Is immediate decompression of high voltage electrical injuries to the upper extremity always necessary?

Surgical Escharotomy and Decompressive Therapies in Burns

Early recognition of the need for escharotomy and other decompressive therapies is imperative for experienced burn providers, as to avoid reversible tissue ischemia and necrosis. With full-thickness burns, the eschar that develops is largely noncompliant. The predictable edema that develops during resuscitation of larger burns increases the likelihood ischemia-inducing pressure, as the underlying tissues swell within noncompliant skin, resulting in burn-induced compartment syndrome. Conventionally, this has been treated with decompressive therapies, such as escharotomy. The most recent surveys have identified that the United States and Canada both face a shortage of practicing burn surgeons. In the event of a burn disaster, many nonburn surgeons would need to provide burn care, including decompressive therapies. We reviewed the literature to provide accurate, accessible, and applicable recommendations regarding this practice following burn injury for both the practicing burn surgeon and those that would provide care in the burn disaster.

Analysis of the Efficacy of Iloprost Treatment in Amputations Due to Burn

The aim of our study was to demonstrate the decrease in amputation rates with iloprost treatment in patients who develop vascular injury due to burns. The data of 366 adult burn patients who were admitted to the emergency department of our hospital between 2016 and 2019 were analyzed. Demographic characteristics, burn factors, vascular examination findings, medical treatments, amputation rates, and levels were recorded. The amputation rates of the patients who were treated with iloprost and who were not treated with iloprost were compared. The mean age of 366 adult patients treated for burns was 37.8 ± 16.4 years, and of these patients, 220 (59.9%) were under 40 years of age. Although heat burns (n = 331.85%) were the most common burn etiology, it was found that the incidence of vascular injury was higher in burns caused by electricity (11.7%) and cold (3.3%) (P < 0.001). Vascular injury was detected in 60 (16.3%) of the patients and 21 (35%) of these patients were treated with iloprost. Amputation was observed in 20 (5.5%) of all burn patients, but only one of the patients treated with iloprost underwent amputation (P < .001). The individual and social impacts of amputations caused by burns are unquestionable. The authors are of the opinion that iloprost treatment is effective in reducing amputations due to burns.

Review of Adult Electrical Burn Injury Outcomes Worldwide: An Analysis of Low-Voltage vs High-Voltage Electrical Injury

The aims of this article are to review low-voltage vs high-voltage electrical burn complications in adults and to identify novel areas that are not recognized to improve outcomes. An extensive literature search on electrical burn injuries was performed using OVID MEDLINE, PubMed, and EMBASE databases from 1946 to 2015. Studies relating to outcomes of electrical injury in the adult population (≥18 years of age) were included in the study. Forty-one single-institution publications with a total of 5485 electrical injury patients were identified and included in the present study. Fourty-four percent of these patients were low-voltage injuries (LVIs), 38.3% high-voltage injuries (HVIs), and 43.7% with voltage not otherwise specified. Forty-four percentage of studies did not characterize outcomes according to LHIs vs HVIs. Reported outcomes include surgical, medical, posttraumatic, and others (long-term/psychological/rehabilitative), all of which report greater incidence rates in HVI than in LVI. Only two studies report on psychological outcomes such as posttraumatic stress disorder. Mortality rates from electrical injuries are 2.6% in LVI, 5.2% in HVI, and 3.7% in not otherwise specified. Coroner's reports revealed a ratio of 2.4:1 for deaths caused by LVI compared with HVI. HVIs lead to greater morbidity and mortality than LVIs. However, the results of the coroner's reports suggest that immediate mortality from LVI may be underestimated. Furthermore, on the basis of this analysis, we conclude that the majority of studies report electrical injury outcomes; however, the majority of them do not analyze complications by low vs high voltage and often lack long-term psychological and rehabilitation outcomes after electrical injury indicating that a variety of central aspects are not being evaluated or assessed.

