ABSTRACT

KEY WORDS: Burn trauma, Complications of high-voltage electrical burn injuries, Fasciotomy, Prevention of burn, Treatment of high-voltage electrical burn injuries

INTRODUCTION
With the discovery of electricity, significant advancements have occurred in industry and social life. Electricity has made highly positive contributions to human life, making work and home life easier and more convenient than in previous eras. However, alongside with the benefits, electricity has also caused fatal complications and disabling consequences for humans. The first death related to electricity was reported in 1879.¹ Although electrical burns are less frequent than some other burn injury mechanisms, they are a highly destructive form of trauma.² Electrical burns are much more complex and associated with higher morbidity and mortality than other skin burns. Electrical burns are not only related to trauma to skin or deep tissues but have serious systemic effects that are hazardous to the body, which have other associated trauma. Electrical burns require more surgical intervention and longer hospital stays, making uncontrolled electrical injuries a significant problem for humanity.^3,4

The mechanism of injury resulting from electrical burns is complex and depends on factors such as the contact area, the duration of contact, and the intensity of the electrical current.^5,6 In Turkey, Haberal was the first researcher to emphasize the significance of electrical burns.^8-12 Treating and caring for electrical burns based on symptoms can improve prognosis. Identifying the mechanism of injury and taking preventive measures are the most effective ways to reduce the frequency and severity of electrical injuries.²

In this retrospective study, we analyzed patients with electrical burns treated at burn centers of Başkent University located in different regions of Türkiye.

MATERIALS AND METHODS
We used medical records to retrospectively review electrical-related burns treated by the Baskent University Hospitals in 3 burn centers (Baskent University Ankara, Adana, Konya Burn Centers) between January 2008 and October 2023. We reviewed 361 electric burn injuries. We analyzed patient demographic characteristics, epidemiology of the injury Figure 1 and Figure 2, the mechanism of injury, size and depth of burn, and method of surgical and medical treatment associated with electrical burns in our centers.

The clinical scenarios of a patient in true high-voltage electrical injury include entry and exit points of electricity in the body Figure 3 and Figure 4, bloody urine due to muscle breakdown Figure 5, and fasciotomy performed due to compartment syndrome as soon as possible Figure 6 and Figure 7.

Initial management
Initial management included ensuring airways in patients were clear and assessing cardiopulmonary functions, as well as hospitalization. Entrance and exit sites of wounds were assessed, and possibility of muscle necrosis or blunt trauma was considered. A careful history was taken.

Monitoring
Monitoring included electrocardiogram, arterial and venous pressures (considering pulmonary arterial catheter), urine output, serum electrolyte, myoglobin, and creatine phosphokinase and coagulation factors. Extremities of patients were closely evaluated to determine possibility of compartment syndrome. Flow to distal extremity was monitored (via Doppler sonography and physical examination), central and peripheral nerve functions were evaluated.

Fluid resuscitation
Patients received fluid resuscitation that included lactated Ringer solution and colloids and blood products as necessary. Patients received mannitol infusion (25 g bolus followed by 12.5 g every 2-4 hours), with sodium bicarbonate added to intravenous solution (to maintain urine pH >7). Patients received low-dose dopamine if large amounts of fluids were necessary and received loop diuretics if pigment load persisted. If necessary, patients received hemodialysis or plasmapheresis if urine alkalization and diuretics were not enough to clear muscle breakdown products.

Infection control
For infection control, patients received wound debridement as soon as they were stable. Patients received tetanus prophylaxis, topical antibiotics to burned regions, and systemic antibiotics according to tissue cultures.

RESULTS
Of 361 patients with electrical burn injuries in our study group, 87.1% were male and 12.9% were female patients. Of total patients, 76.1% had high-voltage electrical burn injury, 13.4% had flash injuries, and 10.5% had low-voltage electrical burn injury. None of our patients were exposed to lightning strikes. Mean age of the patients was 28.93 years Table 1. Accidents occurred at workplaces in 47.3% of patients, in streets or open areas in 33.9% of patients, and in home environments, such as balconies or inside the house, in 18.8% of patients. Of accidents, 70% took place in urban areas and 30% in rural regions; 34.7% of accidents occurred in summer, 26.3% in spring, 20.1% in autumn, and 18.9% in winter. When we look at patients according to their professions, workers were the most exposed to accidents, with a rate of 34.1%. Other professions included self-employed (19.5%) and students (18.9%). All the professional groups involved in accidents are shown in Table 2. Among patients, 85.4% were treated with inpatient care, and 13.8% received mechanical ventilation treatment. In addition, 32.1% were fed with enteral nutrition, whereas 22.8% were fed with parenteral nutrition. A majority of patients (67.2%) received systemic antibiotic treatment. The mortality rate was 8.92% Table 3.

The average transport time from the occurrence of the accident to our centers was 2.5 days. Mean total body surface area percentage was 21.1%. The average length of hospital stay for the patients was 25.5 days. At the time of patient admission, average serum CPK level was 8722.63 U/L and mean blood myoglobin level was 1924.43 ng/mL Table 1.

