Journal of Burn Care & Research440 Arnoldo et al July/August 2006Clinical Problem low-voltage and high-voltage injuries, reinforcing theThe potential for development of cardiac dysrhyth- need for ECG evaluation of all patients. Nonspecificmia, cardiac arrest, and myocardial damage after elec- ST-T changes were the most common ECG abnor-trical injury has been well documented.1–5 Cardiac mality,2,6,7 and atrial fibrillation was the most com-dysrhythmias, cardiac standstill, and myocardial in- mon dysrhythmia.jury can occur after both low- ( 1000 V) and high-voltage ( 1000 V) injury. The potential for cardiac Criteria for Admissiondysrhythmia and injury has prompted routine cardiac Admission and cardiac monitoring for patients withevaluation and low threshold for patient admission history of loss of consciousness, ECG abnormalities,and of all patients who sustain electrical injury. or with other indications for admission (ie, TBSAWhereas obtaining an ECG is a well-established com- burned, need for extremity monitoring) are standardponent of the early evaluation of patients after elec- practices in all series of electrical injuries reviewed. Intrical injury, the indications for patient admission addition, the majority of patients with low-voltageand appropriate duration of cardiac monitoring injuries and normal ECG are discharged home fromhave been less clear. Traditionally, patients with the emergency room without complication. Thelow-voltage injuries who have normal ECGs and no safety of this practice also was confirmed in two serieshistory of loss of consciousness are discharged from of pediatric patients.1,8 The possible exceptions in-the hospital. However, appropriate management of clude patients with other injuries that require hospi-patients who sustain high-voltage injuries has not talization or children with an oral burn that wouldbeen well defined. Generally, patients who have a require monitoring for labial artery bleeding.history of loss of consciousness, ECG abnormalities, Virtually all patients with high-voltage injuries areor have injuries that would otherwise require admis- admitted for cardiac monitoring; however, it is un-sion are admitted to the hospital and are placed on clear whether this step is necessary. With increasingtelemetry monitors. There are several issues related to emphasis on cost-effectiveness, the routine admissionthe cardiac evaluation and monitoring that need to be of all patients with high-voltage injury must be ques-addressed: 1) Should all patients with high-voltage tioned. Hunt,9 Bailey et al,1 and Arrowsmith et al10electrical injuries be admitted to the hospital, even if reported that all cardiac irregularities were evidentthere is no evidence of cardiac abnormality? 2) What either on admission to the emergency room or withinis the role of cardiac enzymes in the evaluation and several hours of hospitalization and in 1986, Purduemanagement of electrical injuries? 3) How long and Hunt5 reported that no serious arrhythmias oc-should patients be monitored on telemetry? curred in any patient who a normal ECG on admis- sion. Taken together, these studies suggest that a negative initial evaluation could obviate the need forProcess hospital admission solely for cardiac monitoring.A Medline search was conducted of all available liter- However, these were observations based on retro-ature from 1966 to 2004 using the key words elec- spective data and are inadequate to form the basis oftrical, burns, cardiac, monitoring. In addition, several a practice guideline. On the basis of their findings,articles were not identified in the Medline search but Purdue and Hunt5 generated the following set ofwere referenced in the articles reviewed and were admission criteria for electrically injured patients: 1)found to be relevant: a total of 27 articles were re- loss of consciousness or cardiac arrest in the field; 2)viewed and found to be relevant. documented cardiac arrhythmia in the field; 3) ab- References were classified as Class 1 evidence (pro- normal ECG; or 4) a separate indication for admis-spective, randomized, controlled trials); Class II evi- sion. They applied these criteria prospectively to 10dence (prospective or retrospective studies based on consecutive patients and reported no complications.clearly reliable data); Class III evidence (evidence This study is the first to investigate not routinelyprovided by clinical series, comparative studies, case monitoring patients who sustained high-voltagereviews or reports); or as a technology assessment (a injuries. However, this series is too small to affectstudy that examined the utility/reliability of a partic- practice.ular technology). One study suggested that presentation of cardiac abnormalities could be delayed. Jensen et al11 re-Scientific Foundation ported three patients with a delay in the onset of Cardiac Abnormalities. All studies reviewed con- symptoms after low-voltage (two patients) and high-firmed that cardiac abnormalities—including dys- voltage (one patient) injuries. All presented to therhythmias and myocardial damage— occur after both emergency room only after they developed chest pain