Lower amputation rate after fasciotomy by straight midline incision technique for a 22,900-V electrical injury to the upper extremities

PURPOSE

The purpose of this study is to compare the major amputation rate following two different fasciotomy techniques, conventional versus straight midline, in patients with high-voltage arc burn injury by electric currents of 22,900V to the upper extremities.

METHODS

A retrospective analysis of 230 patients (270 burned upper limbs) who underwent fasciotomy after high-voltage electrical injuries between 1996 and 2007 was performed. The patients were divided into two groups according to the fasciotomy method used. From 1996 to 2002, 158 patients (184 limbs) underwent conventional fasciotomy by Green's volar-ulnar incision (conventional fasciotomy group). From 2003 to 2007, 72 patients (86 limbs) underwent fasciotomy using a straight midline curved incision (midline fasciotomy group). The patients were also divided into two groups based on whether the fasciotomy procedure was performed early or late. Patients who underwent fasciotomies <8h after injury were classified as early, while those who underwent it >8h after injury were classified as late. Major amputation rates were compared between two fasciotomy methods and analyzed following fasciotomy timing.

RESULTS

The midline fasciotomy group had a significantly lower major amputation rate (33.7%) than the conventional fasciotomy group (59.2%) (p<0.001). A subsequently decreased major amputation rate of 27.8% was observed in the early fasciotomy subgroup of the midline fasciotomy group (p=0.025).

CONCLUSION

Early fasciotomy remarkably reduced the major amputation rate after high-voltage arc injury; in the setting of minimized vascular exposure after fasciotomy, a midline straight incision could ensure that various types of reconstructive microsurgical procedures and primary skin closures can be used to save limbs.

Early debridement and delayed primary vascularized cover in forearm electrical burns: A prospective study

AIM

To look into the management options of early debridement of the wound, followed by vascularized cover to bring in fresh blood supply to remaining tissue in electrical burns.

METHODS

A total of 16 consecutive patients sustaining full thickness forearm burns over a period of one year were included in the study group. Debridement was undertaken within 48 h in 13 patients. Three patients were taken for debridement after 48 h. Debridement was repeated within 2-4 d after daily wound assessment and need for further debridement.

RESULTS

On an average two debridements (range 1-4) was required in our patients for the wound to be ready for definitive cover. Interval between each debridement ranged from 2-18 d. Fourteen patients were provided vascularized cover after final debridement (6 free flaps, 8 pedicled flaps). Functional assessment of gross hand function done at 6 wk, 2 mo, 3 mo and 6 mo follow-up.

CONCLUSION

High-tension electrical burns lead to significant morbidity. These injuries are best managed by early decompression followed by multiple serial debridements. The ideal timing of free flap coverage needs further investigation.

