ANALYSIS OF ELECTRICAL BURNS IN ALBANIA: A FOUR-YEAR REVIEW

SUMMARY

This is an epidemiological review of electrical burns admitted to the Service of Burns and Plastic Surgery, UHC “Mother Theresa” of Tirana, Albania, covering a four-year period, from 2019 to 2022. Twenty-seven patients were identified as having sustained an electrical burn injury, all of them males and most of them, namely 85%, belonging to the “working force” age group 19-65 years old. Most of the accidents, 70% of them, occurred at work, and these were all high voltage electrical burns. A total 65% of the cases had at least one of the upper limbs involved and the mean surface area burned was estimated at around 20% TBSA, mortality rate 11.1%, and all the fatal cases were from occupational burns. Serum level of BUN, creatinine and liver enzymes were evaluated on admission and at least 7 days after, with no significant changes. WBC count was found to be elevated in almost all the patients, and remained elevated in the second week and even longer for patients with sepsis. Four of our patients needed amputations. Besides these, no other serious complications were registered.

Introduction

Electrical burns constitute a small part of all burns in our country but still pose a constant challenge to the team dealing with them, due to certain characteristics that differentiate such burns from all other types of burns. Consequences on wellbeing and the social and economic burden they cause, furthermore, are heavier than those from other burning accidents. Duration of stay for patients sustaining true electrical burns is longer and the cost of treatment (including surgery) is higher. The risk of morbidity, systemic infections, and permanent incapacity (because of amputation of the affected extremities) is higher. Early use of flaps may reduce these risks and further complications.¹

Mechanism of damage in electrical burns is related to the passage of electricity through body tissues, and the extent and severity of the consequences depend on the intensity of the current (in Ampers).² This amperage depends upon the resistance of the tissue that the current is passing through, inversely related to it, and is proportionally related to the voltage.

Severity of damage in true electrical burns derives from the fact that this kind of injury involves not only the skin with all its layers, like other types of burns, but also deeper tissues and important anatomical structures. This characteristic of the injury may often result in multiorgan damages and the necessity for amputation. Furthermore, the electric current passing through the human body causes complex reactions in the body tissues and organs: these reactions affect the organism’s histological, biochemical and structural composition, leading to damage to other organs like heart, kidneys, lungs, bone marrow etc.

Although the overall number of burned patients has significantly fallen in the last 10-15 years in our country, electrical burn incidence has remained almost the same, albeit the socioeconomic situation in Albania has changed for good.

We conducted this study to evaluate the epidemiology of electrical burns in the last four years in Albania, to identify the possible risks for sustaining an electrical burn, and see if any of these risks could be avoided in order to prevent, as much as we can, this often serious and devastating injury.

Materials and methods

This is a retrospective study of all patients with electrical burns, admitted to the Service of Burns and Plastic Surgery, University Hospital Center “Mother Theresa” of Tirana, Albania during the period January 2019-December 2022. One of the patients sustained the injury in 2018 but was included in the study because most of their hospital stay was in 2019.

Institutional Board Review approval was taken before beginning the study. Medical records were used to obtain all the data. Electrical burns were stratified as: true electrical burns and arc burns. The study aims to make an overview of data regarding:

incidence of electrical burns: distribution of electrical burns in different age groups and geographical distribution;

occurrence of electrical burns regarding site of accident: occupational or non-occupational (mainly domestic);

occurrence of electrical burns regarding location of wounds (parts of the body involved);

most significant lab parameters (BUN, Creatinine, WBC, liver tests,) and ECG changes;

severity: size (TBSA burned) and depth of burns;

length of hospital stay;

complications, amputations, mortality, final outcome;

effect of different variables on important issues like length of stay, complications, final outcome.

Statistically, analysis was done using SPSS statistics vers.27.0. Results were considered statistically significant when P value <0.05. Descriptive statistics were used to have a clear view on means, medians and other features. One-way ANOVA and Kruskal-Wallis test was used when comparing two or more independent samples.

Single table analysis was used when frequencies of proportional data output were organized by having a single statistics table for variables. Chi Square and P value were calculated for the statistical significance of tables.

Paired sample t-tests were done to evaluate means of continuous variables.

Results

There is an almost constant incidence of electrical burns in Albania (Fig. 1). Even for 2020 when the total number of burned patients decreased significantly because of the Covid-19 pandemic and the following lockdown, the incidence of electrical burns, strangely, did not change.

Fig. 1.

Electrical burns vs. total burns

All burned patients were males, with an average age of 43.5 yrs old (range: 10-82 yrs, Std. Dev. 17.5, Skewness 0.04). When considering age, we organized data into three main groups, to identify the most vulnerable age group: working age (19-65 years old), not working age (0-18 years old) and elderly (older than 65 years). As seen in Fig. 2, the most affected age group is that of active age, i.e. people in the active working age. Only 2 cases belonged to pediatric ages, and 2 were of the third age.

Fig. 2.

Electrical burns in different age groups

Therefore the active age, which is also the working age, had the highest incidence. The age of more than 85% of electrical burned cases was between 19 and 65 yrs old.

Most of the cases came from urban areas, more often from our big cities like Tirana (the capital), Durres and Shkoder (Fig. 3). 70% of our patients had the accident at work. Only 1/3^rd got the electrical injury while operating with electricity at home (Table I).

Fig. 3.

Geographical distribution of cases

Table I.

Occupational and domestic electrical burns

	N	%
Occupational	19	70.4%
Domestic	8	29.6%

Most of the burns occurred on the extremities (Table II). More than 65% of patients had at least one limb involved. And, as it may be seen from Table II, true electrical burns occurred mostly in extremities and electrical arc flash burns involved mainly the face/hands/anterior trunk and, less often, other parts of the body.

