Electrical Injury

Electrical Injury

• In the U.S. 52,000 admissions/yr

• 3-8 % of all burn unit admissions

• May-Sept lightning related.

• Decrease in incidence due to GFCIs

Electrical Injury - Epidemiology

• Ages 15-44 yrs.

• High voltage mostly occupational injury

• 20% Children– Low voltage injuries in toddlers

M:F 1.7:1– High voltage injuries in adolescents

97% male

Electrical Injury - Pathophysiology

• Electrical – tetany, arrhythmia

• Thermal – burns, coagulation

• Mechanical – fractures, dislocation

I= current V= voltage R= resistence

Ohm’s Law

I= V/R

E= energy I= current R= Resistence T= time

E=I²RT

Joule’s Law

Electrical Injury - Pathophysiology

Current pathway defines resistence

- Vertical higher incidence of complication

- Hand – to – hand pathway

- Below symphysis, stradle pathway

Electrical Injury - Classification

• High (>1000 Volt) vs. low (<1000 Volt) voltage

• Direct (lightning) vs. alternating (50 Hz) current

• Arc injury (high temperature), flashover

Cardiovascular Involvment

• Mostly in vertical injury

• DC – Asystole

• AC– High VF/ VT, asystole– Low ectopic beats, AF, tachycardia,

bradycardia, ECG changes

• Coagulation necrosis, coronary spasm, MI

Respiratory Involvement

• Tetany of respiratory muscle

• Brain stem injury

• May induce hypoxia, acidosis cardiac arrest

Nervous System

• Immediate - loss of consciousness, amnesia

• Early - intracranial hemorrhage, vertebral fractures

• Late - ALS, transverse myelitis, ascending paralysis

• Peripheral neuropathy, RSD

Vascular Injury

• Large arteries – medial necrosis, aneurisms

• Small vessels – intimal injury, coagulation necrosis

• Secondary to compartment syndrome

Limb Injury

• Dislocations and fractures

• Coagulation of blood vessels

• Muscle ischemia and edema

• Compartment syndrome

• Thermal injury from bone heating

• Infection clostridial, streptococcal

Other Injuries

• GI – ileus, stress ulcers, direct injury

• Ophthalmic – cataract, iridiocyclitis, autonomic injury

• Otologic – tympanic membrane perforation, vertigo, sensoryneural injury

Injury Characteristics

Low VoltageLow Voltage

• 77% 0-5 YO

• 60% extremity

• 40% oral commisure

• No mortality

• Complete functional recovery

High VoltageHigh Voltage

• 76% 11-18 YO

• 33% limb amputations

• 30% deep muscles

• 12% fasciotomy/ escharotomy

• No mortality

Electrical Injury - Management

• Combined ATLS + ACLS protocols

• Cardiac monitoring for 24 hrs if LOC, ECG changes or arrhythmias

• IM dT

• IV H2 - blockers

Electrical Injury – Resuscitation

• 1.7 X Parkland formula or 9 ml/kg/%TBSA

• Urine output 70 - 100 ml/hour

• Clearance of any pigment in urine

• Bicarbonate - blood pH > 7.45

• Osmotic diuresis – IV MANNITOL 25 gr

Electrical Injury – Wound Managemant

“True” high tension

• Sharply demarcated

• Always full thickness

• Leathery appearence

Electrical injury – Wound Management

• Primary resuscitation.• Early exploration and debridment • “Second look” in 24-48 hrs –definitive Tx

– Primary closure– Coverage– Amputation

•“Progressive necrosis” theory

• Frequent envolvement of the hand

• Exit point in one or both legs

• Arc injury in distal fore arm or axilla

Wound Management – Extremities

Wound Management – Extremities

• Initial assessment usually predicts outcome:– Depth of burns– Ischemia– Anasthesia– Flexion position– Muscle viability- response to

electrocautery

Electrical Burn - Extremities

• Exploration - large volume underlying necrotic area

• Full thickness burns

• Proximal periosseous myonecrosis

• Retained questionable tissue may lead to contamination and further compromise

Wound Management – Extremities

Wound Management - Scalp

• Saucer shaped, deapest in the middle

• Delayed Tx osteomyelitis and epidural abscess

• Debridment of soft tissue, outer cortical bone and skin grafting

• Full thicknss skull - devitalization & flap coverage

Wound Management – Trunk & perineum

• Suspect visceral injury

• Lung – Atelectasis and edema

• Abdomen – consider as penetrating wound

• Perineum –urinary and bowel diversion & debridment +STSG

Electrical Injury -Summery

סוג הפגיעה ומיקומה•

ATLS ו- ACLSטיפול ראשוני לפי פרוטוקולים •

החייאת נוזלים•

אקספלורציה והטרייה מוקדמים•

טיפול דפיניטיבי מוקדם – בכל שיטות השחזור •המקובלות