Practice guidelines for the management electrical

Practice Guidelines for the Management
of Electrical Injuries
Brett Arnoldo, MD,* Matthew Klein, MD† Nicole S. Gibran, MD

There has been increasing emphasis on the develop- no history of loss of consciousness, and no other
ment of practice guidelines and validated measure- indications for admission (ie, soft-tissue injury),
ments to evaluate surgical practice. Initiatives such as can be discharged from the emergency room.
the National Surgical Quality Improvement Program 2. All patients with history of loss of consciousness
(NSQIP) have demonstrated the importance of an or documented dysrhythmia either before or af-
outcome-based approach to improving surgical care. ter admission to the emergency room should be
The development of guidelines and outcome-based admitted for telemetry monitoring. Patients
benchmarks requires established standards of practice with ECG evidence of ischemia should be ad-
that should be based on level I data from well- mitted and placed on cardiac monitors.
designed prospective randomized trials. 3. Creatine kinase enzyme levels, including MB
Electrical burns are potentially devastating injuries fraction, are not reliable indicators of cardiac
with both short- and long-term sequelae. In 2001, the injury after electrical burns and should not be
American Burn Association published a set of practice used in decisions regarding patient disposition.
guidelines for various aspects of burn care in the Journal Insufficient data exists on troponin levels to for-
of Burn Care and Rehabilitation. However, guidelines mulate a guideline.
for the management of electrical burns were not in- Options. Electrical injuries can result in potentially
cluded. Two fundamental—and controversial—issues fatal cardiac dysrhythmias. The need for cardiac eval-
in the management of electrical burns are cardiac mon- uation and subsequent cardiac monitoring are critical
itoring and evaluation and treatment of the injured up- components in electrical burn management. Most pa-
per extremity. We have reviewed and analyzed the avail- tients who sustain electrical injuries undergo ECG
able literature in an effort to develop practice guidelines evaluation, and patients with documented dysrhyth-
for these two important issues. mias, cardiac ischemia, or history of loss of conscious-
ness will be admitted to the hospital for further eval-
SECTION I: CARDIAC MONITORING uation and monitoring. However, the appropriate
AFTER ELECTRICAL INJURIES cardiac diagnostic tests and the indications for hospi-
tal admission, necessity of cardiac monitoring, and
Recommendations appropriate duration of cardiac monitoring have not
Standards. An electrocardiogram (ECG) should been well established.
be performed on all patients who sustain electrical
injuries (high and low voltage).
Guidelines
OVERVIEW
1. Children and adults who sustain low-voltage
electrical injuries, have no ECG abnormalities, Purpose
The purpose of this guideline review is to review the cur-
rent data on practices for diagnosing cardiac injury and
From the *University of Texas Southwestern Medical Center, indications for cardiac monitoring after electrical injury.
Parkland Memorial Hospital, Dallas; and †University of
Washington Burn Center, Harborview Medical Center, Seattle.
Address correspondence to Nicole S. Gibran, MD, University of
Washington Burn Center, Harborview Medical Center, Box Users
359796, 325 9th Avenue, Seattle, WA 98104.
Copyright © 2006 by the American Burn Association. These guidelines are designed to aid physicians in making
1559-047X/2006 decisions regarding patient disposition, diagnostic tests
DOI: 10.1097/01.BCR.0000226250.26567.4C and management of patients following electrical injury.

