Electrical injury

The occurrence of single and multiple organ dysfunction in pediatric electrical versus other thermal burns

BACKGROUND

Multiple organ failure (MOF) is a major contributor to morbidity and mortality in burned children. While various complications induced by electrical injuries have been described, the incidence and severity of single organ failure (SOF) and MOF associated with this type of injury are unknown. The study was undertaken to compare the incidence and severity of SOF and MOF as well as other complications between electrically and thermally burned children.

PATIENTS AND METHODS

Between 2001 and 2016, 288 pediatric patients with electrical burns (EB; n = 96) or thermal burns (CTR; n = 192) were analyzed in this study. Demographic data; length of hospitalization; and number and type of operations, amputations, and complications were statistically analyzed. Incidence of SOF and MOF was assessed using the DENVER2 classification in an additive mixed model over time. Compound scores and organ-specific scores for lung, heart, kidney, and liver were analyzed. Serum cytokine expression profiles of both groups were also compared over time. Significance was accepted at p < 0.05.

RESULTS

Both groups were comparable in age (CTR, 11 ± 5 years, vs EB, 11 ± 5 years), percent total body surface area burned (CTR, 33% ± 25%, vs EB, 32 ± 25%), and length of hospitalization (CTR, 18 ± 26 days, vs EB, 18 ± 21 days). The percentage of high-voltage injury in the EB group was 64%. The incidence of MOF was lower in the EB group (2 of 96 [2.1%]) than the CTR group (20 of 192 [10.4%]; p < 0.05). The incidence of single organ failure was comparable between groups. Incidence of pulmonary failure was comparable in both groups, but incidence of inhalation injury was significantly higher in the CTR group (p < 0.0001). Patients in the EB group had more amputations (p < 0.001), major amputations (p = 0.001), and combined major amputations (p < 0.01). Mortality was comparable between the groups. Serum cytokine expression profiles were also comparable between the groups.

CONCLUSIONS

In pediatric patients, electrical injury is associated with a lower incidence of MOF than other thermal burns. Early and radical debridement of nonviable tissue is crucial to improve outcomes in the electrical burn patient population.

LEVEL OF EVIDENCE

Retrospective chart review, level III.

Neuromuscular complications following electrical injury — incidence and special problems in rehabilitation

Among the 1206 burn patients admitted on a five-year period, 116 were as a result of high tension electrical injuries. These cases were analyzed for neuromuscular complications. The incidence of neurological complication was 44%, amputations 26% and significant muscle damage 24%. Many patients had combinations of neurological involvement and musculoskeletal involvement. The detection of the neurological complications is often difficult in these patients with multisystem trauma. It is our feeling that neurological lesions, especially spinal cord injury following electrical accidents, are more frequently encountered than is generally recognized. Sometimes clinical manifestations are transient and may go unnoticed. Rehabilitation of patients with electrical injuries are often complicated because of the combination of the disabilities. Awareness of some of the common complications and evaluation of these complications in the early stages will help initiation of the rehabilitation programme before any permanent deformities have set in.

[Preclinical treatment of severe burn trauma due to an electric arc on an overhead railway cable]

Severe burns due to electrical accidents occur rarely in Germany but represent a challenge for emergency physicians and their team. Apart from extensive burns cardiac arrhythmia, neurological damage caused by electric current and osseous injury corresponding to the trauma mechanism are also common. It is important to perform a survey of the pattern of injuries and treat acute life-threatening conditions immediately in the field. Furthermore, specific conditions related to burns must be considered, e.g. fluid resuscitation, thermal management and analgesia. In addition, a correct strategy for further medical care in an appropriate hospital is essential. Exemplified by this case guidelines for the treatment of severe burns and typical pitfalls are presented.

Factors affecting the clinical outcome of low-voltage electrical injuries in children

PURPOSE

This study evaluated the clinical features of low-voltage (220-240 V) electrical injuries and their mortality in children.

METHODS

This cross-sectional study evaluated 36 patients younger than 18 years who suffered a low-voltage electrical shock and presented to the emergency department between January 2009 and October 2011. For statistical analysis, Fisher exact test was used for categorical variables, and the Mann-Whitney U test for continuous variables.

