1How to cite this article: Hameed-Ud-Din, M Ibrahim Khan, MuhammadSaaiq. Electrical trauma: Presentation and management outcome in aPlastic surgical unit. Ann Pak Inst Med Sci 2007; 3(4): 206-10.ORIGINAL ARTICLE ELECTRICAL TRAUMA : PRESENTATION AND OUTCOME IN A PLASTIC SURGICAL UNIT AUTHORS: Hameed-ud-din* Muhammad Ibrahim Khan** Muhammad Saaiq*** *Assistant Professor and Head, **Seniour Registrar ***Trainee Registrar, Department of Plastic Surgery, PIMS, Islamabad.
2 ABSTRACTObjective : To document and analyse the presentation and outcome ofelectrical trauma in a tertiary care hospital.Study Design : Descriptive study.Place and duration : This study was carried out in the Department ofPlastic and Reconstructive Surgery, Pakistan Institute of Medical Sciences(PIMS), Islamabad during the period from Jan 01, 2005 to June 30,2007.Subjects and Methods: Initially all patients with various burn injuries whowere managed at our department were included in the study byconvenience sampling technique. Those patients who did not consent toparticipate in the study were excluded. Subsequently the data ofonly electrical trauma patients were further analysed. Initial assessmentand diagnosis was made by history, physical examination andnecessary investigations. The sociodemographic profile of the patients,type of injury, type of surgical procedure undertaken, complicationsencountered, morbidity and mortality etc. were all recorded on aproforma. The data were subjected to statistical analysis. Results : Out of a total of 561 patients with various burn injuries, therewere 32 patients ( 5.70% of the total ) with electrical trauma. Out ofthese, 59.38% (n=19) were males while 40.62 % (n=13) were females. Themean age was 33 ± 17 years and over 50 % of the patients were in their3rd , 4th and 5th decades of life. Household injuries constituted thecommonest cause of electrical trauma. 62.50%(n=20) of the injuries wereof high voltage while 37.50% (n=12) were of low voltage. The variousprocedures undertaken included radical debridements 65.62% (n=21),various amputations 46.87%(n=15), flaps 25%(n=8), skin grafts 21.87%(n=7) and fasciotomies for hand and forearm compartment syndrome18.75%(n=6). The rate of hospitalisation was 71.87%(n=23). The averagehospital stay was 17 days (range 3-63 days). There was one inhospitalmortality.Conclusion : Though electrical trauma represents only a small fraction ofthe burn injuries overall, it still carries a substantial risk of lifelong morbidityin the form of upper limb loss. Since electrical trauma stems largely fromavoidable hazards, the need for preventive strategies can’t beoveremphasized in this regard.Key words : Electrical trauma. Electrical injuries. Upper limb amputations.
3INTRODUCTION :Electrical trauma represents a distinct form of acute traumatic lesions thathave a unique pathophysiology. These are often highly complex andpose a management challenge both in the acute phase as well asthrough the phase of rehabilitation. They are attended by a high rate oflife long morbidity owing to loss of upper limb. Electrical trauma accountsfor an estimated 1000 fatalities and around 3,000 admissions to burn carecentres per year. 1-3Electrical trauma is classified as high voltage ( caused by a voltage of >1000 volts) or low voltage (caused by a voltage of < 1000 volts). Lightningis considered as a type of high voltage injury characterized byunidirectional flow of massive current from cloud to ground in a splitsecond. 4 The electrical injuries are caused by one or more of the threemechanisms i.e. electrical energy causing direct tissue damage; thermalenergy causing coagulative necrosis and thrombosis of microcirculation;mechanical injuries secondary to falls or violent muscle contractions. Thedegree of the resultant injuries depend on a variety of factors such as themagnitude of energy, type of current, duration of exposure, pathway ofcurrent and resistance offered to the current by the body tissues etc. Thetransthoracic and transcranial flow of current is frequently fatal. 5-7The present study was undertaken to measure the frequency of electricaltrauma among patients receiving burn care, analyse thesociodemographic profile of the electrical trauma victims, assess theassociated morbidity and mortality and collect actionable evidence basefor evolving meaningful preventive strategies to address this major publichealth issue.MATERIALS AND METHODS :This study was carried out in the Department of Plastic and ReconstructiveSurgery, Pakistan Institute of Medical Sciences (PIMS), Islamabad duringthe period from Jan 01, 2005 to June 30, 2007.Initially all patients with various burn injuries who were managed at ourdepartment were prospectively included in the study by conveniencesampling technique. Those patients who did not consent to participatein the study were excluded. Subsequently the data of only electricaltrauma patients were further analysed. Initial assessment and diagnosiswas made by history, physical examination and necessaryinvestigations. In addition to the basic essential work up, ECG, urinalysis formyoglobin and serum creatine kinase were done in all patients. All thepatients were initially managed with the standard trauma protocol ofABCDE and subsequent fluid management and any surgical procedurerequired was instituted according to the condition of the individualpatients.
