Serial Case
Characteristics of Electric burn patients
in Sanglah General Hospital, Denpasar, Bali
During 2014
A Descriptive Study.
Teguh Dwi Nugroho*, Nyoman Putu Riasa**
Department of General Surgery.*Plastic Reconstructive and Aesthetic Surgery Division.**
Burn Unit Sanglah Hospital/ Faculty of Medicine University of UdayanaDenpasar
Submitted asan assignment
fora General Surgery Registrar
Department of Surgery
Characteristics of Electric burn patients
in Sanglah General Hospital, Denpasar, Bali
During 2014
A Descriptive Study.
Teguh Dwi Nugroho*, Nyoman Putu Riasa**
Department of General Surgery.*Plastic Reconstructive and Aesthetic Surgery Division.**
Burn Unit Sanglah Hospital/ Faculty of Medicine University of UdayanaDenpasar
ABSTRACT
Electrical injuries are relatively uncommon. High-voltage burns are mainly labour ooccupation-related. The most common mechanism of electrical injuries in construction workers is due to contact with over head high voltage power-line at workplace. The variables analysed included: gender, age, profession, length of hospital stay, electrical current voltage, mechanism of injury (MOI), burnt total body surface area (TBSA), burnt body region, acute complications, treatment, and mortality.
Electrical injuries accounted for 24.06% (32/133) of all patients admitted with burns; 89.47% (17/19) of the burns were due to high voltage and 10.53%(2/19) to low voltage.The majority of the patients were young men at the beginning of their professional lives.Patients were predominantly young men (median age 26.5 years old) and those who resulted from work related accidents.The median of the total burn surface area was 10%. The median length-of-stay was 13 days. Two patients died, on the fourth and fifth day of care, accounting for a mortality rate of 9%. One because of multiple organ failure and the other cannot be traced as the medical record cannot be retrieved.
Overall, the most commonly entrance burn was in the right upper extremities(75%, n=20). Patients were treated with debridement and early reconstruction 52.63% and26.31% need a second debridement or more.
INTRODUCTION
Electrical burns are still a problem in our society, resulting in important complications and socio-economic impact.1-3An electrical injury occurs when a human body comes
into contact with an electric arc, due to elctricity passing through the human body. 2The
passage of electric energy through the human body triggers a very complex reactions in the body’s tissues and organs.1,4
The pathological effects of electric energy are to be seen in two active mechanisms, i.e. thermal action at body level and electrolytic action at cell level.The resistance of tissues increases gradually from nerves to vessels, muscles, skin, tendons, fat and bone.1
Many difficult decisions surfaces in the early management of the severely burned patient.5 The first death due to electrical burn was reported in Lyon in 1879. 6
They have traditionally been classified as high voltage (ш 1000 V), low voltage (ч 1000 V), ‘flash burn’ and burns caused by lightning.1,3Typically, high-voltage injury causes
damage at the contact point and deeper structures, resulting in a large area of necrosis.1,7Low-voltage thermal trauma is mainly confined to the entry and exit sites. 3
As a global health concern, electrical burns have usually been more frequent in undeveloped countries with an inefficient electric energy system, a low social and economic level, lack of safety in the workplace, as in our country, Indonesia.2,8Along
with the advance burn cares, trends have been attracted to the preventive approaches as the main modality of cure for electrical burn injury.8For this reason, the epidemiology
and characteristics of this type of injury should be documented, so further prevention strategies could be implemented.8,9
In this retrospective study, we reviewed the medical records of patients injured by electricity who were admitted to the Sanglah General Hospital. The different causes of electrical burns and the different aspects of each one of these injuries as was the selected for electric burns, but only 19 complete medical records can be retrieved.The variables analysed includes: gender, age, profession, length of hospital stay, electrical current voltage, mechanism of injury (MOI), burnt total body surface area (TBSA), acute complications, treatment, and mortality.1
The protocol for treating these patients confirmed to general principles of burns management.Initially, all the patients with electrical burns had been admitted to the emergency room and evaluated in accordance to the Advanced Trauma Life Support (ATLS) algorithm and later transferred to the Burn Unit.1
result of myoglobin release secondary to muscular necrosis and red cell destruction. These aspects of the burn patient contribute to an intratubular precipitation of pigments, leading to acute renal failure (ARF). The main purpose of the treatment is to keep the urine output between 30 and 50 ml/h in adults and 1 ml x kg/h in children, in order to prevent this complication. If myoglobinuria occurs, the volaemic replacement should be more aggressive, wherein the goal is to achieve a urine output from 75 to 100 ml/h. If the volaemic replacement is non adequate, 12.5 g of mannitol per litre of replacement solution can be added for oliguria non-responsive to volume resuscitation alone.1,2,6
Patients were monitored for any compartment syndrome signs secondary to the tissue injury.Early surgical management of electrical injuries should focus on the need for fascitotomy or compartment release. On day 3 all unhealthy necrotic tissue can be debrided and definitive wound closure can be achieved. 1,2
RESULTS
DuringJanuary to December 2014, 133 burn patients were admitted, 24.06% (32) suffered electrical burns. The variables analysed includes: gender, age, profession, length of hospital stay, electrical current voltage, mechanism of injury (MOI), burnt total body surface area (TBSA), burnt body region, acute complications, treatment, and mortality.
All electrical burn patientswere men (100%). The median age of high-voltage trauma patients was 26.5 years old, ranges from 17 to 54 years old (n=36). The median burn surface area (%TBSA) was 10% (range: 1-47, n=35) and the median length of hospital stay was 13 days (range: 2-51 days, n=31).1 Of19patients, 89.47% suffered high-voltage
electrical trauma, 10.53%low-voltage elctrical trauma and no electrical trauma case caused by lightning was admitted to our hospital during the study period.