439

Journal of Burn Care & Research
440 Arnoldo et al July/August 2006

Clinical Problem low-voltage and high-voltage injuries, reinforcing the
The potential for development of cardiac dysrhyth- need for ECG evaluation of all patients. Nonspecific
mia, 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 Admission
dysrhythmia and injury has prompted routine cardiac Admission and cardiac monitoring for patients with
evaluation 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, TBSA
Whereas obtaining an ECG is a well-established com- burned, need for extremity monitoring) are standard
ponent of the early evaluation of patients after elec- practices in all series of electrical injuries reviewed. In
trical injury, the indications for patient admission addition, the majority of patients with low-voltage
and appropriate duration of cardiac monitoring injuries and normal ECG are discharged home from
have been less clear. Traditionally, patients with the emergency room without complication. The
low-voltage injuries who have normal ECGs and no safety of this practice also was confirmed in two series
history 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 would
been 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 are
or 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 increasing
telemetry monitors. There are several issues related to emphasis on cost-effectiveness, the routine admission
the 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 al10
electrical injuries be admitted to the hospital, even if reported that all cardiac irregularities were evident
there is no evidence of cardiac abnormality? 2) What either on admission to the emergency room or within
is the role of cardiac enzymes in the evaluation and several hours of hospitalization and in 1986, Purdue
management 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 for
Process
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 of
trical, 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 of
were 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 10
dence (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 routinely
provided by clinical series, comparative studies, case monitoring patients who sustained high-voltage
reviews or reports); or as a technology assessment (a injuries. However, this series is too small to affect
study 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 the
rhythmias and myocardial damage— occur after both emergency room only after they developed chest pain

Volume 27, Number 4 Arnoldo et al 441

and palpitations. However, none of the patients had high-voltage injuries and normal ECGs. The two
ECGs or any sort of evaluation at the time of injury studies that addressed this question have population
and, 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 establish
Duration of Monitoring practice guidelines. In addition, there is inadequate
No published studies have directly studied the appro- evidence to formulate guidelines for the duration of
priate 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 that
admission if there were no ECG abnormalities on CK-MB is an unreliable diagnostic test for cardiac
admission or monitoring for 24 hours after resolution injury after electrical injury. The presence of skeletal
of dysrhythmias.1,8,12 Arrowsmith et al10 reported muscle injury in these patients confounds the results
that all patients with dysrhythmias resolved within of this laboratory test. No studies identified in this
48 hours of admission either spontaneously or with review examined the specificity and utility of troponin
pharmacologic intervention. However, there are no levels in determining cardiac injury.
data available to formulate appropriate management
guidelines for this issue. Key Issues for Further Evaluation
1. Utility of troponin: CK and CK-MB not specific
Utility of Creatine Kinase for cardiac muscle. Insufficient data exists eval-
Creatine kinase levels frequently are obtained after uating the utility of troponin in assessing cardiac
electrical 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 exists
extent of extremity muscle injury. The MB subunit to determine the optimal duration of telemetry
has been reported to be more specific for myocardium monitoring after electrical injury for patients
and, therefore, has been used to evaluate cardiac in- who have abnormal ECGs or history of loss of
jury after electrical injury. Only one study reported a consciousness. There have been no studies that
reliable 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: insufficient
course of the MB fraction increase and decrease was a data exists to establish guidelines for whether to
reliable indicator of cardiac ischemia. However, this admit patients who sustain high-voltage injuries
study does not correlate the elevated enzyme levels with but have normal ECG’s and no history of loss of
any other study of cardiac injury. Conversely, the evi- consciousness. The available data suggest that
dence 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 the
elevated enzyme levels likely result from noncar- Evidentiary Table
diac muscle injury.7,13–15 Housinger et al7 sug-
Studies on the practices of cardiac evaluation and
gested that positive MB fractions in the absence of ECG
monitoring are summarized in Table 1.
findings should be interpreted with caution because
they may not signify cardiac injury. Given the paucity of
evidence supporting the utility of CK-MB levels, this II. EVALUATION AND MANAGEMENT
laboratory value should not be used as a diagnostic OF THE UPPER EXTREMITY
criterion for cardiac injury after electrical injury.
Recommendations
Standards. Insufficient data exist to support a
SUMMARY treatment standard for this topic.
The current practices of admitting patients with his- Guidelines
tory of loss of consciousness, documented dysrhyth- 1. Patients with high-voltage electrical injury to
mia 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 referral
injuries and normal ECGs is well established. How- criteria.
ever, few data are available to support establishment 2. Indications for surgical decompression include
of guidelines for the management of patients with progressive neurologic dysfunction, vascular


Table 1. Evidence table
Reference Study Description Data Class Conclusions/Comments

Ahrenholz 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 injury
Arrowsmith 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 monitoring
Bailey 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 region
Bailey 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 tetany
Chandra 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 damage
Cunningham, 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
complication
Guinard et al, Prospective evaluation of 10 patients III Demonstrated poor reliability of CK-MB to identify
198715 admitted with electrical injuries cardiac injuries
Housinger 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
injury
Hunt 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 hospitalization
Jensen 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 injury
Lewin 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 injury
Purdue 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 studied
Wallace 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 monitored
Zubair 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


