Ausmaß und Behandlung elektrischer Verletzungen
Electrical injuries - morbidity, outcome and treatment rationale
J. Hussmann, J. O. Kucan, R. C. Russell, T. Bradley and W. A. Zamboni Southern Illinois University, School of Medicine, Institute for Plastic and Reconstructive Surgery, Springfield, Illinois, USA
Electrical injuries are unique with respect to low mortality rates, but very high rates of short- and long-term morbidity, and overall outcome. Controversy still exists regarding the advantages of one-stage debridement versus early serial debridement of necrotic tissue. The purpose of this study was a retrospective evaluation of treatment, morbidity and outcome in a group of patients ivith electrical injuries. Over a 13-year period 1992 patients were admitted with acute burns to our burn centre. Electrical injuries occurred in 129 (6.5 per cent) of these patients. There were 38 high-tension injuries and 91 low-tension injuries. The average age was 33. 7 years (5 months to 63 years), with burn wounds ranging from 1 to 57 per cent total body surface area (mean 9.5 per cent). Ninety-four (72.9 per cent) of these injuries were work related, and most occurred in males (85 per cent). A total of 323 surgical procedures were performed on those 129 patients. An average of 0.48 surgical debridemenis per patient was necessary in the loto-tension injury group and only three partial finger or toe amputations were necessary. In the high-tension group, 2 7 major limb amputations were performed after 2.3 debridemenfs per patient, resulting in an overall major limb amputation rate of 35 per cent. The average length of stay was 22 days, and the cost of hospitalization rangedfrom $900 to $120 000 (mean $14 901). Significant long-term neurological deficits persisted in 73 per cent of patients at long-term follow-up‘ (mean 4.5 years). Only 5.3 per cent of patients after high-voltage electrical injury were able to return to their premorbid job.
Burns, Vol. 21, No. 7, 530-535, 1995
The discovery of electricity and the introduction of dynamo machines presented a major industrial advance. It also caused death soon after its discovery. Jex-Blake and Oxon1 reported that a stage carpenter was killed in 1879 at Lyon, France, by an alternating current of 250 volts.
D‘ Arsonval 2 discussed the physiological action of highfrequency alternating currents and its possible usefulness in medical treatment. Numerous electrical injuries have been reported thereafter followed by clinical and experimental investigations on the pathophysiology and causes of death3-6• The most striking finding was a high incidence of death after contact with electricity which did not seem to depend upon the magnitude of electrical tension.
Reports include death after exposure to 46 volts or after therapeutic application of so-called sinusoidal currents with tensions as low as 30-50 volts7• One of the most effective precautions was expressed by Kennelly“ in 1927, who recommended keeping one hand in the pocket when
visiting an electric plant. Today advanced security precautions help to reduce the incidence of electrical injuries, but the high rate of major limb amputation, between 45 and 71 per cent, remains essentially unchanged'<‚“. According to Lee13, mortality ranges from 3 to 15 per cent and accounts for more than 1000 deaths per year in the USA. The most common cause of death remains cardiac arrest following acute arrhythmias at the site of the accident. After arrival in the burn centre, general morbidity is the major problem, with the mortality rate usually being low.
Electrical injuries are divided into low-tension ( < 1000 volts) and high-tension injuries ( > 1000 volts)14. A lowtension injury can produce death from cardiac arrhythmias. Severe morbidity following high-tension electrical injuries is generally the result of massive necrosis of deeper
structures, often necessitating major limb amputations or extensive reconstruction. Several clinical approaches based on different theories regarding the pathophysìology of injury are in current use, but the complete pathophysiological mechanism of electrical injury remains poorly understood.