Lightning and thermal injuries

Electrical burns are classified as either high voltage (1000 volts and higher) or low voltage (<1000 volts). The typical injury with a high-voltage electrical contact is one where subcutaneous fat, muscles, and even bones are injured. Lower voltages may have lesser injuries. The electrical current has the potential to injure via three mechanisms: injury caused by current flow, an arc injury as the current passes from source to an object, and a flame injury caused by ignition of material in the local environment. Different tissues also have different resistance to the conduction of electricity. Voltage, current (amperage), type of current (alternating or direct), path of current flow across the body, duration of contact, and individual susceptibility all determine what final injury will occur. Devitalized tissue must be evaluated and debrided. Ocular cataracts may develop over time following electrical injury. Lightning strikes may conduct millions of volts of electricity, yet the effects can range from minimal cutaneous injuries to significant injury comparable to a high-voltage industrial accident. Lightning strikes commonly result in cardiorespiratory arrest, for which CPR is effective when begun promptly. Neurologic complications from electrical and lightning injuries are highly variable and may present early or late (up to 2 years) after the injury. The prognosis for electricity-related neurologic injuries is generally better than for other types of traumatic causes, suggesting a conservative approach with serial neurologic examinations after an initial CT scan to rule out correctable causes. One of the most common complications of electrical injury is a cardiac dysrhythmia. Because of the potential for large volumes of muscle loss and the release of myoglobin, the presence of heme pigments in the urine must be evaluated promptly. Presence of these products of breakdown of myoglobin and hemoglobin puts the injured at risk for acute renal failure and must be treated. The exact mechanism of nerve injury has not been explained, but both direct injury by electrical current overload or a vascular cause receive the most attention. Because electrical injuries carry both externally visible cutaneous injuries and possible hidden musculoskeletal damage, conventional burn resuscitation formulas based on body surface area injured may not provide enough fluid to maintain urine output. Damaged muscle resulting in swelling within the investing fascia of an extremity may result in compartment syndromes, requiring further attention. If myoglobin has been detected in the urine, treatment is aggressive volume resuscitation and possibly alkalinization of the urine or mannitol is given IV push to minimize pigment precipitation in the renal tubules. Approximately 15% of electrical burn victims also sustain traumatic injuries. This is because of falls from height or being thrown against an object. The tetanic contractions that result from exposure to electrical injury cause imbalance in flexor versus extensor muscles, with the flexor groups being stronger. Not only is the victim unable to release from the electrical contact, but they are at risk for fracture of bones from this prolonged muscular contracture. Neurologic and psychological symptoms were the most common sequelae of electrical and lightning injuries. Many of these symptoms are nonspecific, and they often do not appear until several months after the injury. A full neurologic examination must be performed on admission, documenting initial presentation and at any change in symptoms. Electrical injuries can have devastating consequences. Prevention of electrical injuries is clearly the preferable strategy for treatment.

Toe Tissue Transfer for Reconstruction of Damaged Digits due to Electrical Burns

BACKGROUND

Electrical burns are one of the most devastating types of injuries, and can be characterized by the conduction of electric current through the deeper soft tissue such as vessels, nerves, muscles, and bones. For that reason, the extent of an electric burn is very frequently underestimated on initial impression.

METHODS

From July 1999 to June 2006, we performed 15 cases of toe tissue transfer for the reconstruction of finger defects caused by electrical burns. We performed preoperative range of motion exercise, early excision, and coverage of the digital defect with toe tissue transfer.

RESULTS

We obtained satisfactory results in both functional and aesthetic aspects in all 15 cases without specific complications. Static two-point discrimination results in the transferred toe cases ranged from 8 to 11 mm, with an average of 9.5 mm. The mean range of motion of the transferred toe was 20° to 36° in the distal interphalangeal joint, 16° to 45° in the proximal interphalangeal joint, and 15° to 35° in the metacarpophalangeal joint. All of the patients were relatively satisfied with the function and appearance of their new digits.

CONCLUSIONS

The strategic management of electrical injury to the hands can be both challenging and complex. Because the optimal surgical method is free tissue transfer, maintenance of vascular integrity among various physiological changes works as a determining factor for the postoperative outcome following the reconstruction.

Train surfing and other high voltage trauma: differences in injury-related mechanisms and operative outcomes after fasciotomy, amputation and soft-tissue coverage

BACKGROUND

In the context of scarce reports on train surfers among high voltage electric injuries, we conducted a retrospective review between January 1994 and December 2008.

METHODS

After matching for inclusion criteria we reviewed patient records of 37 true high voltage injuries (12 train surfers [TS] and 25 other high voltage injuries [HV]).

RESULTS

TS were significantly younger (TS 15.8 years vs. HV 33.3 years, p<0.0001), and had a greater %TBSA (TS 49.7%TBSA vs. HV 21.5%TBSA, p=0.0003) without affecting the median length-of-stay (TS 52 days vs. HV 49 days) or number of operations (TS 4 vs. HV 3). TS had different injury patterns, with a higher percentage of affected extremities (TS 72.9% vs. HV 52.0%, p=0.0468) and associated injuries (TS 58% vs. HV 20%, n.s.) than HV. Both groups demonstrated comparable fasciotomy (TS 71.4% vs. HV 55.8%) and amputation rates (TS 17.1% vs. HV 15.4%). While TS required less flaps (TS 3/12 vs. HV 18/25; p=0.0153), soft-tissue reconstruction revealed an overall low incidence of complication rates (one partial pedicled flap loss and two total free flap losses).

