey. According to our previous epide- miological studies, as niany as 20% of the bums treated in our bum unit were caused by electricity. 1,2 Severe complications, including injuries to the visceral organs and amputation in the four extremities, were not infrequent in our series.' This study was performed to investigate the overall complications caused by electrical burns treated in our centre.

Between 1979 and 1992, 1065 patients were admitted to the Burn Unit at the Hacettepe University Hospital, Ankara. Of these, 219 (20.1%) presented electrical injury (Fig. 1). The male to female ratio was 9.3A.

The majority of the patients were young dult males but there were also 67 children (30. 1 %) under the age of 15 yr, of whom twelve (17.9%) were aged between 0 and 6 yr and 55 (82.1%) between 7 and 15 yr (Fig. 2). The most frequent causes of the accidents were carelessness, the employment of young persons without occup ' ational education, negligence by the electrical company, lack of parental supervision, and mischievous behaviour. The patients were treated according to a routine protocol. Following fluid and electrolyte resuscitation, all the systems were examined to detect any associated injury due to electricity, including stroke. Emergency dialysis was performed when massive myoglobulinuria and acute renal failure were bserved. Necrotic tissues were usually debrided sequentially in order to preserve any salvageable part. The topical agents preferred were polyvidone iodine and silver sulphadiazine.

Fig. 2 - Distribution by age of patients with electrical burns.

Wound closure was effected with flaps or skin grafts., as needed. The physical, psychological and social rehabilitation of the patients was provided during and after hospitalization.

The severe complications noted in this series are summarized in Table 1.

Musculoskeletal: Fifty-six patients (25.6%) underwent at least one partial or total amputation of the injured extremities. Of these patients, 16, 6 and 1 required total or partial amputation of respectively two, three and four extremities. Rib fractures were found in three patients. Bilateral femur fracture was observed in one patient, metatarsal bone fracture in another, and there were three fractures of cranial bones. One patient had paraplegia due to T3-T4 fracture.
Neurological: Thirty-five patients fell following a stroke and eight of the 18 patients with severe cerebral complications (haemorrhage) died. Eighteen patients developed various neurophysiological complications due to electrical injury to the brain. Disorientation was common in these patients. One patient had transient anisocoria, and one became epileptic. Six patients suffered severe impairment of hand function due to neuromuscular destruction by the electric current. Two of these underwent free neurovascular gracilis musculocutancous flap transfer to substitute flexors of the hand.
Cardiac: Important electrocardiographic alterations were present in four patients (non-specific ST-T waves and sinus tachycardia were not considered). Three of these had supraventricular tachycardia, while the fourth showed evidence of inferior myocardial ischaernia, which had not been recorded prior to the electrical injury.
Renal: Thirty-two patients (14.6%) presented acute renal failure. Of these, twenty required peritoneal dialysis or haemodialysis (Table II).The mean delay in arrival time in these patients was 3.5 days. Only two patients arrived on the day of the accident. Some patients were sent to our burn unit for haemodialysis. Most of these patients had not received appropriate fluid and electrolyte therapy during transportation or at the previous hospital. Seven patients died, despite vigorous fluid and electrolyte resuscitation and dialysis.
Visceral: Four patients had visceral injuries involving thoracic or abdominal organs. One of these patients was a 36-year-old male electrician, who was brought to our hospital the day after an electrical injury in the abdomen. He had received inappropriate resuscitation. Following emergency resuscitation ptocedures, he underwent massive small bowel resection but died the following day of multiple organ failure. The second patient was a 15-year-old male with electrical injuries in the abdomen and the lower extremities. After surgery for stomach perforation and amputation of both legs, he developed a high-output intestinocutaneous fistula. Hyperalimentation was initiated but the patient died 40 days post- operatively owing to sepsis. The third patient had colostomy, which was subsequently closed. The fourth patient was subjected to thoracotomy and resection of the third and fourth ribs. A thoracic tube was applied and the patient was discharged after two months. Two patients had gastrointestinal bleeding.
Ocular: Two patients with keratoconjunctivitis were attended by ophthalmologists. Cataract developed in two patients several months following discharge. Both patients underwent lens extraction.

The mortality rate was 21.5% (47 patients). Twentysix of these (55.3%) died of multiple organ failure. In thirteen patients (27.7%) the cause of death was sepsis, and in eight (17.0%) severe cerebral trauma.