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 Foundation
reaching within 10 to 20 mm Hg of diastolic pres- Electrical injuries, including lightning strikes, should
sure, 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 within
appropriate clinical setting. Technetium-99m pyro- the first 24 hours), and decompression of patients
phosphate 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 to
as the sole indicator of deep-tissue viability and ade- interpret; however, because of the differences in the
quate 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 the
electrical 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 fasciotomy
electrical 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 approach
Clinical Problem however, commits the patient to several operations
Burns 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 underwent
of deep-tissue injury than is initially appreciated. As a emergency exploratory surgery and amputation for
result 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 for
sociated 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 neither
morbidity, 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 10
increased amputation rates along with increased or- extremities salvaged, which the authors attribute to
gan failure and mortality.31 early aggressive operative intervention. Haberal’s se-
ries of 94 patients had an amputation rate of 43%. The
Process authors attributed this high amputation rate in part
A Medline search from 1966 to the present was used because of a delay in surgical exploration as a result of
to 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 patients
tremity. A search for the key words, “electrical in- with an amputation rate of 40%. They recommend
jury,” “fasciotomy,” “compartment syndrome,” “extensive debridement of all damaged tissue and ex-


Table 2. Evidentiary table: high-voltage electric injury to upper extremity
Reference Description Data Class Comments

Quinby 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 amputations
DiVincenti 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
extremities
D’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
amputation
Hussmann 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 patients
Saffle 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 findings
Moylan 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 ischemia
Salisbury 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)


Table 2. (Continued)
Reference Description Data Class Comments

Smith 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 Hg
Chen 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 injury
Hunt 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 injury
Affleck 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 infection
Hammond 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 decompressed
a 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 is
al24 series of 65 patients, there was an amputation rate similar to previous studies, which appear to include
of 32.5%. There are no studies that specifically eval- patients with lesser degree of injury. In the series from
uated 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 evidence
ber 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 compartment
et al31 followed a selective management algorithm for pressures (repeated measurements 30 mm Hg). A
upper-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 measuring
function, clinical manifestations of compartment compartment pressures in the setting of high-voltage
syndrome, 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 of
hours of admission), surgical decompression was re- compartment pressures in circumferential extremity
quired in 22% of injured upper extremities. An am- burn wounds has been recommended by Saffle et al.35