Early débridement is necessary to prevent wound infection as well as the systemic challenge with myoglobins and toxic waste products-„?“. Different surgical regimens fail to prove the superiority of one regimen over another, since valuable objective measures like rate of -retum to work are only sparsely reported. The concept of ‚progressive‘ wound necrosis has been introduced by Baxter17, Skoog18, Bingham11 and Rouse and Dimick19 showed beneficial results after debridement of only obviously non-viable tissue, and stated that within 2 weeks after the injury, there is usually a good wound base for wound closure. Hunt et al.20, Quinby et al.21, Luce and Gottlieb22 and others favour an aggressive surgical approach with early radical débridement and coverage of the wound incorporating the entire reconstructive armamentarium from skin grafts to free flaps23. Wang et al.24 reported the use of early vein grafting to save limbs from amputation. Chick proposed the use of free flaps for wound
PD Dr. med. habil. Jürgen Hussmann
The Memorial Medical Center Bum Center admitted 1992 patients with acute burns between January 1980 and December 1993. One hundred and twenty-nine of these patients (6.5 per cent) sustained electrical injuries. The patients ranged in age from 5 months to 63 years, with an
average of 33. 7 years. All but seven patients were males. The average size of burn wounds was 9.5 per cent total body surface area (TBSA), ranging from 1 to 57 per cent TBSA. Ninety-four (72.9 per cent) of the injuries were work related. Involvement of the dominant upper extremity
occurred in 56 patients (61.5 per cent) in the lowtension group and in 31 patients (81.6 per cent) in the high-tensión groqp. The distribution of injuires is shown in Table I. During the time in hospital, the patients‘ average weight decreased from 81.4 to 78.9 kg. The average length of hospital stay was 21.6 days, and the costs of hospitalization ranged from $900 to $120 000, averaging $14 901. There were 91 (70.5 per cent) patients with low-tension electrical injuries, and 46 of those patients required surgery (Table II). Only three minor amputations including one tip of thumb amputation, one finger DIP amputation and one amputation of the fifth toe were performed (Table III). No major limb amputations or major reconstructions were necessary. Cardiac arrhythmias occurred in 31 per cent of patients in this group, all started within 24 h following admission of the patient. The average length of hospital stay was 11 days.
The high-tension injury group comprised 38 patients (29.5 per cent). The average number of surgical débridements was 2.3 before final wound closure, and an additional 1.2 procedures per patient were later required to improve the function of the injured site. Compartment syndromes were treated with a total of 55 fascìotomíes, 42 on the upper extremities and 13 on the lower extremities. They resulted in 28 amputations of the upper extremities, and in ten amputations of the lower extremities (Table III). A total of 39 amputations were performed, including six bilateral and one tripod amputation (Figure 1 ). There were 27 major limb amputations (Table III), and numerous reconstructive procedures including, 15 pedicled flaps and six free flaps ·(Table II). Nine groin flaps, nine local flaps, four pedicled and one free rectus abdominis flap, two pedicled and three free latissimus dorsi flaps (Figure 2 ), two free deltopectoral flaps, and one free fibula transfer were used to achieve wound closure or lengthening of the amputation stump in these 38 patients. The average length of hospital stay during the acute admission was 38 days.
Only 5 .3 per cent of patients were able to return to their premorbìd job. coverage of radically debrided wounds within 1-10 days after the injury25• These different philosophies have led to a controversy over optimal surgical treatment which is still not resolved.
PD Dr. med. habil. Jürgen Hussmann
Figure l. An 18-year-old male who accidentally touched a power line of 7200 volts. a, A fasciotomy was performed immediately following admission. b, Massive necrosis of all tissue layers required disarticulation of the arm at the shoulder joint. e, A small exit wound on the plantar surface of the right foot. d, A knee disarticulation of the right leg and an above-knee amputation of the left leg were required because of massive necrosis of all tissue layers. Both amputation stumps required an additional two surgical débridements each before final wound closure.
Complications included two patients with pulmonary emboli, one with empyema of the elbow, two cases of heterotopíc calcifications, and one death from cardiac arrest prior to admission (Table IV). There was no incidence of renal insufficiency or of clostridial infection. Peripheral neurological symptoms of dysaesthesias, cold intolerance, and others persisted in nine patients (10 per cent) after low-tension injuries, and in 23 patients (60.5 per cent) after high-tension injuries (Table V). Other neurological longterm sequelae in the high-tension group included insensate
limbs (four patients), persistent motor palsy (eight patients) and seizures (two patients). The overall mortality rate was 0.8 per cent (one patient).
Following low-tension electrical injury cardiac arrhythmias presented as the most serious medical problem in our series (41 per cent of patients), whereas local wound problems were minor. Surgical treatment included only one debridement before full thickness or split thickness skin graft coverage. No local or distant flaps were necessary. In all patients wound closure was accomplished 2-5 days after injury. This clinical approach is supported by experimental findings26 indicating that low-voltage burn wounds did not ‚progress‘ more than 48 h after the injury.
Figure 2. A 33-year-old male who accidentally touched a power line of 7200 volts. a, The entrance wound is visible on the thénar eminence of the right hand. b, The debridement required resection of skin, subcutaneous tissue and peritendinous tissue down to the plane of the flexor tendons and the median nerve. e, Wound closure was achieved using a free latissimus dorsi flap with microvascular anastomosis to the radial artery and two
accompanying veins. d, e, The functional result after 3 months shows complete active flexion and extension of the thumb and fingers.
