Practice guidelines for the management of electrical injuries

An increase in electrical burns during the covid lockdown in Western Cape, South Africa

BACKGROUND

A severe Covid lockdown in South Africa may have changed burn patterns due to the downturn of the economy and stay-at-home policies. We describe the volume and type of burn admitted to a tertiary hospital before and during the Covid lockdown.

MATERIALS AND METHODS

This was a retrospective study from before (April 2019-March 2020) and during (April 2020-March 2021) the Covid pandemic. Patient demographics, burn etiology, and clinical outcomes were described. Logistic regression was used to model associations between burn etiology and the Covid period.

RESULTS

Of 544 burns, 254 (46.7%) occurred before and 290 (53.3%, p = 0.051) during Covid. The proportion of electrical burns doubled during Covid n = 20, 32.3% vs n = 42, 67.7%, (p = 0.053) periods. At least half were associated with suspected cable or copper theft. On multivariate analysis, flame burns (OR=2.42, p < 0.001), electrical burns (OR=4.88, p < 0.001), and paying patients (OR=4.21, p < 0.001) were more likely to be associated with the Covid period.

CONCLUSION

Electrical burns doubled during Covid, potentially related to an increase in cable and copper wire theft, a phenomenon described during hard economic times in other settings. More studies to understand this potential relationship are indicated to prepare burn centers during future pandemics and/or economic hardship.

Predictors of mortality following electrical and lightning injuries in Malawi: A decade of experience

INTRODUCTION

Electrical injuries can be devastating, and data is lacking in low-resource settings. We aimed to identify predictors of mortality following electrical and lightning injuries (ELI) in Malawi.

METHODS

We performed a retrospective observational study of patients presenting with ELI and burn injuries at a tertiary hospital in Malawi from 2011 to 2020. Outcomes were compared and predictors of mortality were modeled.

RESULTS

A total of 382 ELI and 6371 burn patients were included. The mean ages for ELI and burn groups were 24 ± 14 and 11 ± 14 years, respectively (p < 0.01). Most patients were injured at home (91% in the burn group versus 51% in the ELI group, p < 0.01). The crude mortality rate in the ELI group was 28%, compared to 12% in the burn group (p < 0.01). On multivariate logistic regression, predictors of mortality included ELI (odds ratio [OR] 13.3, 95% confidence interval [CI] 7.2-24.5) and total body surface area burned (OR 1.1, 95% CI 1.1-1.1). Predicted mortality for ELI has increased over time (p = 0.05).

CONCLUSIONS

ELI confers more than 13 times higher odds of mortality than burn injuries in Malawi, with mortality risk increasing over time. More efforts are needed to prevent electrical hazards and implement timely interventions for patients with ELI.

Temporal Fascia Free Flap for Thumb Coverage in Electrical Burn Injuries: A Case Series Analysis With DASH Score Outcomes Evaluation

Electrical burns pose unique challenges in reconstructive surgery due to the extensive tissue damage they cause. The thumb is particularly susceptible to electrical burns, leading to severe functional impairment. This case series introduces the use of the temporal fascia free flap for thumb coverage in patients with electrical burn injuries. The study aims to assess the functional outcomes of this approach using the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. Six male patients underwent thumb reconstruction using temporal fascia free flaps following electrical burn injuries. The extent of the injury was assessed, and necrotic tissue was debrided. Functional outcomes were evaluated using the DASH questionnaire 6 months postoperation. All procedures were conducted in accordance with ethical guidelines, and informed consent was obtained from all patients. All patients achieved successful transplants using temporal fascia free flaps. The average DASH score at the 6-month follow-up indicated satisfactory functional recovery. Patients reported improvements in thumb mobility and functionality, and the cosmetic appearance of the thumb was acceptable. The appearance of the scar in the donor area was well-received. The temporal fascia free flap proved to be an effective method for thumb reconstruction following electrical burn injuries. Its thin and flexible nature allows for optimal contouring and improved range of motion. Although one case of partial flap loss was observed, overall functional and aesthetic outcomes were satisfactory. Further research with larger sample sizes is warranted to optimize surgical techniques and postoperative care for better outcomes.

Electrical Injuries and Neurosurgery: A Case Report and Review of Literature

Introduction Electrical injuries account for 5 to 27% of admissions to burn units. The nervous system is affected in as much as 21% of nervous injuries, with reported mortality.

Case Report The authors report a case of a patient presenting to the neurosurgical service with a traumatic brain injury (TBI) caused due to an electrical burn. Available data was reviewed through a PubMed search of literature, with special attention to the nature of presentation, classification of such injuries, the pathophysiology of the events that arise, complications to be expected, and the guidelines for management.

Conclusion It is possible for electrical injuries to cause TBIs requiring neurosurgical intervention.