RESULTS

In the 34-month period, 36 patients (27 boys [75%] and 9 girls [25%]) were injured. The mean patient age was 9.19 ± 4.10 years (range, 2-17 years). Of the 36 patients, 5 (13.9%) died. Significant relationships were found between mortality and age (P =0.004), unconscious at the time of admission to the emergency department (P =0.013), the presence of clinical shock (P = 0.005), sinus tachycardia (P = 0.003), and high lactate dehydrogenase levels (P = 0.001). There were also significant relationships between mortality and hospital stay (P = 0.005), intensive care unit stay (P = 0.002), and detection of bacterial growth in blood culture (P = 0.024). By contrast, sex, the presence of an electrical exit wound, degree of the burn, surface area of the burn (%), accompanying flash burn, time elapsed transferring the patient from the accident scene to hospital, incomplete bundle-branch block or ST-wave changes on the electrocardiogram, increased troponin T, and creatine phosphokinase myocardial bundle did not affect mortality.

CONCLUSIONS

Complications such as sepsis and electrolyte imbalance lead to mortality rather than low-voltage electrical injury itself.

"Train surfers": analysis of 23 cases of electrical burns caused by high tension railway overhead cables

The term "train surfers" describes a group of adolescents from the outskirts of the city of Rio de Janeiro, who are compelled by the overcrowded railway trains to travel on the roofs of the wagons. Collision with electrical high-tension wires is a relatively frequent occurrence, causing extensive and complex injuries. This study analyzes this clinical and surgical phenomenon which has caused over 100 fatalities in more than 200 registered accidents over the past 10 years.

Electrical and lightning injuries

Electricity and lightning can cause injury in a variety of ways, some of which may remain hidden from the unsuspecting physician until it is too late. Prompt and, if necessary, prolonged resuscitation are of proven benefit. Particular attention must be paid to the patient who suffers high-voltage injury, and deep electrothermal burns on damage to vital organs should be excluded. Uncommonly late sequelae are seen, and such patients require appropriate care.

Cardiac monitoring of children with household electrical injuries

STUDY OBJECTIVE

Because death has occurred with injury involving voltage as low as 50 to 60 V (probably the result of arrhythmias), we wanted to evaluate the necessity of cardiac monitoring in children sustaining electrical injuries with 120 or 240 V.

DESIGN

The charts of 151 children who presented to the emergency department between April 1, 1989, and March 31, 1992, were reviewed.

SETTING

A tertiary care pediatric teaching hospital.

RESULTS

A total of 141 patients presented with 120-V electrical injuries. An ECG or a rhythm strip was performed in 93 patients (66%), and no arrhythmias were believed to have resulted from the electrical injury. Cardiac monitoring was done in 113 patients (80%) for a mean duration of 7.4 +/- 6.6 hours (median, 4 hours), and no arrhythmias were observed. Creatine phosphokinase levels were measured in 62 patients (44%) with a mean of 137 +/- 154 U/L (median, 96 U/L). The levels were elevated in 8 patients (12%), with no clinical significance. Follow-up was done in 112 patients (77%), and no significant adverse outcome was reported. There were only 10 patients in the 240-V group; no arrhythmias or adverse outcomes had occurred.

CONCLUSION

On the basis of our findings, initial cardiac evaluation (ECG) and monitoring do not appear to be necessary in children sustaining household electrical injuries (120 and 240-V); however, the significance of loss of consciousness, tetany, wet skin, or current flow that crossed the heart region could not be determined in our investigation. Therefore, cardiac monitoring should be performed if one of these factors is present.

Severe electric injuries of the hand and forearm

Electrical injuries of the upper limb produce major destruction of tissue mainly affecting the forearm, since the hand is usually the site of entry of current. Limb salvage, if it is to be successful, requires the rapid institution of a number of surgical procedures. Vein grafting to restore blood supply is frequently required and just as frequently requires skin flap cover following adequate debridement. The most commonly used flap is the groin flap. Despite the progression of necrosis beneath the flap for a period of up to three weeks, healing is usually successful and it is usually possible to avoid amputation. Several surgical procedures are required as a rule. The initial surgery is followed, in order, by nerve graft, tendon transfer and skin transfer following the use of tissue expanders. Results long term, with regard to function and appearance, were judged good.

High-tension electrical-arc-induced thermal burns caused by railway overhead cables

Eleven patients with high-tension electrical-arc-induced thermal burns due to railway overhead cables were treated at the Bratislava Burn Department during a relatively short period of 18 months. All the injuries occurred by the same mechanism, that is persons climbing on top of railway carriages and approaching the 25,000 V a.c. overhead cables. All the burns were the result of an electrical arc passing externally to the body, with subsequent ignition of the victim's clothes. The cutaneous burns, ranging from 24 to 79 per cent of the BSA, were mostly deep partial to full skin thickness injuries. One patient died on day 5 postburn, the other survived. In spite of high-tension aetiology, no true electrical injuries appear to have occurred and no amputations were necessary. The pathophysiology and possible preventive measures are discussed. It must be stressed that arcing can be induced by an earthed object approaching, but not touching, a cable carrying a high voltage.