CONCLUSIONS

Train surfers have proven to be a distinct group of patients among high-voltage injuries notably as a result of a younger age, a shorter electric contact duration and higher velocity-induced trauma. With a possibly declining trend of train surfing-related accidents in an aging society, it will be interesting to see if emerging economies will face comparable phenomena, for which prevention strategies remain key.

Temporal changes in deep venous thrombosis risk after electrical injury

Previous work has used the National Burn Repository to examine deep venous thrombosis (DVT) after electrical injury. However, these studies were limited and could not examine when DVT occurs after electrical injury. In addition, the utility of risk assessment models for DVT risk stratification has not been examined in this patient population. The authors performed a retrospective chart review of electrically injured patients at a single, American Burn Association- and American College of Surgeons-verified burn center over a 9-year period. Risk factors were identified and used to calculate Caprini scores at baseline and time of discharge. Outcomes of interest included symptomatic DVT or pulmonary embolism and time to DVT or pulmonary embolism. A total of 77 electrically injured patients were identified. DVT incidence was 6.5%. Patients with DVT had significantly higher TBSA (27.8% vs 3.8%), mean number of operations (4.8 vs 0.3), central venous catheter insertion (100% vs 5.3%), ventilator days (16.2 vs 0.3), intensive care unit days (24.4 vs 0.9), and mean change in Caprini score (18.6 vs 1.3) during hospitalization. Baseline Caprini scores were low, and DVT events occurred only after multiple risk factors were present; the average time-to-event was hospital day 17. Among patients with Caprini score >8, DVT incidence increased to 62%. In our single-center experience, the Caprini score was able to quantify DVT risk after electrical injury. In our series of 77 patients, the overall incidence of DVT was 6.5%. However, among patients whose Caprini score reached >8 during hospitalization, DVT incidence increased to 62%.

Analysis of factors influencing limb amputation in high-voltage electrically injured patients

BACKGROUND

Limb amputation is considered one of the most devastating consequences of electrical injury. Any factors that correlate with the degree of muscle damage can be used to predict the necessity of limb amputation. The aim of this study was to determine the factors that can be used to predict limb amputation in high-voltage electrically injured patients.

METHODS

Eighty-two high-voltage electrically injured patients were admitted to our hospital during a 17-year period. A retrospective analysis of the possible related risk factors between amputation and non-amputation patients was performed.

RESULTS

A total of 68 patients were enrolled for analysis. Thirteen patients underwent limb amputations. Multivariate analysis of the risk factors between amputation and non-amputation groups showed statistical significance for day 1 creatine kinase-isoenzyme MB (CK-MB) level. A serum CK-MB level above 80 ng/ml predicted high risk of limb amputation with high specificity (84%) and sensitivity (77%). Only one patient with a remarkable decrease of creatine kinase (CK) and CK-MB levels after fasciotomy avoided a major limb amputation.

CONCLUSION

Our results suggest that CK-MB level is an independent factor for prediction of limb amputation. We suggest that the addition of CK-MB evaluation to clinical symptoms screening may be a valuable method to early detection of muscle damage.

Bilateral upper extremity vascular injury as a result of a high-voltage electrical burn

High-voltage electrical burns are rare but cause devastating injuries, resulting in potential limb loss and major morbidity and mortality. These injuries are more insidious than flame burns in that the extent of the injury is not obvious at first glance. Damage to underlying muscle, nerve, and vessels may occur, resulting in limb-threatening ischemia and delayed hemorrhage. The management of such injuries remains controversial and can be challenging for the vascular and reconstructive surgeon. We present a case of high-voltage electrical injury to bilateral upper extremities resulting in limb-threatening ischemia, review the literature on the management of such injuries, and propose an algorithm to guide the management of these devastating injuries.