Journal of Burn Care & ResearchVolume 27, Number 4 Arnoldo et al 441and palpitations. However, none of the patients had high-voltage injuries and normal ECGs. The twoECGs or any sort of evaluation at the time of injury studies that addressed this question have populationand, therefore, this study does not provide substan- sizes that are too small to support changes in practice.tive evidence of truly late dysrhythmia presentation. Future prospective and randomized studies (as de- scribed herein) are needed to effectively establishDuration of Monitoring practice guidelines. In addition, there is inadequateNo published studies have directly studied the appro- evidence to formulate guidelines for the duration ofpriate duration of telemetry monitoring after injury. monitoring for patients with ECG abnormalities.Several series reported monitoring for 24 hours after Sufficient data are available to conclude thatadmission if there were no ECG abnormalities on CK-MB is an unreliable diagnostic test for cardiacadmission or monitoring for 24 hours after resolution injury after electrical injury. The presence of skeletalof dysrhythmias.1,8,12 Arrowsmith et al10 reported muscle injury in these patients confounds the resultsthat all patients with dysrhythmias resolved within of this laboratory test. No studies identified in this48 hours of admission either spontaneously or with review examined the specificity and utility of troponinpharmacologic intervention. However, there are no levels in determining cardiac injury.data available to formulate appropriate managementguidelines for this issue. Key Issues for Further Evaluation 1. Utility of troponin: CK and CK-MB not specificUtility of Creatine Kinase for cardiac muscle. Insufficient data exists eval-Creatine kinase levels frequently are obtained after uating the utility of troponin in assessing cardiacelectrical injury. CK has long been used as an indica- injury.tor of muscle injury and can help in determining the 2. Duration of monitoring: insufficient data existsextent of extremity muscle injury. The MB subunit to determine the optimal duration of telemetryhas been reported to be more specific for myocardium monitoring after electrical injury for patientsand, therefore, has been used to evaluate cardiac in- who have abnormal ECGs or history of loss ofjury after electrical injury. Only one study reported a consciousness. There have been no studies thatreliable correlation between serum CK-MB levels and directly examined this specific question.cardiac injury. Chandra et al6 reported that the time 3. Admission for high-voltage injuries: insufficientcourse of the MB fraction increase and decrease was a data exists to establish guidelines for whether toreliable indicator of cardiac ischemia. However, this admit patients who sustain high-voltage injuriesstudy does not correlate the elevated enzyme levels with but have normal ECG’s and no history of loss ofany other study of cardiac injury. Conversely, the evi- consciousness. The available data suggest thatdence of poor or questionable correlation was quite these patients could be discharged but further,strong. Several studies demonstrated that CK-MB prospective evaluation is required.levels poorly predict cardiac injury and that theelevated enzyme levels likely result from noncar- Evidentiary Tablediac muscle injury.7,13–15 Housinger et al7 sug- Studies on the practices of cardiac evaluation andgested that positive MB fractions in the absence of ECG monitoring are summarized in Table 1.findings should be interpreted with caution becausethey may not signify cardiac injury. Given the paucity ofevidence supporting the utility of CK-MB levels, this II. EVALUATION AND MANAGEMENTlaboratory value should not be used as a diagnostic OF THE UPPER EXTREMITYcriterion for cardiac injury after electrical injury. Recommendations Standards. Insufficient data exist to support aSUMMARY treatment standard for this topic.The current practices of admitting patients with his- Guidelinestory of loss of consciousness, documented dysrhyth- 1. Patients with high-voltage electrical injury tomia in the field, or ECG abnormalities are well the upper extremity should be referred to spe-supported in the literature. Similarly, discharging cialized burn centers experienced with these in-patients from the emergency room with low-voltage juries as per American Burn Association referralinjuries and normal ECGs is well established. How- criteria.ever, few data are available to support establishment 2. Indications for surgical decompression includeof guidelines for the management of patients with progressive neurologic dysfunction, vascular