Most prominent factors contributing to burn injury-related amputations: an analysis of a referral Burn Center

Amputations are un-common surgical procedures in patients with severe burn injuries. However, these patients often face extreme physical and psychological challenges that result in social stigmatization and inadequate rehabilitation facilities. A retrospective cohort study was designed for the patients admitted to the Burn Center of Adana City Training and Research Hospital (ACTRH). During the study period, a total of 2007 patients aged 0.5 to 92 years were hospitalized and treated at the burn center from January 2016 to June 2020. The incidence of amputation observed among inpatient burn injuries regardless of the etiology was 1.9%, and 87.2% were male. The univariate and multivariate logistic regression analysis was performed to detect the most prominent factors contributing to burn injury-related amputations. The cause of burns appears to be one of the main factors in the past research, and in this context, the electrical burns stand out, likewise, the fire-flame-related burns, full-thickness burns, the existence of infection, male gender, patients aged within the 18 to 64 age group, and the burn extent within the total body surface area (TBSA) range of 10 to <50% were found to be the most leading factors of amputations among patients having severe burns. Although they are rare, amputations related to burns commonly cause a decrease in quality of life. Therefore, besides increasing occupational health and safety methods for these risk groups, especially for adults of working age; also, it is essential to increase the importance and awareness of the precautions to be taken in daily life.

Use of troponin assay after electrical injuries: a 15-year multicentre retrospective cohort in emergency departments

Background

Patients with electrical injury are considered to be at risk of cardiac arrhythmia. Assessing the risk of developing a major adverse cardiac event (MACE) is the cornerstone of patient management. The aim of this study was to assess the performance of initial troponin and troponin rise to predict Major Adverse Cardiac Events (MACEs) in all patients with electrical injuries admitted to the Emergency Department.

Methods

This is a multicentre retrospective study in which consecutive patients with electrical injuries admitted to the Emergency Departments (ED) (adult and paediatric) of five French Hospitals were included between 2005 and 2019. The threshold for troponin elevation is based on the European Society of Cardiology guidelines for patients presenting without persistent ST segment elevation. The primary endpoint was the rate of MACE.

Results

A total of 785 included patients were admitted to ED with a first diagnosis of electrical injury during the study period. Troponin assays were performed in 533 patients (67.9%), including 465 of 663 adults (70.1%) and 68 of 122 children (55.7%) and 17/533 (3.2%) of patients had an initial elevated troponin. If none of the clinical criteria for MACE were present (i.e., previous known heart disease, exposure to a high voltage of ≥ 1000 Volts, initial loss of consciousness, or an abnormal initial ECG), this defined a low-risk subgroup (n = 573, 76.0%) that could be safely discharged. The initial positive troponin assay had a sensitivity of 83.3 (95% CI 35.9–99.6%), a specificity of 97.7 (95% CI 96.1–98.8%), a positive likelihood ratio 36.6 (95% CI 18.8–71.1%) and a negative predictive value of 99.9 (95% CI 99.2–99.9%) in predicting a MACE.

Conclusions

Troponin assay appears to be a predictive marker of MACE risk and should be considered in high-risk patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13049-021-00955-6.

Development of a framework for managing severe burns through a 17-year retrospective analysis of burn epidemiology and outcomes

Burns are one of the most common injuries in daily life for all ages of population. This study was to investigate the epidemiology and outcomes among burn patients in one of the largest burn centers in the southwest of China. The study was performed at the Institute of Burn Research in the first affiliated with the Army Medical University (AMU). A total of 17,939 burn patients were included in this retrospective study. Information regarding burn epidemiology and outcomes in 17 years were collected, calculated and compared. The age ranged from 257 days to 95 years old. Scalding and flame were the two most common causes to burn injuries, comprising of 91.96% in total. Limbs, head/face/neck, and trunk were the most frequently occurred burn sites, with the number and the percent of 12,324 (68.70%), 7989 (44.53%), and 7771 (43.32%), respectively. The average total body surface area (TBSA) was 13.64 ± 16.83% (median 8%) with a range of 0.1–100%. A total of 874 (4.9%) patients had TBSA > 50%. The presence of a burn with an inhalation injury was confirmed in 543 patients (3.03%). The average LOS was 32.11 ± 65.72 days (median: 17 days). Eventually, the retrospective analysis resulted in the development of a burn management continuum used for developing strategies to prevent and manage severe burns. The annual number of burn injuries has kept decreasing, which was partially attributed to the increased awareness and education of burn prevention and the improved burn-preventative circumstances. However, the burn severity and the economic burden were still in a high level. And the gender difference and age difference should be considered when making individualized interventions and rehabilitative treatments.

