Aggressive approach to the extremity damaged by electric current

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.

Team Approach Helps Patient Survive High-voltage Electric Burn

A 20-year-old man was subjected to high-voltage electric burn, which was occupational. The patient was admitted to AlGalaa Military Medical Complex almost 2 weeks after the accident had happened. According to Lund and Browder’s chart, the patient had a 40% total body surface area burn involving the upper limbs, anterior and posterior trunks, and the left thigh (third- and fourth-degree burns). The aim of this study was to stabilize the patient by conducting lifesaving operations in multiple scheduled sessions, bilateral below-elbow amputations, escharotomies, and excision of affected ribs and cartilages. A left latissimus dorsi flap used to cover the left side of the anterior chest wall. Skin grafting (split thickness, meshed 1:3) was done to cover the raw areas. Multiple aggressive operations by a multidisciplinary team saved the patient’s life. The victim suffered a major injury and was handicapped, but he survived. It was not necessary to replace the excised ribs with prosthesis because of the preserved sternum. An electric burn poses a burden on many people in addition to the patients themselves.

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.

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.

Notfallmedizinische Versorgung von Blitz- und Stromschlagverletzungen

The pattern of injuries following electrical accidents and the treatment by emergency teams differ depending on whether exposure was to a low-voltage or high-voltage power source or to a lightning bolt. Tissue damage results from the direct effect of current on cell membranes and from conversion of electrical energy into heat. Depending on the magnitude of electrical energy and the duration of exposure, cardiac dysrhythmia, damage to nerve tissue, extensive burns and shock may occur. Multi-system injury is frequently observed, either directly related to electrical shock or secondary to concurrent trauma. Extrication of victims from the energy field must be performed under strict observance of self-protection measures for the rescuers. In high-voltage incidents the rescuers must wait at a distance until the power supply has been turned off and demonstrably grounded. Analgesia, anxiolysis and administration of crystalloid fluids are needed, especially for injuries from high-voltage power sources. Severe burns of the face and neck call for early intubation and ventilation. Monitoring is performed with pulsoximetry, blood pressure measurement and ECG, giving highest priority to the unconscious patient with cardiac and respiratory arrest. Cardio-pulmonary resuscitation (CPR) follows the international guidelines for resuscitation and may be effective after delayed onset and even after prolonged resuscitation attempts.

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.

A histological analysis of a high voltage electric current injury to an upper limb

The mechanisms and patterns of high voltage electric current injury to living tissues are not fully understood. Most available data is derived from animal experimentation using voltages that are considerably lower that those encountered by human victims during electrocution accidents. This work aims to contribute human tissue histological data by analyzing the pattern of tissue damage after a real life unfortunate high voltage electrocution accident.

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.

Four limb amputations due to electrical burn caused by TV antenna contact with overhead electric cables

A 22-year-old man who sustained four limb amputations due to an electrical burn caused by contact of a TV receiver antenna with overhead electric cables is presented. The indications for limb amputation and the necessary preventive measures for such injuries are discussed.

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

OBJECTIVE

To determine if immediate decompression is required for all high voltage injuries to the upper extremity.

DESIGN

Retrospective review.

MATERIALS AND METHODS

Charts reviewed of 62 patients who had upper extremity contact with >1,000 volts of electricity over a 10-year period.

MAIN RESULTS

One hundred upper extremities were treated. Twenty-two percent were decompressed within 24 hours because of progressive nerve dysfunction, clinical compartment syndrome, or failure of resuscitation. This group required a mean of 4.2 operations with an amputation rate of 45%, similar to other series. Thirty-five percent of burned extremities had their first operative procedure delayed until resuscitation was complete. This group required a mean of 2.1 operations with no amputations. Forty-three percent of extremities did not require operations to achieve healing. Overall results show a 10.0% amputation rate and mean hospital stay of 27 days.

CONCLUSIONS

We conclude that the need for amputation and multiple operations is determined by the injury itself and that immediate decompression is only required for the usual clinical signs of compartment syndrome. Selective decompression may actually preserve tissue and decrease the need for eventual amputation because fasciotomy can lead to soft tissue dessication by exposing viable tissue.

Outcome of amputations in patients with major burns

There is little mention in the literature of the outcome of patients who require amputations for large surface area burns. To determine their outcome, we devised a case-control study. Fifteen patients who underwent amputations between 1984 and 1993 at the University of Louisville Burn Unit were analysed and compared to a similarly injured control group. Both groups represented severely burned patients with high total body surface areas involvement. Apache II scores, and per cent of inhalation injuries. The results showed a 60 per cent survival rate in each group. Unlike previous reports on electrical burns, the amputations in this series of primarily thermal injuries (12 of 15 patients) were performed late in the hospital course (mean, 15 days) and after previous attempts at limb salvage (mean, two procedures). By eliminating either non-viable or infected tissue, amputations served a role in obtaining a respectable survival rate for these severely injured patients that also compared favourably with the control group.

Electrical injuries--morbidity, outcome and treatment rationale

Electrical injuries are unique with respect to low mortality rates, but very high rates of short- and long-term morbidity, and overall outcome. Controversy still exists regarding the advantages of one-stage debridement versus early serial debridement of necrotic tissue. The purpose of this study was a retrospective evaluation of treatment, morbidity and outcome in a group of patients with electrical injuries. Over a 13-year period 1992 patients were admitted with acute burns to our burn centre. Electrical injuries occurred in 129 (6.5 per cent) of these patients. There were 38 high-tension injuries and 91 low-tension injuries. The average age was 33.7 years (5 months to 63 years), with burn wounds ranging from 1 to 57 per cent total body surface area (mean 9.5 per cent). Ninety-four (72.9 per cent) of these injuries were work related, and most occurred in males (85 per cent). A total of 323 surgical procedures were performed on those 129 patients. An average of 0.48, surgical debridements per patient was necessary in the low-tension injury group and only three partial finger or toe amputations were necessary. In the high-tension group, 27 major limb amputations were performed after 2.3 debridements per patient, resulting in an overall major limb amputation rate of 35 per cent. The average length of stay was 22 days, and the cost of hospitalization ranged from $900 to $120 000 (mean !4,901). Significant long-term neurological deficits persisted in 73 per cent of patients at long-term follow-up (mean 4.5 years). Only 5.3 per cent of patients after high-voltage electrical injury were able to return to their premorbid job.

Electrical burns in Kuwait: a review and analysis of 64 cases

Sixty-four patients with electrical burns were admitted to the Department of Plastic Surgery, Ibn Sina Hospital, Kuwait during the past 6 years. There were 1202 admissions during this period, the incidence of electrical burns being 5.3 per cent. Sixty-nine per cent of the patients sustained injury from direct contact with live electrical wire, the remaining 31 per cent sustained flash burns. The incidence of low voltage injury was much higher as compared to high voltage. Forty-four per cent of these injuries were not work related. Less than 10 per cent of the body surface area was involved in about 80 per cent of the patients. A total of 65 operations was carried out in 39 patients. Twenty of these patients had repeated debridements until the wound was ready for coverage. All 64 patients survived.