Overall, the most commonly entrance burn was in the right upper extremities(75%, n=20).10 cases involved only the right upper extrimity, and 5 cases involved right and left upper extrimities.
Two patients died, accounting for a mortality rate of 9%.They died on the forth and fifth day of care,one because of multiple organ failure and the other cannot be traced as the medical record cannot be retrieved.
DISCUSSION
This electrical burns incidence of 24.06%in Sanglah Hospital is higher than in other reports in Europe, as well as the rest of the world. Other reports have the following data: USA 3%, China 3-5%, Slovakia 2.7%, India 3-9%, Turkey 16%.2
Rates of adult injury are significantly higher in men than in women, likely because of occupational predisposition. In our study, all electric burn patients were men, 100%. Most series show more than 80% of electrical injuries occur in men.This increased risk reflects the fact that males typically have a higher risk occupations, involving work activities that expose them much more frequently to high voltages, electric currents, equipment and machinery, than female workers.No racial susceptibility to electrical burns exists.3,4,7
Among this population of electric utility workers, workers in their thirties and forties had the highest injury rates.7In electrical injury-related publications, the average age of
high-voltage trauma patients ranges from 29 to 34 years.3We had not received pediatric
patients in our burn center in the year due to electrical injury, which is in contrast to other publications. Luz et al from Brazil reported pediatric cases accounting for 13% of high-voltage and 35% of low-voltage trauma, respectively. Reports from the United States and Australia confirmed that pediatric electrical trauma is mainly a result of low-voltage injury in developed countries. 3
The burn accident occurs in 62% to 75% at work. 4 The majority of injured people are
related to the civil construction field or are electricians, who most often do not work for companies that provide services or have legislated codes and rigid guidelines that are designed to protect workers.3Unfortunately, this high-risk group is the one least affected
by the prevention effort, which is the most effective form of therapy.1,3
It is not surprising that high-voltage injuries presented with a significantly higher %TBSA, increased demand for operative treatment. 3This, in itself, generates a longer
hospital stay in order to control the complications. 1
Aggressive treatment including surgical debridement of devitalised tissues, or those with doubtful viability, frequently exposes vital structures in patients who have suffered high-voltage burns. 1
Overall, the hand/finger, upper extremities, head and eyes were by far the most commonly injured body region for all burn-related injuries, for flasburn/electric shock/electrocution injuries, and for thermal/heat burns. This is consistent with the distribution by body region found in other studies, which also found that the upper extremities were the most common sites for burn injuries. The frequent involvement of the extremities can be explained by the observation that, when an electrical incident occurs, the worker has typically been engaged in an activity that relies on their extremities, such as reaching, or touching.7
The percentage of patients who suffered high-voltage burns was 89.47%in the present study, while in other studies the mortality rate varied from 0 to 25 %.1,9 This variation
may simply arise from severity of injury, characteristics of electricalinjury, and level of specialized care that each patient receives. 8
While in-hospital mortality remained low, morbidity following electrical injuries was still significanct. However, we have observed a comparable amputation rate 5% (1/19) as compared with the literature, which ranges between 18% and 45%. 3
public educational programs. Regarding the increasing growth of industrialisation in developing countries, and ignorance of labor standards, electrical burn can be considered as one of the most important health problems in our country in near future and if occupational medicine is not considered. Public educational programs for the people and those working in electrical fields can be beneficial to reduce the incidence of electrical burns. 6
References
1. Luz, D.P., Millan, L.S., Alessi, M.S., Uguetto, W.F., Paggiaro, A., Gomez D.S. & Ferreira, M.C. 2009. Electrical burns : A retrospective analysis across a 5-year period. Burns 35, 1015-1019.
2. Buja, Z., Arifi, H. & Hoxha, E. 2010. Electrical burn injuries. An eight-year review. Annals of Burns and Fire Disasters, vol XXIII – n.1.
3. Vierhapper, M.F., Lumenta, D.B., Beck, H., Keck, M., Kamolz, L.P. & Frey, M. 2011. Electrical injury A long-term Analysis with Review of Regional Differences. Ann Plast Surg, 66, 43-46.
4. Gajbhiye, A.S., Meshram, M.M., Gajaralwar, R.S. & Kathod, A.P. 2013. The Management of Electrical Burn. Indian J Surg, 75(4), 278-283
5. Kennedy, P.J., Young, W.M., Deva, A.K. & Haertsch, P.A. 2006. Burns and Amputations : A 24-year Experience. J Burns Care Res, 27, 183-188.
6. Mohammadi, A.A., Amini, M., Mehrabani, D., Kiani, Z. & Seddigh, A. 2008. A survey on 30 months electrical burns in Shiraz University of Medical Sciences Burn Hospital. Burns, 34, 111-113.
7. Fordyce, T.A., Kelsh, M., Lu, E.T. Sahl, J.D. & Yager, J.W. 2007. Thermal burn and electrical injuries among electrical utility workers, 1995-2004. Burns, 3, 209-220. 8. Salehi, S.H., Fatemi, M.J., Asadi, K., Shoar, S., Ghazarian, A.D. & Samimi, R. 2014.
Electrical injury in construction workers: A special focus on injury with electrical power. Burns, 40, 300-304.
9. Marcuci, P.A., Smith, S., Gomez, M. & Fish, J.S. 2010. An Effective Prevention Program to Reduce Electrical Burn Injuries Caused by the Use of Multimeters. J Burn Care Res, 31, 333-340.