4 The sociodemographic profile of the patients, type of injury, type ofsurgical procedure undertaken, complications encountered, morbidityand mortality were all recorded on a proforma. Figures I through IVshow some representative pictures of the included patients.statistical analysis: The data were analysed through SPSS for Windowsversion 10. The nominal variables were reported as frequency andpercentages. The numerical data were reported as Mean ± S.D.RESULTS:Out of a total of 561 patients with various burn injuries, there were 32patients ( 5.70% of the total ) with electrical trauma. ( Fig. V) Out ofthese, 59.38% (n=19) were males while 40.62 % (n=13) were females. Themean age was 33 ± 17 years and over 50 % of the patients were in their3rd , 4th and 5th decades of life. Household injuries constituted thecommonest cause of electrical trauma. ( Fig. VI ) 62.50%(n=20) of theinjuries were of high voltage while 37.50% (n=12) were of low voltage. Thevarious associated injuries found among the electrical trauma patientsincluded pelvic fracture, long bone fracture, mild head injury and genitalinjury, one each. The various procedures undertaken included radicaldebridements 65.62% (n=21), various amputations 46.87%(n=15), flaps25%(n=8), skin grafts 21.87% (n=7) and fasciotomies for hand and forearmcompartment syndrome 18.75%(n=6). Table I depicts the variousamputations undertaken among the victims of electrical trauma. Table IIshows our share of complications. The rate of hospitalisation was71.87%(n=23). The average hospital stay was 17 days (range 3-63 days).There was one inhospital mortality.DISCUSSION:In our study electrical trauma constituted 5.70% of the overall burn injuryadmissions. This share of the electrical trauma is relatively more than whatis reported from the Western countries 4,8 and is in conformity with thatreported from other parts of the country 9,10 as well as from otherdeveloping countries. 11-13Electrical trauma often poses a complex management challenge to thehealth care team. Both local as well as systemic effects of the electricaltrauma contribute to the complexity of the injuries. The actual injury isusually more than the apparently benign looking burn lesions. There isoften widespread thermal necrosis, coagulation of microcirculation, tissueedema which together may lead to limb loss. Additionally there is high riskof fatal arrthymias, renal failure, septicaemia and limb compartmentsyndrome. There is often progressive necrosis necesssitatig serial radicaldebridements. 1-3, 8The great majority of our patients were in the 3rd , 4th and 5th decades oftheir life. One can easily imagine the socio-economic implications of the
5devastating electrical injuries in this economically productive strata of thepopulation. The loss of hand or upper limb renders the victim professionallydisable for lifelong. It entirely changes his interpersonal meaning and he isno more able to effectively contribute his tangible productively yields tothe society. In our given circumstances the resultant disability is even moredrastic owing to the fact that our rehabilitative services are ofteninadequate.There was 46.87%(n=15) amputation rate in our series. Majority of thesewere major amputations. A similar high amputation rate is reported byother researchers. 3,9 The disconcertingly high rate of amputationsperhaps constitutes the most worrisome aspect of the electrical injuries.Household accidents remained the most common cause of electricaltrauma in our series. Loose wiring, exposed extension cords, homemadeequipment and faulty electric instruments were the various underlyingcauses of electrical injuries in these patients. All these domestic electricalaccidents are largely preventable.34.37%(n=11) of our patients were linemen who sustained electrical injuriesat workplace. This represents an other potential area of prevention. Infactinstitution of safety measures and protocols can greatly reduce the risk ofelectrical trauma to the at-risk professionals. There were two more victimsof high voltage electrical trauma but they were not wapda workers. Theywere rather indulging in the unlawful act of stealing electricity. The causesunderlying this complex issue of electricity stealing need carefulexploration and evolution of preventive strategies at national level. Two cases of electrical trauma were because of surgical diathermy. This iscertainly not acceptale in this day and age. It is best to employ a bipolarcautry than the unipolar one. If a uniploar diathermy is used the surgeonmust personally ensure that the plate electrode has a good contact of atleast 70 cm2 area of skin to prevent such injuries.Fortunately there was no case of lightning in our series, though asignificant number of such victims are reported by some researchers. 7,14There was one inhospital mortality in our series while studies from thedeveloped countries quote alarmingly high mortality rate. This certainlyreflects our poor pre-hospital care and lack of proper scoop and runsystem for those with potentially life threatening injuries. 15 As a resultseriously injured patients either die on-scene or when en-route to thehospital.Our study clearly highlights the gravity of this major public health issue aswell as the inadequacy of preventive measures. We would make thefollowing recommendations to address this issue: 1) All doctors, public health authorities and non-governmental organizations should make collaborative efforts to address this challenging public health issue.