The diagnosis and management of electrical injuries

Electrical injuries to the extremity can result in significant local tissue damage and systemic problems. An understanding of the pathophysiology of electrical injuries is critical to the medical and surgical management of patients who sustain these injuries.

A case-matched controlled study on high-voltage electrical injuries vs thermal burns

The aim of this study was to provide an increased level of evidence on surgical management of high-tension electrical injuries compared with thermal burns using a case-controlled study design. Sixty-eight patients (64 males, 4 females, aged 33.7 +/- 13 years) with high-tension electrical burns were matched for age, gender, and burnt extent with a cohort of patients sustaining thermal burns. Data were analyzed for cause of accident (occupational vs nonoccupational), concomitant injuries, extent of burn and burn depth, surgical management, complications, and hospital stay. High-tension electrical burn patients required an average of 5.2 +/- 4 operations (range, 1-23 operations) compared with 3.3 +/- 1.9 (range, 1-10 operations) after thermal burns (P = .0019). Amputation rates (19.7% vs 1.5%), escharotomy/fasciotomy rates (47% vs 21%), and total hospitalization days (44 d vs 32 d) were significantly higher in high-tension electrical injuries (P < .05). Creatinine kinase levels were significantly elevated during the first 2 days in patients with subsequent amputations. Free flap failure was observed during the first 4 weeks after the trauma, whereas no flap failure occurred at later stages. Local, pedicled, and distant flaps were used in 15% of the patients. The mortality in both groups was 13.2% vs 11%, respectively (nonsignificant). High-voltage electrical injury remains a complex surgical challenge. When performing free flap coverage, caution must be taken for a vulnerable phase lasting up to 4 weeks after the trauma. This phase is likely the result of a progressive intima lesion, potentially hazardous to microvascular reconstruction. The use of pedicle flaps may resemble an alternative to free flaps during this period.

Electrical burns of the upper extremity in the pediatric population

Electrical burns of the upper extremity, particularly high-voltage injuries, are becoming more prevalent in today's society and are often times devastating to the patients' appearance and functionality. The basic tenants of flame burn reconstruction apply to electrical injuries. Namely, a patient should undergo basic trauma resuscitation, decompression and debridement within a reasonable timeframe, and definitive closure as soon as possible. Reconstruction of the 3 main areas of injury (hand, elbow, and axilla) follows the basic reconstructive ladder from least invasive, that is, local wound revision, to most extensive, that is, free tissue transfers. Whereas the role of the surgeon continues to be the creation of ingenious techniques to deal with complications, the real treatment lies in education and prevention. This article will look to do a comprehensive review of electrical injuries to the upper extremity.

Rehabilitation methods for the burn injured individual

Physiatrists play a critical role in managing the medical and functional consequences of serious burn injuries. Goals of rehabilitation include wound healing, scar prevention, hypertrophic scarring suppression, full range of motion, strengthening, and independent mobility and activities of daily living. This article is an overview of burn rehabilitation principles and patient management. The ultimate rehabilitation goal is independence in all spheres of an individual's life. Achievement of independence depends on the commitment of the injured individual and the entire health care team.

Burn rehabilitation: an overview

Burn injuries result in significant physical and psychologic complications that require comprehensive rehabilitation treatment and coordination with the acute care burn team. This interdisciplinary rehabilitation treatment is focused on preventing long-term problems with scarring, contractures, and other problems that limit physical function. Adequate pain management and recognition of psychologic issues are important components of treatment after burn injuries. Burn injuries present significant barriers to community integration, but many people can successfully return to work and other activities.

Thermal and electrical injuries

Through progress in wound management, resuscitation, intensive care treatment, and a coordinated rehabilitation process, modern burn care has been able to deliver substantial increases in survival and improvement in functional outcomes for burn victims. The development of regionalized burn centers has contributed greatly to this progress. As the field of burns matures, burn centers are preparing to meet future challenges through collaborative efforts in disaster management and outcomes research.