PD Dr. med. habil. Jürgen Hussmann
The treatment of high-tension injuries must focus on several problems simultaneously, including maintenance of multiple organ function, elimination of waste products, accompanying injuries related to fall or unconsciousness, and obvious as well as occult soft tissue destruction. The rate of renal failure has been drastically reduced over the last decades due to vigorous fluid supplementation (i.e. 9ml/kg/o/o TBSA)2 7 • Furthermore, the overall mortality has been reduced. Our principles for wound treatment following hightension electrical injuries included early serial debridement of obviously dead tissue to minimize the risk of infection and subsequent complications. Four patients required acute amputations following admission because life-threatening systemic challenges from myoglobin, potassium and toxic waste products was expected. The remainder of the initial débridements was performed as soon as the patient was stable, usually 1 or 2 days postinjury. The debrided wounds were temporarily covered with porcine xenograft or allograft to prevent desiccation. Definitive wound closure was achieved on the second or third visit to the operating room in 87 per cent of our patients (day 5 after injury). This regimen, in our opinion, preserves the greatest amount of structures and tissues because it reduces desiccation of vital tissues and diminishes the rate of wound infection. Great care was taken to preserve the maximum functional limb length. A free fibula transfer was performed in one case to lengthen the amputation stump to achieve a better functional result. The major limb amputation rate in our series (Table VI) was 35 per cent, which compares favourably with major limb amputation rates reported in the literature, which are as high as 71 per cent 19. The highest hospital cost ($120 000) was in a patient who sustained deep partial and full skin thickness injuries of 38 per cent total body surface area from a high-tension injury. He required seven surgical debridements prior to final wound closure. The high number of surgical procedures was the most expensive factor during the acute hospital stay, but this helped to preserve a maximum of amputation stump length. He and four other patients had preservation of below-elbow stumps instead of proximal amputations of the humerus. Below-elbow prostheses were fitted in all patients, two of whom were able to return to work. The most important economic factor was not the cost of medical treatment and rehabilitation, but the life-long disability of these young handicapped patients. We feel strongly that the whole spectrum of reconstructive surgery, including free fibula transfer, should be applied to preserve or restore maximal stump length in order to provide optimal function. If an amputation cannot be avoided, great care must be taken to provide sufficient stump length and stable soft tissue coverage for adequate prosthetic fitting.
High-tension electrical injuries carry a low mortality but exceedingly high morbidity. Early serial debridement and adequate fluid resuscitation28 decrease mortality and morbidity, but amputation rates are still high. Artz compared the complexity of the injury pattern to crush injuries29 • Early fasciotomy did not reduce significantly the amputation rate in our series. We performed 39 amputations in 38 patients with high-tension injuries, and three amputations in 91 patients with low-tension injuries. The mechanisms of muscle necrosis from electrical injury remain incompletely understood. However, several promising approaches have been presented to explain the pathophysiology. Those include thermal damage'“. direct cellular damage by strong electric fields13, rupture of the cellular membrane by electrical and thermal forces12’31, biochemical alterations32, and others. Our own experimental in vivo microcirculatory studies in a rat gracilis muscle have shown severe coagulation necrosis close to the interfaces between electrical wires and muscle tissue after a standardized electrical injury. The middle portion of the muscle, however, showed increased leucocyte adherence in postcapillary venules and initial arteriolar vasodilatation followed by progressive vasoconstriction during the 4-h observation period after the injury33. Studies using monoclonal antibodies against CD-18 or ICAM-1 have shown partial reversibility of tissue changes in this experimental electrical injury model34. Similar tissue responses have been reported following ischaemia-reperfusion injury35.
Treatments which have been shown to be beneficial after ischaemia-reperfusion injury might also be applicable after electrical injuries.
PD Dr. med. habil. Jürgen Hussmann
1 Jex-Blake AJ, Oxon BC. The Goulstonian Lectures on death by electric currents and by lightning. Br Med J 1913; 1: 425-430.
2 D’Arsonval MA. Action physiologique des courants alternatifs à grande fréquence. Arch Physiol Norm Paihol 1983; 5: 401-408.
3 Di Vincenti FC, Moncrief JA, Pruitt BA Jr. Electrical injuries: a review of 65 cases. J Trauma 1969; 9: 497-507.
4 Stances A Jr, Larson SJ, Mykleburst J et al. Electrical injuries. Surg Gynecol Obsle! 1979; 149: 97-108.
5 Hunt JL, Sato RM, Baxter CR. Acute electrical burns; current diagnostic and therapeutic approaches to management. Arch Surg 1980; 115: 434-438.