Institutional Experience Using a Treatment Algorithm for Electrical Injury

Electrical injury has low incidence but is associated with high morbidity and mortality. Variability in diagnosis and management among clinicians can lead to unnecessary testing. This study examines the utility of an electrical injury treatment algorithm by comparing the incidence of testing done on a cohort of patients before and after implementation. Demographics, injury characteristics, and treatment information were collected for patients arriving to a regional burn center with the diagnosis of electrical injury from January 2013 to September 2018. Results were compared for patients admitted before and after the implementation of an electrical injury treatment algorithm in July 2015. There were 56 patients in the pre-algorithm cohort and 38 in the post-algorithm cohort who were of similar demographics. The proportion of creatine kinase (82% vs 47%, P < .0006), troponin (79% vs 34%, P < .0001), and urinary myoglobin (80% vs 45%, P < .0007) testing in the pre-algorithm cohort was significantly higher compared to post-algorithm cohort. There were more days of telemetry monitoring (median [IQR], 1 [1-5] vs 1 [1-1] days, P = .009) and greater ICU length of stays (4 [1-5] vs 1 [1-1] days, P = .009), prior to algorithm implementation. There were no significant differences in total hospital lengths of stay, incidence of ICU admissions, in-hospital mortality, or 30-day readmissions. This study demonstrates an electrical injury evaluation and treatment algorithm suggests a mode of triage to cardiac monitoring and hospital admission where necessary. Use of this algorithm allowed for reduction in testing and health care costs without increasing mortality or readmission rates.

Electrical Injuries in Children: A 10-Year Experience at a Tertiary Pediatric Burn Center

Electrical injuries comprise 4% of cases but have higher morbidity and mortality. This study aims to share our experiences with pediatric electrical injuries and propose strategies to prevent them. The files of pediatric electrical injuries between 2010 and 2020 were reviewed retrospectively. The following were investigated: age, gender, cause, length of stay in the pediatric burn center, total burned surface area, voltage-type, and surgical procedures performed. The patients from low- and high-voltage groups were compared. Eighty-five patients were treated in the last 10 years. Seventy were males, the mean age was 9.9 years, the average length of stay in pediatric burn center was 18.2 days, and the average total burned surface area was 11.7%. Forty-three patients were injured with high-voltage and 42 with low-voltage electricity. Fasciotomy was performed in 25 patients, grafting in 40 patients, and amputation in 12 patients. The most often amputated limb was the right arm/forearm. Psychiatric disorders developed in 24 patients. One patient died. In conclusion, the incidence of high-voltage electrical injuries increases with age. They are more prevalent in males, more often accompanied by additional trauma, and have higher total burned surface area, surgical procedures are performed more often, and hospitalization times are longer. For prevention, precautions should be taken by governments and families, and education is critical.

Late myocardial sequelae of electrical injury

Electrocution poses serious complications seen mostly at the time of the event. Physicians and patients are usually not aware of the progressive nature and its potentially delayed effect as demonstrated in our case. We believe that a risk stratification model should be designed to guide physicians for proper management.

Electrical Burns During Fruit Harvesting

Electrocutions during tree trimming or fruit harvesting are occasionally reported in the public media, but the actual incidence is unknown. Some fruit trees (eg, mango and avocado) can exceed 30 feet, with dense foliage concealing the fruit and overlying power lines so burns associated with harvesting these fruits are often exacerbated with falls. However, there are limited data on this subject. To fill this gap, we provide some of the first information on this unique injury pattern. All electrocutions from 2013 to 2018 were retrospectively reviewed at an ABA-verified burn center. Demographics, injury patterns, and complications were analyzed. Of 97 electrocutions, 22 (23%) were associated with fruit procurement. This population was aged 43 ± 14 years, 95% (n = 21) male, injury severity score of 15 ± 13, and total body surface area burned 4% [1%-9%]. Third-degree burns were present in 36% (n = 8). ICU admission was required in 59% (n = 13) and 39% of the survivors required operative interventions for the burn. Compartment syndrome occurred in 18% (n = 4) and 14% (n = 3) patients required amputations. Falls complicated the care in 50% (n = 11), with associated head, chest, and/or extremity trauma. Mortality was 32% (n = 7), with three patients presenting dead on arrival. All but 3 injuries occurred between June and December, coinciding with mango and avocado season. Electrocution during fruit picking is a seasonal injury often exacerbated by falls. Management is challenging, and favorable outcome depends on recognition of the complexity of the polytrauma.

Development of nursing care guideline for burned hands

Aim

To develop an evidence-based guideline to care for hand-burned patients.

Design

An integrative review.