The most common complication observed in our patients was invasive wound infection (67.1%). This complication was followed by deep muscle involvement (43.4%), sepsis (34.6%), peripheral nerve damage (20.2%), and acute respiratory distress syndrome (13.8%). In addition to these frequently encountered complications, other complications included altered consciousness, pneumonia, head trauma, acute kidney failure, eye complications, gastric ulcer bleeding, decubitus ulcers, pneumothorax, cardiac arrest, spinal cord injury, and splenic injury Table 4.

When we examined the surgical procedures performed on our patients, debridement was applied to 62.2%, grafting to 54.6%, fasciotomy to 33.7%, amputation to 15.1%, and flaps to 14.24% of patients Figure 8. Anatomical regions of the amputations are shown in Table 5 and Figure 9; amputation occurred in a total of 55 anatomical regions.

DISCUSSION
Electrical injury contributes to pathology through 3 distinct mechanisms, 2 of which are directly proportional to the intensity of the current. These mechanisms define what is referred to as “true” electrical burn injury. In true electrical burns, the current passes through the body of the affected individual. When the current exceeds 1000 volts, the burn is classified as a high-voltage electrical burn injury, whereas currents below 1000 volts passing through the body are referred to as low-voltage electrical burn injuries.¹³

Although low-voltage electrical burns are more common, fewer people with this type of injury require hospitalization. However, high-voltage electrical burns are more often observed in industrial areas and are more prevalent among individuals aged 20 to 40 years. Consequently, men and laborers are more commonly affected.¹⁴ Our study showed similar patterns.

Unlike the mechanisms in low- and high-voltage electrical burn injuries, in flash injuries, the electrical current does not pass through the body. Instead, the 4000 ℃ heat generated near the electrical source affects the individual. The person is affected similarly to a flame burn, with clothing ignition contributing to damage.¹³ In our study, we surmised that 21.1% TBSA was attributed to flash injuries.

The incidence of electrical burns varies by region; however, developed countries have lower incidence due to educational measures. In East Asia, incidence was reported as 3.2%, whereas a study conducted in Turkey in 2003 reported an incidence of 21%.^15,16

The burn centers where patients in this study were seen are in hospitals affiliated with our university. One center in Adana, Turkey, is located in a region dominated by a Mediterranean climate and characterized by warm weather for most of the year. Approximately 60% of the injuries in included patients occurred during the spring and summer months. The autumn months in our country are also relatively warm. Electrical burns in our study primarily occurred in mild and warm weather conditions.

In a study conducted in the United State, mortality rate in electrical burns varied between 3% and 15%.^17,18 In our study, the mortality rate was 8.92%.

Among workers, those involved in electrical work, construction workers, farmers, and truck drivers are at risk of exposure to electrical injuries, similar to that shown in our study.^19,20 In addition, unique to our study, painters working on exteriors of building and workers installing glass balconies were identified as high-risk occupational groups for electrical burns.

Another important finding in our study was that high-voltage electrical burns are from multiple causes, occurring in occupational and domestic settings Figure 1 and Figure 2. Domestic settings were linked to electricity poles located near residential balconies. Children playing on balconies were exposed to high voltage, housewives drying laundry faced the risk of electric shock, and residents were also affected by electric currents through television antennas on balconies.

In electrical burns caused by high voltage, varying degrees of skin burns can occur, and damage frequently extends to deeper tissues, such as muscles, blood vessels, and nerves. As a result, limb loss, acute renal failure, or acute tubular necrosis may develop due to the accumulation of myoglobin and cell fragments in the renal tubules.¹³ In our patient group, acute renal failure developed in 11 patients. In such cases, non-burn-related secondary injuries due to falls from height were also encountered. In our study group, head trauma, blunt abdominal trauma, pneumothorax, and spinal cord injury occurred as a result of falls from height. These complications are indicated in Table 4.

Electrical burns caused by high voltage resemble crush injuries to some extent because of the deep tissue damage that such burns cause. Various electrolyte imbalances can occur, including elevated potassium, decreased calcium, and increased phosphorus levels. Significant inflammatory process may cause increased capillary permeability. These factors result in fluid and electrolyte shifts. In addition, these changes and the electrical current itself can lead to cardiac arrhythmias. Because of the complications mentioned above, patients exposed to such trauma are hospitalized and may even require treatment in intensive care units. Patients with electrical burns should be treated in hospitals that are equipped, experienced, and staffed with personnel trained in this field.

The amputation rate in electrical burns caused by high voltage is higher than in those caused by low voltage. This has been statistically proven.¹³ However, no definitive risk factor for amputation has been identified. In our opinion, fasciotomy or escharotomy should be performed on patients within the first 8 hours to save the extremity. In our study group, the average transportation time to our center was approximately 2.5 days. This leads to the conclusion that fasciotomy and escharotomy were delayed. Although such compartment syndrome-preventive interventions do not entirely prevent amputation, they can save the proximal joint. Having this procedure positively affects the quality of life of patients in the long term.

CONCLUSIONS
Public education and governmental legislation are important for preventing work-related accidents. Coexisting traumas have to be considered in this type of injury. Resuscitation is important at the beginning of treatment. Early fasciotomy can prevent limb salvage or can prevent extensive amputations. After resuscitation, early debridement and reconstruction via grafting or flaps are important. Physiotherapy is crucial after reconstruction.

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