6 Hanumadass ML, Voora SB, Kagan RJ et al. Acute electrical burns: a 10-year clinical experience. Bums 1986; 12: 427-431.
7 Meinhold G. Zur Frage der Todesfälle bei sinusoidalem Strom. Dtsch Med Wochenschr 1918; 44: 490.
8 Kennelly A. The danger of electric shock from electrical engineering standpoint. Phys Ther 1927; 45: 16-23. 9 Solem L, Fischer RP, Strate RG. The natural history of electrical injury. J Trauma 1977; 17: 487-492. 10 Nafs FJE, Aromir CF, Carreira Set al. High tension electrical burns. Eur J Plast Surg 1993; 16: 84-88.
11 Bingham H. Electrical burns. Clin Plast Surg 1986; 13: 75-85.
12 Lee RC, Gaylor ÒC, Bhatt D, Israel DA. Role of cell membrane rupture in the pathogenesis of electrical trauma. J Surg Res 1988; 44: 709-719.
13 Lee RC. The pathophysiology and clinical management of electrical injury. In: Lee RC, Cravalho EG, Burke JF, eds. Electrical Trauma. New York: Cambridge University Press, 1993; p 33.
14 Lee RC, Gottlieb LJ, Krizek TJ. Pathophysiology and clinical manifestations of tissue injury in electrical trauma. ln: Habal MB, ed. Advances in Plasticand Reconsiructiue Surgery, vol 8. St Louis: Mosby Year Book, 1993; p 1.
15 Sevitt S. A review of the complications of burns, their origin and importance for illness and death. J Trauma 1979; 19: 358-369.
16 Parshley PF, Kilgore J, Pulito JF et al. Aggressive approach to the extremity damaged by electric current. Am J Surg 1985; 150: 78-83.
17 Baxter CR. Present concepts in the management of major electrical injuries. Suri Clin North Am 1979; 50: 1401-1418.
18 Skoog T. Electrical injuries. J Trauma 1970; 10: 816-830.
19 Rouse RC, Dimick AR. The treatment of electrical injury compared to burn injury: a review of pathophysiology and comparison of patient management protocols. J Trauma 1978; 18: 43-47.
20 Hunt JL, Mason AD, Masterson TS et al. The pathophysìology of acute electrical injuries. J Trauma 1976; 16: 335-340.
21 Quinby WC, Burke JF, Trelstad RL et al. The use of microscopy as a guide to primary excision of high-tension electrical burns. J Trauma 1978; 18: 423-431.
22 Luce EA, Gottlieb SE. True high-tension electrical injuries. Ann Plast Surg 1984; 12: 321-326.
23 Lister GD, Scheker L. Emergency free flaps to the upper extremity. J Hand Surg 1988; 13A: 22-28.
24 Wang X, Roberts BB, Zapata RL et al. Early vascular grafting to prevent upper extremity necrosis after electrical burns. Commentary on indications for surgery. Burns 1985; 11: 359-366.
25 Chick LR, Lister GD, Sowder L. Early free flap coverage of electrical .and thermal burns. Plast Reconsir Surg 1992; 89: 1013-1019.
26 Laberge LC, Ballard PA, Daniel RK. Experimental electrical burns: low voltage. Ann Plast Surg 1984; 13: 185-190.
27 Luce EA. The spectrum of electrical injuries. In: Lee RC, Cravalho EG, Burke JF, eds. Elecirical Trauma. New York: Cambridge University Press, 1993; p.106.
28 Barisoni D, Bertolini D. Kidney function in the extensive bum. Burns 1981; 7: 361-364.
29 Artz CP. Electrical injury simulates crush injury. Surg Gynecol Obstet 1967; 125: 1316-1317.
30 Lee RC, Kolodney MS. Electrical injury mechanisms: dynamics of the thermal response. Plast Recensir Surg 198 7; 80:
31 Benz R, Beckers F, Zimmermann U. Reversible electrical breakdown of lipid bilayer membranes: a charge-pulse relaxation study. J Memb Biol 1979; 48: 181-204.
32 ( Robson MC, Hayward PG, Heggers JP. The role of arachidonic acid metabolism in the pathogenesis of electrical trauma. In: Lee RC, Cravalho EG, Burke JF, eds. Electrical Trauma. New York: Cambridge University Press, 1993; pp 179-188.
33 Hussmann J, Zamboni WA, Russell RC et al. A model for recording the microcirculatory changes associated with standardized electrical injury of skeletal muscle. J Surg Res (in press).