Method

The search was conducted of EMBASE, PubMed, Web of Science, SCOPUS, Clinical Key, Iranmedex, Magiran, Scientific Information Database (SID), Cochran, CINAHL and Google Scholar databases from January 2000-August 2019. Following the formation of the research team, two researchers independently selected the eligible studies. The initial search resulted in 2,230 records; ultimately, 40 articles were identified to be the review after screening the records based on the study's inclusion and exclusion criteria. Quality of selected studies was evaluated with the MMAT method.

Results

Data syntheses of selected studies, coded by highlighting the relevant parts of the text, and assigning code words to these areas were done. Following this, a constant comparison was used to develop categories by combining codes. Finally, hand burns nursing care guideline was developed by categorizing descriptive themes in two main phases.

Conclusion

This review results have shown that evidence-based guidelines present high-quality recommendations for the healthcare team, which improves the quality of clinical care. Due to a lack of established guidelines in our context, it seems to be helpful to use evidence-based guidelines in managing burned hands.

Evaluating the risks of arrhythmia following electrical injury: Two cases of electrical injuries in the upper limbs

Electrical injuries induce ventricular arrhythmias, which are lethal. Therefore, it is important to evaluate the risk of arrhythmias at initial presentation to the emergency department in cases of electrical injuries. Here, we report two cases with electrical injuries, where current flowed between the upper limbs, requiring 24-h hospitalization for arrhythmia monitoring. The patients were 57- and 30-year-old men, who sustained separate electrical injuries (6600 V, line voltage), with current flow from one hand to the other. They did not develop any ventricular arrhythmias during hospitalization and were discharged. The risk for ventricular arrhythmias is lower for electrical injuries occurring between the upper limbs than for those occurring between the upper and lower limbs. We conclude that 24-h hospitalization for monitoring of patients with electrical injuries of the upper limbs may be sufficient.

Epidemiology of electrical burns: a 10-year retrospective analysis of 376 cases at a burn centre in South China

OBJECTIVE

To investigate the epidemiological profile and associated outcomes of electrical injuries at a major burn centre in southern China.

METHODS

This retrospective study enrolled consecutive electrical burn patients admitted to the burn centre of the First Affiliated Hospital of Guangxi Medical University between 2008 and 2017. Demographic and clinical data and outcomes were recorded. Mann-Whitney U tests/Pearson's chi-squared tests were used to examine the differences between low-voltage and high-voltage injuries.

RESULTS

There were 217 high-voltage injuries and 159 low-voltage injuries. High-voltage burns were frequently observed between March and August, and low-voltage burns peaked between June and September. Burn patients were mainly men. Most burns occurred in participants aged 21 to 50 years and in industrial workers and electricians at work or householders at home. Only one person with high-voltage burns died (a mortality rate of 0.46%). Amputation rates were 37.33% for high-voltage burns and 22.01% for low-voltage burns. High-voltage injuries were associated with more extensive burns, longer hospital stays, and more complications and amputations.

CONCLUSIONS

More attention should be paid to prevention of electrical burns in male adults. Particular focus is needed on industrial workers, incidents in the spring and summer, and high-voltage injuries.

Electrical cardiac injuries: current concepts and management

Electrical injuries are a commonly encountered hazard in both the home and workplace. However, clinicians are often uncomfortable when faced with the patient who presents with an electric shock due to sparse literature and lack of systematic recommendations on this topic. Electrical injuries can range from minor skin burns to life threatening internal organ damage. A thorough clinical assessment to ascertain the path of current through the body and possible internal injury is essential. The main concern in an apparently stable individual after an electric shock is the potential for delayed occurrence of cardiac arrhythmias which will require monitoring in the intensive care setting. While it may be reasonable to discharge home from the emergency room selected patients with low voltage injuries, absence of syncope and a normal ECG, others may require monitoring for at least 24 h. Public education and increasing workplace as well as home safety measures are key steps in prevention. The present review summarizes current knowledge in pathophysiology, manifestations and management of electrical injuries, with specific focus on cardiac effects.

Perioperative in Intensive Medicine of reconstructive surgery and burned patients

Burned patients may need prolonged admissions in the Intensive Care Service, both for initial care and for the pre and postoperative treatment of the multiple surgeries they require. The initial resuscitation of critically burned patients requires adequate monitoring to calculate the fluid therapy necessary to replenish the losses and ensure tissue perfusion, but without excesses that increase interstitial edema. In addition, monitoring can evaluate the systemic inflammatory response that can lead to shock and organic dysfunctions. After this initial phase we will find a critical patient who requires multiple reinterventions in non-optimal situations, so he will need special care over a long period of time. In addition, the Intensive Care Service offers specific postoperative care for reconstructive surgery and the transplantation of composite tissues (upper limb and face) in which its success depends on a rigorous control through adequate monitoring and treatment.