The high overall incidence and rate of severe complications in electrical burns compared with those reported in other countries show that electrical injury still constitutes a life-threatening problem in Turkey.
Musculoskeletal complications constituted one of the major complication groups in our series. However, the high amputation rate (37.4%) in our previous series in 1985 declined to 25.6% in the present study. This may be due to earlier decompression and debridement of the injured extremities in recent years .6 This rate is consistent with reports from other countries .
A decrease from 18.1 % to 14.6% was also noted in the rate of renal failure compared with our previous series.',' This may be correlated to the early administration of fluid and electrolyte resuscitation during transportation. This rate was however higher than that reported in other series (15-7.5 %).4, ' The mean delay in arrival time from a nonspecialized facility to our unit of patients suffering from severe renal insufficiency was 3.5 days. Although these patients were subjected to extensive haemodialysis and peritoneal dialysis, no improvement could be obtained.
Neurological complications occurred in two ways, either by direct electrical trauma or by a fall from a height, resulting sometimes in severe intracranial haemorrhage and death. The mortality rate with this complication was hirgh in the present series.Neurophysiological disorders were also common. One patient presented persistent epilepsy. Severe peripheral nerve disorders were also not uncommon. One patient became paraplegic as a result of T3-T4 fracture.
Cardiac complications were rarely observed, contrary to theoretical expectations. Only one patient developed myocardial infarction and none died of cardiac complications.
Septic complications were consistent with those in other series.' The mortality rate due to sepsis was however higher. This may be attributed to the late arrival of patients who had already become septic in a non-specialized facility and received inappropriate treatment.
Although not frequent, visceral injuries may be encountered following electrical injury in the thoracic and abdominal walls.' In the present series four cases were reported. Two patients died from this type of injury. It is essential to operate on patients with abdominal or thoracic electrical injuries as soon as possible. In the present series and in those of other authors, death was inevitable when surgery was delayed.
Ocular complications were also noted, but not frequently. Two patients (1.8%) developed cataract.
The present study reflects the importance of electrical burns in our country. The victims often suffered the physical and psychological consequences of late complications, such as amputation. To avoid these unwelcome circumstances, preventive measures are urgently required, with wide-ranging education campaigns and the achievement and perfection of industrial standards.

RESUME. Pendant une période de 13 ans (1979-1992), 1065 patients ont été hospitalisés dans l'Unité de Brûlures de l'Hôpital Universitaire Hacettepe, Ankara. De ces patients 219 (20, 1 %) souffraient de lésions électriques. Les patients ont été traités selon un protocole de routine. Les plus importantes complications précoces étaient l'insuffisance rénale aiguë, la sepsis, et les lésions associées squelettiques et du système nerveux central. Les complications tardives incluaient l'amputation totale ou partielle des extrémités, les cicatrices et les contractures, la cataracte, et l'épilepsie. Le taux de mortalité était 21,5% (47 patients, dont 26 pour insuffisance organique multiple, 13 pour sepsis, et 8 pour trauma cérébral sévère). Le haut niveau de l'incidence et du taux des complications sévères des brûlures électriques par rapport à celui observé par d'autres chercheurs indique que les lésions électriques continuent à représenter un danger mortal dans notre pays. Souvent les victimes souffrent des conséquences physiques et psychologiques pour les complications tardives, comme l'amputation. Pour éviter ces effets malheureux il faut appliquer des mesures de prévention à travers une campagne massive d'éducation, et dans le même temps réaliser et maintenir un niveau élevé des standards de sécurité industrielle.

1. Haberal M.: Electrical bums: a five-year experience - 1985 Evans Lecture. J. Trauma, 26: 103, 1986. Haberal M., Ugar N., Bayraktar C., Oner Z.: Analysis of 1005 bum patients treated in our centre. Ann. Medit. Bums Club, 6: 73, 1993.
2. Haberal M., Oner Z., Gfilay H. et al.: Severe electrical injury and rehabilitation. Ann. Medit. Bums Club, 1: 121, 1988.
3. Hanumadass M.L., Voora S.B. et al.: Acute electrical bums: a tenyear clinical experience. Burns, 12: 427, 1986.
4. Gordon M.W., Reid W.H., Awwaad A.M.: Electrical burns - incidence and prognosis in Western Scotland. Bums, 12: 254, 1986.
5. Holliman C.J., Saffle J.R., Kravitz M. et al.: Early surgical decompression in the management of electrical injuries. Am. J. Surg., 1:13,1982.
6. Haberal M., Yilmaz E., Oner Z.: Renal complications in electrical bums. Bull. Clin. Rev. Burn Injury, 1: 37, 1984.
7. Wilkinson C., Wood M.: High voltage electric injury. Am. J. Surg.,136:693,1978.
8. Luce E.A., Gottlieb S.E.: "True" high tension electrical injuries. Ann. Plast. Surg., 12: 321, 1984.