Journal of Burn Care & Research442 Arnoldo et al July/August 2006Table 1. Evidence table Reference Study Description Data Class Conclusions/CommentsAhrenholz et al, Retrospective study of 125 patients II Demonstrated that there is a poor correlation between 198813 admitted with electrical injuries elevated CK-MB levels and cardiac injuryArrowsmith et al, Retrospective study of 145 patients II All patients with cardiac complications had them at the 199710 admitted with electrical injuries to time of admission. Patients with normal ECG and no determine incidence of cardiac loss of consciousness do not require admission for complications cardiac monitoringBailey et al, Retrospective review of 141 children II Children with normal ECG and low voltage injuries do 199543 admitted to the emergency department not require cardiac monitoring. Authors also suggested with household electrical injuries that ECG is not indicated for children with low-voltage injuries, no loss of consciousness, no tetany, no water contact, and no current crossing the heart regionBailey et al, Prospective evaluation of a set of admission II Guidelines for admission were used in the majority of 20001 guidelines after electrical injury. cases. According to the guidelines, all patients with Guidelines were applied to a total of 224 high-voltage injuries were admitted, as were patients patients with low-voltage injuries with ECG abnormalities, past cardiac history, water contact, and tetanyChandra et al, Prospective evaluation of 34 patients II Time course of CK-MB elevation in patients with 19906 admitted with high-voltage electrical electrical injuries suggests that it is cardiac in etiology. injuries to determine predictors of ECG may not be reliable for diagnosing myocardial myocardial damage damageCunningham, Retrospective study of 70 patients admitted II Discharged all patients with low-voltage injuries who are 199144 with electrical injury asymptomatic and had normal ECG without complicationGuinard et al, Prospective evaluation of 10 patients III Demonstrated poor reliability of CK-MB to identify 198715 admitted with electrical injuries cardiac injuriesHousinger et al, Prospective study of 16 patients to determine III Demonstrated poor correlation between elevation of 19857 incidence of possible myocardial damage CK-MB levels and ECG abnormalities. Pyrophosphate following electrical burn scans were used as diagnostic standard for cardiac injuryHunt et al, Retrospective review of 102 patients with II All cardiac abnormalities were evident either on 19809 high-voltage injuries admission of within several hours of hospitalizationJensen et al, Three case reports of late presentation of III Three patients with late presentation of cardiac 198711 cardiac abnormalities after electrical injury abnormalities. However, none of the patients were evaluated immediately after injuryLewin et al, Case report of 19-year old patient with III Demonstrated correlation of CK-MB levels with ECG 19834 myocardial injury after electrical injury abnormalities and myocardial injuryPurdue and Hunt, Retrospective study of 48 patients admitted II Designed a protocol for determining which patients 19865 with high-voltage injuries. On the basis of should be admitted following high voltage injury. No these findings, a prospective study of 10 complications following discharge of patients with high patients applying guidelines for admission voltage injuries and no other indications for admission.Comment: First study to demonstrate safety of discharging patients with high-voltage injuries and normal ECGs. However, small group of patients studiedWallace et al, Retrospective study of 35 pediatric patients II Children with low-voltage injuries and normal ECGs can 19958 with both low and high voltage injuries be discharged. However, all patients with high-voltage injuries were admitted and monitoredZubair et al, Retrospective study of 127 pediatric patients II Recommend 4 hours of monitoring for all patients before 199712 with low- and high-voltage injuries discharge and admission of all patients with high- voltage injuries, loss of consciousness, or ECG abnormalities