A voltage-based analysis of fluid delivery and outcomes in burn patients with electrical injuries over a 6-year period

INTRODUCTION

Electrical injuries are associated with significant morbidity for affected patients. While cardiac and surgical interventions have been extensively reported, no practice guidelines or studies have specifically addressed fluid delivery and associated outcomes of patients with electrical injuries. The study objective was to evaluate the differences in fluid delivery in patients with high (≥1000V) and low (<1000V) voltage electrical injuries.

METHODS

This retrospective, observational study included adult electrical injury patients admitted for acute care. Patients with reported voltages were classified into high and low voltage subgroups. Primary outcomes of fluid administration and urine output over the first 24h after injury were assessed between subgroups. Secondary outcomes included renal, cardiac, surgical, and additional complications such as mortality, cost, and length of stay.

RESULTS

Data were analyzed in 36 patients with reported voltages, including 26 patients in the high and 10 patients in the low voltage subgroups. Patients in the high voltage subgroup had a statistically significant higher median (IQR) total IV fluid given [46.6 (22.4-61.9) vs. 22.5 (8.3-31.4) mL/kg, p=0.033] in the first 24h to achieve a similar urine output to the low voltage subgroup. The high voltage patients had higher rates of myoglobinuria, rhabdomyolysis, and creatinine kinase elevation. Patients in the high voltage vs. low voltage group had significantly longer median (IQR) length of stay (days) [11 (2-19) vs. 1 (1-6); p=0.015] and higher cost of hospital stay [$124,608 (19,486-296,991) vs. $16,165 (12,409-69,659); p=0.033].

CONCLUSIONS

These results reinforce the importance of assessing electrical injuries and obtaining a voltage to provide patient-specific care, as high voltage electrical injuries receive more fluid than estimated maintenance rates. This study is the first of its kind to characterize fluid given for high and low voltage electrical injuries and effects on patient outcomes.

Electrical injury - a dual center analysis of patient characteristics, therapeutic specifics and outcome predictors

BACKGROUND

Electrical injuries represent life-threatening emergencies. Evidence on differences between high (HVI) and low voltage injuries (LVI) regarding characteristics at presentation, rhabdomyolysis markers, surgical and intensive burn care and outcomes is scarce.

METHODS

Consecutive patients admitted to two burn centers for electrical injuries over an 18-year period (1998-2015) were evaluated. Analysis included comparisons of HVI vs. LVI regarding demographic data, diagnostic and treatment specific variables, particularly serum creatinine kinase (CK) and myoglobin levels over the course of 4 post injury days (PID), and outcomes.

RESULTS

Of 4075 patients, 162 patients (3.9%) with electrical injury were analyzed. A total of 82 patients (50.6%) were observed with HVI. These patients were younger, had considerably higher morbidity and mortality, and required more extensive burn surgery and more complex burn intensive care than patients with LVI. Admission CK and myoglobin levels correlated significantly with HVI, burn size, ventilator days, surgical interventions, amputation, flap surgery, renal replacement therapy, sepsis, and mortality. The highest serum levels were observed at PID 1 (myoglobin) and PID 2 (CK). In 23 patients (14.2%), cardiac arrhythmias were observed; only 4 of these arrhythmias occurred after hospital admission. The independent predictors of mortality were ventilator days (OR 1.27, 95% CI 1.06-1.51, p = 0.009), number of surgical interventions (OR 0.47, 95% CI 0.27-0.834, p = 0.010) and limb amputations (OR 14.26, 95% CI 1.26-162.1, p = 0.032).

CONCLUSIONS

Patients with electrical injuries, HVI in particular, are at high risk for severe complications. Due to the need for highly specialized surgery and intensive care, treatment should be reserved to burn units. Serum myoglobin and CK levels reflect the severity of injury and may predict a more complex clinical course. Routine cardiac monitoring > 24 h post injury does not seem to be necessary.

Electrical Burns and Their Treatment in a Tertiary Hospital in Albania

INTRODUCTION:

The electrical current burns represent a very aggressive pathology that leaves many functional and aesthetic consequences.

AIM:

To evaluate the epidemiology of electrical burn injury and its associated complications and treatment.

MATERIAL AND METHODS:

Demographic data, aetiology, burn percentage and other measures related to electrical burn injury of 33 electrical burn patients in a tertiary hospital during the years 2015-2017.

RESULTS:

The mean age of patients is 31 (± 8.3) years old with a predominance of males (94%). The vast majority of injuries occurred at work (p < 0.01), superior extremities were more affected with hand (21.2%) and fingers (18.2%) being the main point of contact (p < 0.01). Muscular fasciotomy was performed in all patients who were treated surgically (n = 27), amputation was performed in 11 (40.7%) of cases, but amputated sites were more than the number of patients affected. Myoglobinuria (39.4%), cardio-respiratory distress (12.1%) contusion cerebri (6.1%), were the complication encountered in patients.