6 2) At national level, a national prevention programme should be launched. It should ensure active participation of both community as well as health care professionals. It should aim at creating public awareness and foster education on various preventive strategies. 3) Occupational safety protocols should be developed. Electrical trauma awareness programmes should be evolved for electricity workers. The use of protective gloves, shoes and masks etc. should be encouraged. 4) For all residential and commercial areas there should be well planned electricity codes. The transformers, metres and live wires should be well protected and inaccessible to the public. The power poles should also be well away from roadsides, playgrounds and rooftops etc. 5) Safe home and kitchen environment should be ensured particularly with reference to children. Awareness and education of mothers about the risky activities of their children would help to reduce the incidence of childhood electrical injuries. 6) Legislators should formulate laws and regulations to ensure that all the aforementioned strategies are enacted by parliament and implemented by law enforcing agencies.Conclusion: Though electrical trauma represents only a small fraction ofthe burn injuries overall, it still carries a substantial risk of lifelong morbidityin the form of upper limb loss. Since electrical trauma stems largely fromavoidable hazards, the need for preventive strategies can’t beoveremphasized in this regard.REFERENCES: 1) Wright RK. Electrical injuries. (Serial online) 2007 july ( Cited 2007 Oct 27): (3 screens). Available from: URL: www.emedicine.com/emerg/topic 162.htm 2) Benson BE. Electrical burns. (Serial online) 2006 Oct (Cited 2007 Nov 04): (3 screens). Available from:URL :www.emedicine.com/ped/topic 2734.htm-110k 3) Babik J, sander, soflo. Electrical burn Injuries. (Serial online) 1998 Sept (Cited 2007 Oct 27): (3 screens). Available from: URL :www.medbc.com/annals/review/vol_11/num_3/text/vol 11n 3 p153.htm 4) Daley BJ. Electrical Injuries. (Serial online) 2006 Aug ( Cited 2007 Oct 18 ): ( 3 screens ). Available from: URL :www.emedicine.com 5) Lee RC, Zhang D, Hannig J. Biophysical injury mechanisms in electrical shock trauma. Annu Rev Biomed Eng. 2000; 2:477-509.
7 6) Lammertse DP. Neurorehabilitation of spinal cord injuries following lightning and electrical trauma. NeuroRehabilitation. 2005;20(1):9- 14. 7) Jost WH, Schonrock LM, Cherington M. Autonomic nervous system dysfunction in lightning and electrical injuries. NeuroRehabilitation. 2005;20(1):19-23. 8) Arnoldo B, Klein M, Gibran NS. Practice guidelines for the management of electrical injuries. J Burn Care Res. Jul- Aug 2006;27(4):439-47. 9) Janjua SA. High Voltage Electrical Injuries. J Coll Physicians Surg Pak 2002;12(3):140-2. 10) Muqim R, Zareen M, Dilbag, Hayat M, Khan I. Epidemiology and outcome of Burns at Khyber Teaching Hospital Peshawar. Pak J Med Sci 2007;23(3):420-4. 11) Abrol A, Saraf R, Singh SH. Thermal and electrical burns in Jammu Province. J K Science 2005;7:61-3. 12) Ahuja BR, Bhattacharaya S. Burns in developing world and burn disasters. Br Med J 2004; 329:447-9. 13) Lari AR, Alghenbanden R, Nikui R. Epidemiological study of 3341 burns patients in Tehran, Iran. Burns 2000;26:49-53. 14) Cherington M. Neurorehabilitation of the multifaceted and complicated neurologic problems associated with lightning and electrical injuries. NeuroRehabilitation. 2005;20(1):1-2. 15) Sikandar I, khaliq T, Iqbal T, Saaiq M, Jamal Sh. Pre-hopital emergency care and role of ambulance staff. Where do our ambulances stand? Ann Pak Inst Med Sci 2006; 2: 57-61.Figure I: Patient with high voltage electrical trauma where serial radical debridements helped to avert the need for amputation.
8Figure II: Patient who lost right upper limb due to an electrical accident.Figure III: Patient who lost his left upper limb due to high voltage trauma.Figure IV: Patient who ended up with below elbow amputation due to high voltage trauma.
9 Miscellaneous 13 Electrical 32 Chemical 81 Scalds 172 Flame burns 263 0 50 100 150 200 250 300Figure V: Distribution of burn injuries Overall ( n=561) Contact with 1 Transformer Contact with 1 E.Pole Iatrogenic 2 Household 17 Accidents Workplace 11 Accidents 0 5 10 15 20 Number of PatientsFigure VI : Various causes of electrical trauma.( n=32)
10iTable I: Various amputations undertaken among the electrical trauma patients. (n=15) Amputation Number Upper limb: Right 6 Left 3 Hand 1 Fingers 5Table II: The various complications encountered among the electrical trauma patients. (n=8) Complications Number Wound infection 5 Cardiac dysrhythmia 1 Renal failure 1 Genital injuries 1