Burns and Amputations: A 24-Year Experience

Although the management of the severely burnt extremity poses a significant therapeutic dilemma, burn injuries resulting in amputation are uncommon, In such cases, however, amputation can reduce the rate of mortality. In a total of 1858 patients from January 1980 to January 2004, there were 34 amputations in 27 patients. There were 23 men (age range, 14-64 years) and 4 women (age range, 34-85 years). The majority of amputations from burns caused by flame injury predominantly after motor vehicle accidents, with only eight cases resulting from high-voltage electrical injury. Nine patients required immediate amputations, with the rest being delayed. There were three deaths, with a survival rate of 89%. The majority of single lower-limb amputees and only one of seven bilateral amputees were independently mobile. The presence of pre-existing psychiatric disease significantly impaired rehabilitation. Free tissue transfer and the usage of bioengineered materials may help reduce the incidence of amputations.

Reconstruction of deep cubital fossa defects with exposure of brachial artery due to high tension electrical burns and treatment algorithm

In this paper, we selected eight patients who had cubital fossa electrical burns with exposure or damage of the brachial artery, during the period 2000 to 2004 and formulated an algorithm to salvage upper limbs. We demonstrated the effectiveness of the algorithm to rescue the extremity from amputation and to restore the functional ability combined with coverage of the defects. After initial management with decompression and debridement of the nonviable tissues surrounding the brachial artery, we used local fasciocutaneous flaps or pedicled latissimus dorsi (LD) muscle/musculocutaneous flaps immediately to cover and also to avoid the perforation of this artery with a mean of 5.5 operations and with an amputation rate of 12.5%. When perforation or necrotic focus was seen on the arterial wall without viable tissue around the brachial artery, circulation was restored with vein grafts. Deep defects in the cubital fossa with exposure of the brachial artery should be covered with well-vascularized tissue as soon as possible after serial debridements. If the necrotic focus is seen on the wall of the artery, it often requires a venous graft with flap coverage. In the presence of viable tissue around the artery, however, fasciocutaneous flaps are useful and they reduce the operation time and duration of hospital stay. We treated deep defects with exposure of the brachial artery in the cubital fossa according to our established algorithm. Adherence to this approach precluded dilemmas in the selection of flap types for the management of bulky tissue defects.

Electrical injuries in Canadian burn care. Identification of unsolved problems

Over the past decade, the Firefighters' Burn Treatment Unit of the University of Alberta Hospital in Edmonton, Alberta, Canada, has treated 1399 inpatients suffering from thermal injury. Regional burn care is provided in a 10-bed intensive care unit with 18 plastic surgery reconstructive beds for a large referral region of central and northern Alberta, portions of the Northwest Territories, and neighboring provinces of British Columbia and Saskatchewan. Of the total burn inpatients during this period, 74 electrical injuries were treated (5.3% of all admissions): 71 were males (95.9%) and 3 females (4.1%). The mean age of all patients was 33.9 +/- 12.6 years (range 1-67). Compared to our general population of thermally injured patients, those with electrical injuries had smaller injuries [9.9 +/- 12.9% TBSA (range 1-65) versus 15.1 +/- 10.1], shorter length of hospitalization [18.6 +/- 7.3 days (range 1-80) versus 26.2 +/- 0.8], and substantially lower mortality once reaching the hospital (0% versus 4%). Electrical injuries were classified as flash in 30 cases, contact in 42 cases, and lightning in 2 cases; 74.3% of injuries occurred during work-related activities. A total of 118 operative procedures were performed during the acute admission (1.6 procedures per patient), including 19 amputations: 12 in the upper and 7 in the lower extremity. The mean time of amputation was 9.3 +/- 5.3 days after admission. In contact injuries of the upper extremity, 14 patients suffered amputations or neurologic injury that required reconstruction with free tissue transfers and nerve grafts. Long-term functional outcome of these patients using sensory testing, the Jebsen-Taylor hand function test, and wound coverage has revealed that these patients have substantial persistent sensory impairment of their upper extremities postinjury despite reconstruction, although many remain active and functional with acceptable wound coverage. Based on our analysis of electrical injury as it presents to one typical Canadian burn unit, our patients suffer limb loss on a delayed basis, which leads to substantial morbidity. Reconstruction of the upper extremity with microsurgical techniques after profound electrical injury has provided acceptable coverage, but in many instances is associated with poor or marginal sensory recovery limiting reemployment options for patients with upper extremity electrical burns. Further understanding of the cellular biology of delayed tissue loss after electric injury would offer the potential for reduction in amputation rate and improvement in functional outcome and overall morbidity.