CONCLUSIONS:

Electrical burn injuries are still amongst the highest accident-related morbidities. Educating the population about the dangers and hazards associated with improper use of electrical devices and instruments is imperative.

High-voltage electrical injury: Modified surgical technique for optimal defect closuring of extra-large cranial defect

Electrical burns are group of traumatic injuries with a mortality rate of 3-15%. High-voltage induced extensive electric burns are rarely seen in the cranial area, compared to upper and lower limbs, but extremely difficult for treatment, due to the limited flexibility in this area. The spectrum of therapeutic interventions in electrical burns in general, evolving initial necrectomy, decompression, and aggressive debridement with early skin coverage is usually not enough in cases of extensive cranial defects. The performance of a suitable flap combined with skin graft in donor site, and further implantation of expander is challenging in this area. We present a case of a high-voltage induced extra-large cranial injury in a 38-year-old man, treated with modified single large rotation flap and a split skin-thickness graft technique, for optimal defect closuring with satisfied aesthetic result.

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.

A 3-Phase Approach for the Management of Upper Extremity Electrical Injuries

Upper extremity electrical injuries present with unique pathophysiologic considerations due to the differing mechanisms of injury produced by the electromagnetic field. The initial phase of treatment consists of recognition of other life-threatening injuries, stabilization of patients, and multisystem resuscitation. The second phase of treatment consists of excising devitalized tissue, appropriate wound care to prevent delayed infection, providing temporary and definitive coverage over vital structures, and preventing contracture and joint stiffness via aggressive therapy. The final phase of treatment consists of sensorimotor functional reconstruction via nerve grafting and tendon transfers available based on patients' deficits and available redundant sources.

Chemical, Electrical, and Radiation Injuries

This article reviews the unique challenges presented by chemical, electrical, and radiation injuries. The authors discuss pathophysiology and diagnosis of these injuries and provide recommendations for management.

Management of Critical Burn Injuries: Recent Developments

Background

Burn injury and its subsequent multisystem effects are commonly encountered by acute care practitioners. Resuscitation is the major component of initial burn care and must be managed to restore and preserve vital organ function. Later complications of burn injury are dominated by infection. Burn centers are often called to manage problems related to thermal injury, including lightning and electrical injuries.

Methods

A selected review is provided of key management concepts as well as of recent reports published by the American Burn Association.

Results

The burn-injured patient is easily and frequently over resuscitated, with ensuing complications that include delayed wound healing and respiratory compromise. A feedback protocol designed to limit the occurrence of excessive resuscitation has been proposed, but no new “gold standard” for resuscitation has replaced the venerated Parkland formula. While new medical therapies have been proposed for patients sustaining inhalation injury, a paradigm-shifting standard of medical therapy has not emerged. Renal failure as a specific contributor to adverse outcome in burns has been reinforced by recent data. Of special problems addressed in burn centers, electrical injuries pose multisystem physiologic challenges and do not fit typical scoring systems.

Conclusion

Recent reports emphasize the dangers of over resuscitation in the setting of burn injury. No new medical therapy for inhalation injury has been generally adopted, but new standards for description of burn-related infections have been presented. The value of the burn center in care of the problems of electrical exposure, both manmade and natural, is demonstrated in recent reports.

Cardiac troponin I: A potent biomarker for myocardial damage assessment following high voltage electric burn

Myocardial infarction (MI) following high voltage electric burn is very rare, and its pathogenesis remains controversial. Electrical burns represent only 4% of all burns. Hence, clinical managements have taken a slow pace in developing. The recent guidelines laid down by the cardiology societies include cardiac troponin I (cTnI) as the gold standard marker for the assessment of myocardial damage assessment. Two patients were admitted to our hospital at the different time with the same kind of high voltage electric burn. Both patients had complained with chest discomfort during admission, and cardiac parameter assessment was done for both the patients. cTnI was also measured for both patients, and marked increase in the values was seen within 5 h of onset of myocardial damage and got into normal range within 72 h. Myocardial damage following electric burn needs to be suspected and assessed as early as possible. Hence, cTnI should be the valuable tool to detect the severity of myocardial damage incurred in the electric burn cases.