Journal of Burn Care & ResearchVolume 27, Number 4 Arnoldo et al 443 compromise, increased compartment pressure, “compartment pressure,” “Doppler flow meter,” and systemic clinical deterioration from sus- “technetium 99m pyrophosphate,” “infrared pho- pected ongoing myonecrosis. Decompression toplethysmography,” and “burn injury” was per- includes forearm fasciotomy and assessment of formed, and relevant articles were reviewed. Stud- muscle compartments. The decision to include ies of patients with lower-extremity injuries were a carpal tunnel release should be made on a included because of the scarcity of data involving ex- case-by-case basis. clusively the upper extremity. An attempt was made Options. There are several methods to evaluate the however to analyze the data involving the upper ex-injured extremity. Compartment pressures may be tremity exclusively where possible.measured as an adjunct to clinical examination. Pres-sures greater than 30 mm Hg, or tissue pressure Scientific Foundationreaching within 10 to 20 mm Hg of diastolic pres- Electrical injuries, including lightning strikes, shouldsure, may be used as evidence of increased compart- be referred to a specialized burn center as per Amer-ment pressure and potential deep-tissue injury, indi- ican Burn Association criteria.18 Many surgeons ad-cating the need for surgical decompression in the vocate immediate surgical exploration (usually withinappropriate clinical setting. Technetium-99m pyro- the first 24 hours), and decompression of patientsphosphate scan may be used as an adjunct to clinical with high-voltage electrical injuries.19,20 –32 Early ex-examination at centers experienced with this technol- ploration, fasciotomy, and debridment are followed ´ogy. Doppler flow meter can be used as an adjunct to by serial debridment of necrotic tissue and subse- ´assess extremity perfusion. It should not be relied on quent closure. These studies are somewhat difficult toas the sole indicator of deep-tissue viability and ade- interpret; however, because of the differences in thequate perfusion. degree of injury no prospective, randomized, con- trolled trials evaluating immediate exploration have been performed. The rational for this aggressive ap-OVERVIEW proach relates to thermal mechanics. Joule’s law de-Purpose fining the amount of power (heat) delivered to an object:The purpose of this guideline is to review the princi- Power (J-Joule) I2 (Current) times R (Resistance).ples of monitoring and treatment of high-voltage Accordingly, deep muscle necrosis can occur in theelectrical burn injury to the upper extremity. The up- muscle adjacent to bone, which has a high resis-per extremity is commonly injured after high-voltage tance.33–35 Failure to perform adequate fasciotomyelectrical and carries with it a high rate of morbidity. and to evaluate all muscle compartments may lead to misdiagnosis of deep thermal injury.20 This approachClinical Problem however, commits the patient to several operationsBurns resulting from high-voltage electric current and may prolong hospital stay and morbidity.( 1000 V) often are associated with a greater degree In the d’Amato20 series, six patients underwentof deep-tissue injury than is initially appreciated. As a emergency exploratory surgery and amputation forresult these rather infrequent injuries, which make up obvious necrotic extremities, followed by serial de- ´only 3% to 12% of burn center admissions,16 are as- bridment. No patient required an amputation forsociated with high amputation rates and greater use misdiagnosed deep muscle necrosis. However,of resources than comparable %TBSA cutaneous missed injury was present in two patients, who re-burns.6,10,17 Unnecessary exploration can increase quired further surgical intervention, although neithermorbidity, length of stay, and the use of scarce re- required amputation because of the missed injury.sources. Delayed exploration and decompression in Parshley’s series evaluated 41 patients with 27 ex-the compromised extremity, however, may result in tremities explored. Amputation rate was 40% with 10increased amputation rates along with increased or- extremities salvaged, which the authors attribute togan failure and mortality.31 early aggressive operative intervention. Haberal’s se- ries of 94 patients had an amputation rate of 43%. TheProcess authors attributed this high amputation rate in partA Medline search from 1966 to the present was used because of a delay in surgical exploration as a result ofto evaluate monitoring and the need for early explo- patients being transferred from nonspecialized facili-ration and fasciotomy in electrical injury to the ex- ties. Achauer et al21 reported a series of 22 patientstremity. A search for the key words, “electrical in- with an amputation rate of 40%. They recommendjury,” “fasciotomy,” “compartment syndrome,” “extensive debridement of all damaged tissue and ex-