Factors contributing to delayed extremity amputation in burn patients

BACKGROUND

Previous series of traumatic amputations have noted that delay in amputation results in prolonged hospital stay and delayed rehabilitation. A series of major extremity amputations after burn injury was analyzed to identify the frequency of delayed amputation and to identify factors resulting in the delay.

METHODS

Chart review of burn admissions between January of 1991 and December of 1995.

RESULTS

Twenty-eight patients underwent a total of 44 major extremity amputations. Thirty-five amputations in 22 patients were performed by postburn day 16 (mean 4.3). Nine amputations in six patients were delayed beyond postburn day 26 (mean, 48.3). Delayed amputations occurred in the subgroups of deep thermal burns with extensive necrosis and thermal burns complicated by infections. Early amputation was associated with a 13.6% mortality rate, delayed amputation with a 50% mortality rate.

CONCLUSION

There is a bimodal distribution of time to amputation determined by mechanism of injury, severity of burn, and infectious complications. Earlier identification of nonsalvageable limbs may decrease infectious complications and improve the chances of patient survival.

Injury by electrical forces: pathophysiology, manifestations, and therapy

The pathogenesis and pathophysiologic features of electrical injury are more complex than once thought. The relative contributions of thermal and pure electrical damage depend on the duration of electric current passage, the orientation of the cells in the current path, their location, and other factors. If the contact time is brief, nonthermal mechanisms of cell damage will be most important and the damage is relatively restricted to the cell membrane. When contact time is much longer, however, heat damage predominates and the whole cell is affected directly. These parameters also determine the anatomic tissue distribution of injury. Damage by Joule heating is not known to be dependent on cell size, whereas larger cells are more vulnerable to membrane breakdown by electroporation. Cells do survive transient plasma membrane rupture under appropriate circumstances or if therapy is instituted quickly. If membrane permeabilization is the primary cellular pathologic condition, then injured tissue may be salvageable and the challenge for the future is to identify a technique to reseal the damaged membranes promptly. Present standards of care for electrical injury require a fully staffed and well-equipped intensive care unit, available operating suites, and the availability of the full range of medical specialists. Major teaching hospitals with burn centers may be the ideal setting for the treatment of an electrical trauma victim. After the initial resuscitation, efforts are directed primarily towards preventing additional tissue loss mediated through the compartment syndrome, compressive neuropathies, or the presence of necrotic tissue. Renal and cardiac failure caused by the release of intracellular muscle contents into the circulation must be prevented. Attention can then be directed towards maximizing tissue salvage and preventing late skeletal and neuromuscular complications. Reconstructive procedures that transfer healthy tissue from a distance are necessary to optimize the functional value of the remaining tissue. Finally, unless the patient is rehabilitated psychologically, the real benefit from other sophisticated care will not be fully realized. These goals are important throughout the acute care of the patient. In the future, new guidelines for treating electrical trauma will be based on a clearer understanding of the relevant pathophysiologic features. These strategies will rely on improved diagnostic imaging and on reversing the fundamental problem of cell membrane damage. Moreover, complex biochemical and organ system pathophysiologic interactions will require careful management. If successful, research efforts presently underway should improve the prognosis of victims after electrical trauma.