A wick-catheter technique was used to measure intra- resolution ultrasound, may add much-needed clarity
muscular pressures. A threshold of 30 mm Hg was an to this clinical problem.
indication for escharotomy (based on vascular com- Surgical Management. Prospective randomized
partment 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 in
clear. In addition, Moylan et al36 showed that ultra- defining guidelines for surgical management of the
sonic (Doppler flow meter) signal from the distal ar- injured extremity.
teries and palmar arch was a more sensitive indicator Evidentiary Table. Table 2 summarizes research
of perfusion than clinical palpation. Salisbury37 dem- on the monitoring and treatment of high-voltage up-
onstrated, however, that this objective measure of per-extremity injury.
perfusion could not be relied on as the sole indicator
of deep tissue viability and need for escharotomy in REFERENCES
circumferential burns. Therefore, more sensitive in-
1. Bailey B, Gaudreault P, Thiviege RL. Experience with guide-
dicators of perfusion have been investigated. lines for cardiac monitoring after electrical injury in children.
Small studies have evaluated the use of infrared Am J Emerg Med 2000;18:671–5.
photoplethysmography (PPG) to assess vascular 2. Das KM. Electrocardiographic changes following electrical
shock. Ind J Pediatr 1974;41:192–4.
compromise in injured extremities, including direct 3. DiVincenti FC, Moncrief JA, Pruitt BA. Electrical injuries: a
vascular injury, crushing forces, and severe burns.38 review of 65 cases. J Trauma 1969;9:497.
PPG correlated well with muscle blood flow, and in- 4. Lewin RF, Arditti A, Sclarovsky S. Non-invasive evaluation of
electrical cardiac injury. Br Heart J 1983;49:190–2.
tramuscular pressure, but not with Doppler measure- 5. Purdue GF, Hunt JL. Electrocardiographic monitoring after
ments. electrical injury: necessity of luxury. J Trauma 1986;26:166.
Recently, high-resolution color and pulse Doppler 6. Chandra NC, Siu CO, Munster AM. Clinical predictors of
myocardial damage after high voltage electrical injury. Crit
ultrasound has been used to evaluate wound area in Care Med 1990;18:293–7.
electrical injuries.39 In this study, 12 patients with 7. Housinger TA, Green L, Shahanigan S, Saffle JR, Warden
deep electric injury were evaluated. It was found that GD. A prospective study of myocardial damage in electrical
injuries. J Trauma 1985;25:122.
degree of injury differed between tissue types. 8. Zubair M, Bessner GE. Pediatric electrical burns: manage-
Changes in course, and blood flow speed also were ment strategies. Burns 1997;23:413–20.
noted in injured tissue. Findings were all confirmed at 9. Hunt JL, Sato RM, Baxter CR. Acute electric burns. Arch
Surg 1980;115:434–8.
subsequent operation. 10. Arrowsmith J, Usgaocar RP, Dickson WA. Electrical injury
Some authors recommend the use of nuclear med- and frequency of cardiac complications. Burns 1997;23:
icine scans in an attempt to identify areas of muscle 676–8.
11. Jensen PJ, Thomsen PEB, Bagger JP, Norgaard A, Baandrup
necrosis.40,41 Other studies have questioned the util- U. Electrical injury causing ventricular arrhythmias. Br
ity of nuclear scans in this setting. They have fallen Heart J 1987;57:279–83.
out of favor in routine cases,42 although some centers 12. Wallace BH, Cone JB, Vanderpool RD, et al. Retrospective
evaluation of admission criteria for paediatric electrical inju-
reported use of this modality selectively. ries. Burns 1995;21:590.
13. Ahrenholz DH, Schubert W, Solem LD. Creatine kinase as a
prognostic indicator in electrical injury. Surgery 1988;104:
SUMMARY 741–7.
14. Baxter CR. Present concepts in the management of major
No definitive data exist to show that immediate sur- electrical injury. Surg Clin N Am 1970;50:1401–18.
gical decompression reduces the need for amputation 15. Guinard JP, Chiolero R, Buchser E, et al. Myocardial injury
after electrical burns: short and long term study. Scand J Plast
in any series. The management of these patients has Reconstr Surg 1987;21:301–2.
traditionally included immediate (within the first 24 16. Vazquez D, Solano I, Pages E, Garcia L, Serra J. Thoracic disc
hours), surgical exploration and decompression. A herniation, cord compression, paraplegia caused by electrical
injury: case report and review of the literature. J Trauma
more selective approach based on clinical findings 1994;37:328–32.
may be used at specialized centers. 17. Arnoldo BA, Purdue GP, Kowalske K, et al. Electrical
injuries: a 20-year review. J Burn Care Rehabil 2004;25:
479–84.
Key Issues for Further Evaluation 18. American Burn Association. Advanced Burn and Life Support
Evaluation of the Upper Extremity. Studies to Course. Chicago: American Burn Association; 2001.
evaluate the utility of measuring compartment pres- 19. Haberal M. Electrical burns: a five-year experience—1985
Evans lecture. J Trauma 1986;26:103–9.
sures in the presence of electrical injury need to be 20. d’Amato TA, Kaplan IB, Britt LD. High-voltage electrical
performed. It is unclear whether data from the ortho- injury: a role for mandatory exploration of deep muscle com-
pedic and vascular literature can be extrapolated to partments. J Natl Med Assoc 1994;86:535–7.
21. Achauer B, Applebaum R, Vander Kam VM. Electrical burn
burn care. In addition, studies evaluating more non- injury to the upper extremity. Br J Plast Surg 1994;47:331–40.
invasive technologies, such as infrared PPG and high- 22. Parshley P, Kilgore J, Pulito JF, Smiley PW, Miller SH. Ag-