Journal of Burn Care & Research444 Arnoldo et al July/August 2006Table 2. Evidentiary table: high-voltage electric injury to upper extremity Reference Description Data Class CommentsQuinby et al, Retrospective review of 44 patients II In conductive burns with entrance site in hand, incision was 197825 divided into 22 with electric arc and carried from hand to interconnect the arc burns at wrist, 22 with flow of current elbow, and shoulder. Fasciotomies done if muscle discolored, or tense, transverse carpal ligament release done. Amputation rate 68%Luce et al, Retrospective review of 31 patients II Fasciotomy and wound exploration and debridement within 198426 24 hours of admission Amputation rate 35.5%Parshley et al, Retrospective review 41 patients with II Early fasciotomy in patients with passage of current 198522 passage of current Amputation rate 40%Achauer et al, Retrospective analysis of electric injury II Extensive debridement and compartment release almost always 199421 of the hand in 22 patients done on day of injury. Amputation rate 40%Mann et al, Retrospective review 62 patients with II Fasciotomy indications: severe pain and loss of arterial 199631 high voltage upper extremity injury Doppler signal, neurologic deterioration, systemic clinical deterioration from suspected ongoing myonecrosis. Carpal tunnel release performed along with fasciotomy. 16 of 62 patients (25.8%) required emergent decompression within first 24 hours. Amputation rate in these patients 45%. Overall amputation rate 10%Yowler et al, Retrospective chart review 51 patients III Indications for fasciotomy: Elevated muscle compartment 199832 with high voltage injuries to the pressure greater than 30 mmHg. Neurologic dysfunction, upper and lower extremity vascular compromise, extensive deep burn. 11 patients under went 18 major amputationsDiVincenti et al, Retrospective review of 65 electrical III Early fasciotomy indicated for cyanosis of distal uninjured skin, 196924 injuries over 17 years, upper and impaired capillary refill, progressive neurologic change, lower extremities included, high and brawny edema and muscle compartment tightness. low voltage injuries included Amputation rate 32.5%Butler et al, Retrospective review of 182 cases over III 40 patients underwent an average of 5 operations. Marked 197723 twenty years. Includes high voltage swelling of the wrist and hand, the volar carpal ligament is and low voltage injuries divided at time of extremity fasciotomy. Amputation rate 65%Mann et al, Series of 8 patients with high voltage III Early decompression fasciotomy and debridement. 197527 injury. Includes upper and lower Amputations done on at least one extremity in all patients extremitiesD’Amato et al, Series of 6 patients with high voltage III Mandatory exploration of forearm and hand compartments 199420 upper extremity injury following initial resuscitation. All patients required amputationHussmann et al, Retrospective evaluation of 38 high III Early serial debridement of obviously necrotic tissue, 199545 voltage injuries. Included upper and fasciotomy including carpal tunnel release for “compartment lower extremity syndrome” 39 amputations performed in 38 patientsSaffle et al, Evaluation of wick catheter to measure II Recommended routine measurement of IMP as a more 198035 intramuscular compartment sensitive than Doppler pulses, and use of a threshold value pressures (IMP) in 31 extremities in of 30 mmHg for performance of escharotomy 18 patients, compared with clinical and Doppler findingsMoylan et al, Prospective evaluation of ultrasonic II Escharotomy is indicated when Doppler flow is absent in distal 197136 flowmeter to assess circulatory arteries or arches. Note: This paper documents that Doppler changes in 60 limbs in 24 patients pulses can be present in the face of clinical evidence of tissue with circumferential burns compression and ischemiaSalisbury et al, Evaluated post-mortem intrinsic II/III Muscle ischemia or necrosis can occur with intact pulses and even 197437 muscle biopsies following extremity following escharotomy. Note: since this was a post-mortem burns. Presence of necrosis was study, tissue necrosis may have been a non specific finding similar in patients with (72.2%) and without (66%) escharotomies (Continued)