34 Hussmann J, Kucan JO, Russell RC et al. Partial reversibility of tissue changes following high voltage electrical injury after use of MAB against CD-18 or MAB against ICAM-1 in a standardized rat model. J Surg Res (accepted).
35 Zamboni WA, Roth AC, Russell RC et al. Morphologic analysis of the microcirculation during reperfusion of ischemie skeletal muscle and the effect of hyperbaríc oxygen. Plast Recensir Surg 1993; 91: 1110-1123.
Paper accepted after revision 18 January 1995.
Correspondence should be addressed to: Dr J. Hussmann, SIU School of Medicine, Institute for Plastic and Reconstructive Surgery, PO Box 19230, Springfield, IL 62794-9230, USA.
Epidemiological data on burn injuries in Angola: a retrospective study of 7230 patients
C. Adamo, G. Esposito, M. Lissia, M. Vonella, N. Zagaria and N. Scuderi Department of Plastic and Reconstructive Surgery, University of Rome ‚La Sapienza‘, Policlinico Umberto I, Rome, Italy
This study describes the work carried out at the Burn Unit of theNeves Bendinha Hospital, Luanda, Angola, during the 3-year period July
1991 to June 1994. During this period we admitted 2569 burned patients to our burn unit, and 4661 were treatedon an outpatient basis,
The data from the patients were analysed to indicate the distributon according to age, sex, TBSA, cause of the lesion and mortality. Our
study gives some epidemiological data on burns in an undeveloped country undergoing a war, outlining the specific problems compared to
the reality in civilized countries.
Burns, Vol. 21, No. 7, 536-538, 1995
This retrospective study describes the work carried out at the Bum Unit of the Neves Bendinha Hospital, Luanda, Angola, during the 3-year period July 1991 to June 1994, by an Italian medical team from the Universities of Padova, in the early stage, and then from Rome. The Neves
Bendinha Hospital is the main centre for the treatment of bums in Angola: it was completely restructured and became operative in February 1990, although we started to treat severely burned patients oaly from April 1991, with the opening of the intensive care unit. It is not possible to
know exactly the number of people served by the unit, because many refugees come into Luanda every day from all other parts of Angola, and quite probably many others try to leave the country. The population of Luanda is now estimated to be about 3000 000 people.
This programme, financed by the European Community in cooperation with the Angolan Ministry of Health, was initiated after the peace agreements in June 1991, in order to provide assistance to the re-entering refugees who had been dispersed to other areas or in neighbouring countries. Unfortunately, the prospect of the first free elections in Angola, which took place on 28 and 29 September 1992, and the general disorder which was feared, slowed down the activities within the country to the extent that even the number of foreign personnel involved in aid projects was reduced for security reasons. The civil war broke out again at the end of October 1992, arid at that time all nonindispensable
foreign personnel‘ were evacuated. The medical team working at the Neves Bendinha Hospital was reduced to the coordinator, the anaesthetist and a nurse, who were kept on due to the absolute necessity for health care in the city. The full team has been operating again since January 1993. During this period we treated 7230 new burned patients, of which 2569 were admitted to the hospital. The aim of our review is to provide some epidemiological data on bums in an undeveloped country under war conditions, outlining the specific problems compared to the reality in
Materials and methods
Between July I 991 and June 1994, we admitted 2569 burned patients to our bum unit, and 466 I were treated as outpatients. A total of 57 beds are available in the Neves Bendinha Hospital, divided into: intensive care unit (ICU) (eight beds: six adult and two paediatric), semi-intensive
care unit (seven beds: five adult and two paediatric), confinements (42 beds: 30 adults and 12 paediatric). There are two operating rooms and two dressing rooms. The ICU is completely isolated, with no visitors allowed. All patients were treated according to our treatment protocol, including resuscitation with a modified Parkland formula, early escharectorny, and local treatment depending on the area involved (open method for face, scalp and perineum, and closed method for all other areas, with silver sulphadiazine dressing).
All information was collected by direct interview with the patient or relative (age, sex, cause of bum, details of habitat). Total burn surface area (TBSA) was estimated from body surface charts. The data were analysed to find out the distribution of the patients according to age and sex, and the distribution of the bums according to TBSA, cause of the lesion and mortality.
Of the 7230 burned patients, 3734 were male (SI.ó per cent) and 3496 (48.4 per cent) were female. Figure 1 shows the number of burned patients by age groups. Children under 14 are the commonest victim (4222 patients, 58.4 per cent), and the single largest group is under 5 years old, numbering 31.7 per cent of the total (2289 patients). Hot liquids were the commonest cause of injury (3430