gressive approach to the extremity damaged by electric cur- 35. Saffle J, Zeluff G, Warden G. Intra-muscular pressure in the
rent. Am J Surg 1985;150:78–82. burned arm: measurement and response to escharotomy.
23. Butler E, Gant TD. Electrical injuries, with special reference Am J Surg 1980;140:825–31.
to the upper extremities. Am J Surg 1977;134:95–101. 36. Moylan J, Wellford W, Pruitt B. Circulator changes following
24. DiVincenti F, Moncrieff JA, Pruitt BA. Electrical injuries: a circumferential extremity burns evaluated by ultrasonic
review of 65 cases. J Trauma 1969;9:497–507. flowmeter: An analysis of 60 thermally injured limbs.
25. Quinby WJ, Burke JF, Trelstad RL, Caulfield J. The use of J Trauma 1971;11:763–849.
microscopy as a guide to primary excision of high tension 37. Salisbury R, McKeel D, Mason A. Ischemic necrosis of the
electrical burns. J Trauma 1978;18:423–9. intrinsic muscles of the hand after thermal injuries. J Bone
26. Luce E, Gottlieb SE. “True” high-tension electrical injuries. Joint Surg 1974;56A:1701–7.
Ann Plast Surg 1984;12:321–6. 38. Smith Jr., D, Bendick PJ, Madison S. Evaluation of vascular
27. Mann RJ, Wallquist JM. Early fasciotomy in the treatment of compromise in the injured extremity: a photoplethysmo-
high-voltage electrical burns of the extremities. South Med J graphic technique. J Hand Surg 1984;9:314–9.
1975;68:1103–8. 39. Chen YX, Xu Y, Guo ZR, et al. The application of ultrasonog-
28. Chilbert M, Maiman DJ, Sances Jr., A, et al. Measures of raphy in the diagnosis of deep electric injury. Zhonghua Shao
tissue resistivity in experimental electrical burns. Trauma
Shang Za Zhi 2003;19(1):38–41.
1985;25:209–15.
40. Hunt JL, Lewis S, Parkey R, Baxter C. The use of techne-
29. Lee LC, Kolodney MS. Electrical injury mechanisms: dynamics
tium-99m stannous pyrophosphate scintigraphy to identify
of the thermal response. Plast Reconstr Surg 1987;80:663–71.
muscle damage in acute electric burns. J Trauma 1978;19:
30. Zelt RG, Daniel RK, Ballard PA, Grissette Y, Heroux P.
High-voltage electrical injury: chronic wound evolution. 409–13.
Plast Reconstr Surg 1988;82:1027–39. 41. Affleck DG, Edelman L, Morris SE, Saffle JR. Assessment of
31. Mann R, Gibran N, Engrav L, Heimbach D. Is immediate tissue viability in complex extremity injuries: utility of the
decompression of high voltage electrical injuries to the upper pyrophosphate nuclear scan. J Trauma 2001;50:263–9.
extremity always necessary. J Trauma 1996;40(4):584–9. 42. Hammond JW, Ward W. The use of technetium-99 pyro-
32. Yowler CJ, Mozingo DW, Ryan JB, Pruitt BA. Factors con- phosphate scanning in the management of high-voltage elec-
tributing to delayed extremity amputation in burn patients. tric injuries. Am Surg 1994;60:886–8.
J Trauma 1998;45:522–6. 43. Bailey B, Gaudreault P, Thiviege RL, Turgeon JP. Cardiac
33. Heckman M, Whitesides TJ, Grewe S, Judd R, Miller M, monitoring of children with household electrical injuries.
Lawrence JD. Histologic determination of the ischemic Ann Emerg Med 1995;25:612–7.
threshold of muscle in the canine compartment syndrome 44. Cunningham PA. The need for cardiac monitoring after
model. J Ortho Trauma 1993;7:199. electrical injury. Med J Aust 1991;154:765–6.
34. Quinn R, Ruby S. Compartment syndrome after elective re- 45. Hussmann J, Kucan JO, Russell RC, et al. Electrical injuries,
vascularization for chronic ischemia. A case report and review morbidity, outcome and treatment rationale. Burns 1995;21:
of the literature. Arch Surg 1992;127:865. 530–35.

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