Initial evaluation and management of the critical burn patient

The major improvement in burn therapy is likely to focus on the early management of hemodynamic and respiratory failures in combination with an aggressive and early surgical excision and skin grafting for full-thickness burns. Immediate burn care by first care providers is important and can vastly alter outcomes, and it can significantly limit burn progression and depth. The goal of prehospital care should be to cease the burning process as well as prevent future complications and secondary injuries for burn shock. Identifying burn patients appropriate for immediate or subacute transfer is an important step in reducing morbidity and mortality. Delays in transport to Burn Unit should be minimized. The emergency management follows the principles of the Advanced Trauma Life Support Guidelines for assessment and stabilization of airway, breathing, circulation, disability, exposure and environment control. All patients with suspected inhalation injury must be removed from the enclosure as soon as possible, and immediately administer high-flow oxygen. Any patient with stridor, shortness of breath, facial burns, singed nasal hairs, cough, soot in the oral cavity, and history of being in a fire in an enclosed space should be strongly considered for early intubation. Fibroscopy may also be useful if airway damage is suspected and to assess known lung damage. Secondary evaluation following admission to the Burn Unit of a burned patient suffering a severe thermal injury includes continuation of respiratory support and management and treatment of inhalation injury, fluid resuscitation and cardiovascular stabilization, pain control and management of burn wound.

Bilateral upper limb amputations in victims of high tension electrical injuries: Three case studies

Bilateral upper limb amputations result in severe disability. High voltage electrical injury is a rare cause of such an outcome and injuries often occur as occupational hazards. We present three case reports of accidental high voltage injuries that occurred in a non-occupational setting. Victims were all initially managed at other centres before referral to our hospital and all subsequently had bilateral upper limb amputations. The high cost of treatment, importance of prevention, and need for rehabilitation are highlighted.

Acute and perioperative care of the burn-injured patient

Care of burn-injured patients requires knowledge of the pathophysiologic changes affecting virtually all organs from the onset of injury until wounds are healed. Massive airway and/or lung edema can occur rapidly and unpredictably after burn and/or inhalation injury. Hemodynamics in the early phase of severe burn injury is characterized by a reduction in cardiac output and increased systemic and pulmonary vascular resistance. Approximately 2 to 5 days after major burn injury, a hyperdynamic and hypermetabolic state develops. Electrical burns result in morbidity much higher than expected based on burn size alone. Formulae for fluid resuscitation should serve only as guideline; fluids should be titrated to physiologic endpoints. Burn injury is associated basal and procedural pain requiring higher than normal opioid and sedative doses. Operating room concerns for the burn-injured patient include airway abnormalities, impaired lung function, vascular access, deceptively large and rapid blood loss, hypothermia, and altered pharmacology.

Perioperative anesthesia management of the burn patient

Burn patients provide numerous challenges to the anesthesiologist. It is important to understand the multiple physiologic disruptions that follow a burn injury as well as the alterations in pharmacokinetics and pharmacodynamics of commonly used anesthetics. Thought must be given to surgery during initial fluid resuscitation and the airway challenges many of these patients present. Finally, the central role of pain management through all phases of care is a constant concern.

Injured workers' perspectives on how workplace accommodations are conceptualized and delivered following electrical injuries

PURPOSE

Returning to work following an electrical injury can be challenging due to the confluence of physical, cognitive and emotional impairments. Workplace accommodations can facilitate return to work. However, while electrical injuries can have potentially devastating consequences, there is a dearth of understanding of how workplace accommodations are obtained following electrical injury. This paper explores workers' experiences of returning to work and accommodations following an occupation electrical injury.

METHODS

Thirteen semi-structured qualitative telephone interviews were conducted with injured workers recruited from acute and rehabilitation burns programs in Ontario, Canada. Thematic analysis was employed to identify themes related to the request and provision of accommodations.

FINDINGS

Findings reveal that accommodations are most frequently narrowly defined in relation to physical work restrictions, leading to the exclusion of cognitive and psychosocial concerns. Challenges within the accommodations process such as perceived legitimacy, a do-it-yourself approach to accommodations, and concerns regarding job security can also influence workers' decisions to request accommodations. Process elements that facilitate the effective provision of workplace accommodations include: (1) finding a "just right" fit between workers' abilities and assigned tasks and duties (2) establishing effective lines of communication between relevant stakeholders; (3) prompt response to needs; (4) having a knowledgeable individual in a position of power to advocate on workers' behalf.

CONCLUSIONS

Further education regarding electrical injuries and workplace accommodations is warranted to increase workers', employers', health and insurance personnels' knowledge about electrical injury and best practices for providing workplace accommodations.

Functional changes of the myocardium in survivors of high-voltage electrical injury

Introduction

There are limited long-term follow-up data on functional changes in the myocardium after high-voltage electrical injury (HVEI).

Methods

Twenty-three patients who had been exposed to HVEI (>20,000 volts) and preserved left ventricular ejection fraction (≥55%) were enrolled in the study. Echocardiographic parameters, including peak systolic strain (S) and strain rate (SR), were evaluated at baseline, six weeks and six months later. These data were compared with a healthy control group who were matched in terms of age, sex and body mass index.