Delayed neurological sequelae of high-tension electrical burns

Five patients showed delayed spinal cord damage following high-tension electrical injury. Early specialist care of this complication is necessary and is best carried out in burn units. Our experience shows that recovery may be complete or only partial.

Electrical injury of the eye

A 17-year-old male suffered superficial and deep facial burns after coming into contact with a high tension electrical cable with his head and right side of the face. The right eye sustained severe thermal coagulative injuries and subsequently was enucleated. Histopathological examination showed that the retinal neuropile was relatively intact although the retinal and choroidal circulations were severely compromised. The left eye was less affected but a dense cataract developed and required lensectomy. Visual acuity remained poor in the left eye due to retinal atrophy, retinal vascular attenuation and optic nerve degeneration. Electroretinographic tests and pseudo-random binary stimulus visually evoked responses were useful in predicting the visual outcome.

Spinal cord injuries following electrical accidents

Injuries from high tension electrical current result in approximately 1000 deaths per year and account for 3% of all major thermal injuries in the United States. Even though the complications from electrical injury can affect almost every organ system in the body, a neurological complication is perhaps the most common non-lethal one. 116 cases of electrical accidents among 1206 burn patients admitted to Kansas University Medical Center were reviewed. There were 5 cases of spinal cord injury which were detected from a few days up to four weeks from the injury. All had incomplete lesions. Two of them had quadriparesis, and 3 paraparesis. Clinical manifestations included motor and sensory involvement, predominantly motor. Possible mechanisms for the spinal cord damage include heating effect, electrogenic changes and vascular damage. Spinal cord injury following an electrical accident is more frequently encountered than is generally recognized.

The Taser weapon: a new emergency medicine problem

The Taser is an electrical law enforcement and self-defense weapon that is being used with increasing frequency. The weapon is described and its effects and ballistic and electrical considerations are reviewed. Clinical aspects of Taser injury, including weapon-fired barb injury, barb removal methods, injury secondary to electrical current, ventricular fibrillation, possible interactions with implanted pacemakers, and injuries secondary to weapon-induced falls, are discussed. Taser injuries are a new and increasingly frequent emergency medicine problem.

Survival from acute renal failure after severe burns

We describe a patient with 50 per cent, third degree flame burns who had a history of paint thinner inhalation for over 10 years. Moreover, chlorpromazine had been administered for the treatment of insomnia caused by chronic thinner intoxication. He developed oliguric acute renal failure soon after the burn injury, although adequate resuscitation therapy was given, and survived following frequent haemodialysis. Although survival from acute renal failure after severe burns is rare, once the diagnosis of acute renal failure has been made, haemodialysis should be instituted as early as possible. Furthermore, in a severely burnt patient with episodes of chronic and acute intoxication from organic chemicals or drugs which may have caused renal damage, acute renal failure may occur, so that careful observation is advised.

Myocardial infarction following electrical injury

Reported is a case of myocardial infarction following electrical injury in a previously healthy 57-year-old man. After coming into contact with high tension electrical current, the patient noted chest pain and electrical burns to his extremities. An electrocardiographic diagnosis of inferior wall myocardial infarction was made in the emergency department and was later substantiated by cardiac enzyme and angiographic studies. Although myocardial infarction following electrical injury has rarely been reported in the literature, most cases of severe electrical injury probably warrant cardiac monitoring.

Acute renal failure in burns

We present the combined experience of a burns unit and a renal dialysis unit in treating acute renal failure in burn injury patients. A total of 28 cases have been treated of whom 4 regained normal renal function. We would like to emphasize the following points which may improve the usually very poor prognosis: early diagnosis, early daily haemodialysis, adequate feeding and the early amputation of non viable limbs. A search of the literature reveals that only 11 previously reported cases of burns injury patients being successfully dialysed for acute renal failure.

Gas gangrene as a complication of burns

Gas gangrene infection in burnt patients is a rare but often fatal complication. It may however, be successfully treated by the use of hyperbaric oxygen and later judicious amputation of dead tissues. Five cases of bacteriologically proven gas gangrene, three of whom survived, occurred out of a total of one thousand and sixty-four burns patients treated since 1964 in the McIndoe Burns Unit, and these we describe.

Salvage and reconstruction of electrical hand injuries

Electrical injury results in serious damage or amputation of the upper extremity in a significant percentage of survivors. Fourteen of sixteen patients with electrical injuries followed over a two and a half year period had major hand wounds. Careful wound assessment, management, and closure combined with appropriate reconstructive technics now available provide the greatest potential for restoration of satisfactory quality of life. Because these injuries are often of an industrial nature, occupational vigilance and prevention remain essential.