Journal of Burn Care & ResearchVolume 27, Number 4 Arnoldo et al 445Table 2. (Continued) Reference Description Data Class CommentsSmith et al, Prospective evaluation of infrared III Advocated use of PPG as a noninvasive method of assessing 198438 photoplethysmography (PPG) to vascular compromise. This study supports an IMP 30 mm evaluate vascular status in burned Hg as an appropriate threshold for escharotomy in burned extremities and compared with IMP, extremities Doppler, and muscle blood flow (MBF). PPG correlated well with IMP and MBF, but poorly with Doppler with changes noted with IMP 30 mm HgChen et al, High resolution color and pulse III Different tissue found to have differing degree of injury. 200339 Doppler ultrasonography used to Concluded that ultrasound could demonstrate morphologic determine burn wound area in 12 changes in subcutaneous tissue, muscle, and blood vessels patients with deep electrical injury after deep electric injuryHunt et al, Technetium-99 m pyrophosphate scans II Location and extent of muscle injury was correctly ascertained 197940 performed in 14 patients with high preoperatively in all patients voltage electrical injury. Scans were performed between first and fifth day post injuryAffleck et al, Retrospective review of computerized III Revealed a sensitivity of 94% and specificity of 100% showing 200141 registry identified 11 patients who demarcation between viable and nonviable tissue, confirmed underwent Pyrophosphate (PyP) at operation scan. Eight patients had high voltage electrical injury, one had frostbite, and two had soft-tissue infectionHammond et al, Early scanning (within 3 days of injury) II Compared to control group of 17 patients treated without 199442 with PyP in 19 limbs in 15 patients PyP scan, the scan was not associated with reduced length with electrical injury. Sensitivity of of stay, or with decreased number of surgical procedures 75% and specificity of 100%tensive compartment release done as an emergency putation was ultimately required in 10% of the ex-(almost always on the day of injury).” Luce reported tremities. Extremities that were not decompresseda series of 31 patients with an extremity amputation immediately did not require amputation. The ampu-rate of 35.5% who “were taken to the operating room tation rate for those patients requiring immediate sur-within 24 hours of admission.” In the DiVincenti et gical decompression was 45%. This amputation rate isal24 series of 65 patients, there was an amputation rate similar to previous studies, which appear to includeof 32.5%. There are no studies that specifically eval- patients with lesser degree of injury. In the series fromuated the impact of timing on treatment outcome. the Army Institute of Surgical research,32 51 patients Some recent literature has supported a more selec- with high-voltage injury were managed selectively.tive approach to management may reduce the num- Indications for operative intervention were evidenceber of operative interventions and subsequently the of neurologic dysfunction, vascular compromise, ex-morbidity of high voltage electrical injury.31,32 Mann tensive deep burn, or increased muscle compartmentet al31 followed a selective management algorithm for pressures (repeated measurements 30 mm Hg). Aupper-extremity high-voltage electrical injury. Indi- total of 11 patients (21.6%) underwent 18 major ex-cations for surgical decompression included extrem- tremity amputations.ities that exhibited progressive peripheral nerve dys- No precedent exists in the literature for measuringfunction, clinical manifestations of compartment compartment pressures in the setting of high-voltagesyndrome, or injury sufficient to cause difficulty in upper-extremity electrical injury. Some surgeons ad-resuscitating the patient. Sixty-two patients had a to- vocate their use, however, on the basis of the ortho-tal of 100 upper-extremity injuries. Early (within 24 pedic and vascular literature.33,34 Measurement ofhours of admission), surgical decompression was re- compartment pressures in circumferential extremityquired in 22% of injured upper extremities. An am- burn wounds has been recommended by Saffle et al.35
Journal of Burn Care & Research446 Arnoldo et al July/August 2006A wick-catheter technique was used to measure intra- resolution ultrasound, may add much-needed claritymuscular pressures. A threshold of 30 mm Hg was an to this clinical problem.indication for escharotomy (based on vascular com- Surgical Management. Prospective randomizedpartment syndrome literature). Whether or not this studies that evaluate immediate vs expectant debrid- ´can be extrapolated to include electric injury is un- ment using well-defined criteria would be useful inclear. In addition, Moylan et al36 showed that ultra- defining guidelines for surgical management of thesonic (Doppler flow meter) signal from the distal ar- injured extremity.teries and palmar arch was a more sensitive indicator Evidentiary Table. Table 2 summarizes researchof perfusion than clinical palpation. 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