Results

The systolic and diastolic blood pressure and the heart rate were significantly higher in the HVEI group compared with the control group at baseline and at six weeks, but not at the six-month follow-up. Conventional echocardiographic data showed no differences between the groups during the study period. In contrast to the S, the baseline and six weeks, SR was significantly increased in the HVEI group compared with the control group. However, at the six-month follow-up, there was no difference in the SR between the groups. Among the 23 patients with HVEI, 17 of the patients had vertical current injury, and 6 patients had horizontal current injury. There was no difference in terms of the conventional echocardiography, S and SR between the patients with vertical injury and those with horizontal injury at baseline and at the six-month follow-up.

Conclusions

The long-term contractile performance of the myocardium is preserved when patient do not experience left ventricular dysfunction in the early stages after HVEI.

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.

Early fasciotomy in electrically injured patients as a marker for injury severity and deep venous thrombosis risk: an analysis of the National Burn Repository

By using the National Burn Repository, the authors sought to identify markers for injury severity and deep venous thrombosis (DVT) risk after electrical injury. They identified adult patients in the National Burn Repository who were admitted with an electrical injury between 1995 and 2007 (n = 1469). Patients who died within 24 hours or were admitted for less than 1 day and hospitals reporting no complications were excluded. Independent variables included TBSA burned, duration of intensive care unit stay and hospital admission, duration of mechanical ventilation, the number of operative procedures, amputation, and early fasciotomy. Early fasciotomy was defined as fasciotomy performed on a patient's first trip to the operating room and was used as a proxy for severity of electrical injury. DVT and death were the dependent variables. Among electrically injured patients, 10.4% had early fasciotomy. Patients who had early fasciotomy had significantly prolonged intensive care unit stays (10.3 vs 4.8 days, P < .001), hospital days (36.7 vs 17.1 days, P < .001), amputations (49.0 vs 4.6%, P < .001), and a number of operative codes (17.6 vs 5.4, P < .001). DVT incidence was 0.9%. Electrically injured patients who had early fasciotomy were significantly more likely to have a DVT when compared with patients who did not have early fasciotomy (7.55 vs 0.95%, P = .002). Early fasciotomy after electrical injury is a marker for increased injury severity. Among patients who underwent early fasciotomy after electrical injury, 7.5% develop DVT, and 49% require amputation during their initial hospitalization.

Use of the pedicled tensor fascia lata myocutaneous flap in the salvage of upper extremity high-voltage electrical injuries

High-voltage electrical burns of the upper extremity are often limb threatening. Typically, emergency fasciotomies are followed by serial debridements until only viable tissue remains. After debridement, flap coverage is required to preserve viable but exposed tendons, nerves, vessels, bones, and joints and to salvage these seriously injured upper extremities. Flap options are generally limited to large pedicle flaps or free tissue transfer. Despite the array of flaps available, surgical options become limited when upper extremity injuries are extensive or the initial flap fails. The most commonly used pedicle flap, the groin flap, may not provide adequate soft tissue coverage in these cases. In addition, free tissue transfer can be difficult due, in part, to the uncertainty in determining the complete zone of injury and whether the flap recipient vessels are suitable for the transfer.An ideal flap for coverage would be relatively thin and pliable; have a constant, reliable pedicle; and be large enough to cover wounds of significant size. Few surgeons have experience with the pedicled tensor fascia lata (TFL) flap for upper extremity coverage. The authors demonstrate its use in the salvage of extensive upper extremity injuries on three limbs in two patients. We believe that this flap offers a distinct advantage compared with the groin flap when pedicled flap coverage of the upper extremity is required. PATIENT 1: A 23-year-old man sustained severe electrical burns to his right upper extremity. After serial debridements, a pedicled TFL myocutaneous flap was used to provide soft tissue coverage of this extensive injury. The flap was delayed at 2 weeks and inset at 3 weeks. There was complete survival of the flap, leading to salvage of the extremity. PATIENT 2: A 27-year-old man sustained bilateral upper extremity electrical burns. Initial free tissue transfers to both arms were unsuccessful. The patient subsequently underwent simultaneous bilateral pedicled TFL myocutaneous flaps. Both flaps were delayed at 2 weeks and divided at 3 weeks. There was complete flap survival bilaterally, leading to salvage of both upper extremities.Limb salvage in severe upper extremity electrical injuries is difficult even in the best circumstances. Dependable flap coverage is mandatory to prevent infection and avoid the need for early or late amputation. The pedicled TFL flap in our series of patients has served to be a dependable flap in these severe upper extremity injuries and should be added to the surgical armamentarium of those caring for these difficult surgical problems.