Table II.

Location of true electrical and flash burns

Mean percentage of BSA burned was 20%, ranging from 5% to 70%. Small burns (BSA: 0-15%) were found in more than half of the patients (Table III). As a matter of fact, the initial diagnosis in our clinic, especially for true electrical burns, rarely has any specifications on either the BSA burned or degree of burn. We always consider true electrical burn as serious damage, and never give any reports on the surface area involved, knowing that in the coming days the first impression, and consequently diagnosis, might be irrelevant to the real damage. So, the diagnosis reported here is a later one, after the picture of what has been involved is completely clear, usually 2-3 days after the initial injury.

Table III.

Body surface area burned

Typically, superficial burns were less common (Table IV). Only less than 25% of patients had burns of less than III degree. Most of our patients had III degree or even deeper burns.

Table IV.

Degree of burns

Degree	Freq	Percent
IIB-III	14	51.9
III	9	33.3
IV	4	14.8
Total	27	100.0

Three patients had a fatal outcome (Fig. 4), representing 11% of all the patients. All of them belonged to the group of High Voltage Injury patients. So, within this group mortality results 14.3%. BSA burned and the type of initial damage, i.e., a true electrical burn or electrical arc flash burn, had the greatest impact on prognosis, P value respectively 0.005 and 0.009 (Table V), whereas fatality was independent of degree of burn.

Fig. 4.

Final outcome

Table V.

Influence of BSA, type of electrical burn and its degree on prognosis of patients

More than 2/3^rd of patients had a stay of more than 5 days in hospital (Table VI). Degree of burn did not show any impact on hospital stay (Fig. 5). No relation was found between TBSA burned and length of hospital stay (Fig. 6). A hospitalization duration of 6-15 days predominates regardless the BSA involved, but this is not statistically significant.

Table VI.

Hospital stay for electrical burned patients (Mean=15,6; Range: 1 – 69 days). (Chi Square 2.04; P=0.729)

Hospital Stay	Freq	Percent
Up to 5 days	5	18.52%
6-15 days	15	55.56%
More than 15 days	7	25.93%

Fig. 5.

Hospital stay as per degree of burn (Chi Square 2.04; P=0.729)

Fig. 6.

Influence of BSA on hospital stay (Chi Square 1.69; P=0.792)

Degree of burn was independent of the type of burn (Fig. 7).

Fig. 7.

Degrees of burns in the two types of burns (Chi-Squared: 3.3; P=0.196

We analyzed some biochemical blood values, taken at the moment of admission and 5-7 days afterwards (Table VII). Creatinine, BUN, ALT and AST showed no significant changes during the hospital stay. What did change significantly was white blood cell count, and this change resulted statistically significant.

Table VII.

Biochemical test on admission and 7 days after

In almost half of the patients there were signs of SIRS. Four patients showed signs and symptoms of sepsis, confirmed by positive growth of S. Aureus in blood samples.

Half of the patients had altered liver enzyme levels, either soon after the accident or during the course of the disease. Five patients had no ALT or AST performed.

ECG changes were not related to the fact that patients had the accident at work (high voltage) or at home (low voltage) (Table VIII). The main cardiac disorders resulting from the electrical injury were rhythm disorders, which disappeared when leaving the hospital. Only one patient left hospital with irreversible cardiopathy (Table IX).

Table VIII.

Cardiac changes and their relation to site of accident (work/domestic) (Pearson Chi square: 2.6; P=0.758)

ECG changes			Occupational
	N	%	Yes	No
Normal	12	44.4%	7	5
Atrio-ventricular block	2	7.4%	2	0
Not applied	3	11.1%	2	1
Problems in repolarization	3	11.1%	2	1
Rhythm disorders	7	25.9%	5	2

Table IX.

Complications of electrical burns

Complication	N	%
Anemia	7	25.9%
Depression	2	7.4%
Diabetes	1	3.7%
Hepatic	1	3.7%
Ischemic cardiomyopathy	1	3.7%
Politrauma	2	7.4%
Exitus letatis	3	11.1%
No complications	10	37.0%

Anemia is a common finding in severely burned patients.³ We found that 25% of our patients showed signs of anemia during the course of disease (Table IX), which ranged from severe to moderate. It was the main complication in our patients, if we leave out the temporary liver disfunction, demonstrated by elevated liver enzyme levels, which in fact returned to normal levels after the first week. Two patients suffered from PTSD (posttraumatic stress disorders/depression) at discharge from the hospital.

Escharectomy was the most frequently used surgical technique (Table X). Almost all patients had one or more escharectomy/debridement procedure during the course of the disease. Escharotomy was done on only 9 patients, fasciotomy on 4.

Table X.

Surgical technique applied in electrical burns

Surgical Technique		Nr	Percent	Exact 95% Conf Limits
Escharectomy	YES	9	33.33%	16.52%	53.96%
	NO	18	66.67%	46.04%	83.48%
Escharotomy	YES	25	92.6	75.71	99.1
	NO	2	7.4	0.91	24.29
Fasciotomy	YES	4	14.81%	4.19%	33.73%
	NO	23	85.19%	66.27%	95.81%
Skin Crafting	YES	7	25.9	11.11	46.28
	NO	20	74.1	53.72	88.89
Amputation	YES	4	14.81	4.19	33.73
	NO	23	85.19	66.27	95.8

Surgical interventions were applied with an average of 2.04 interventions per patient (Table XI). Number of interventions needed for one patient did not depend on the degree of burn (Table XII) nor on the TBSA burned (Table XIII).

Table XI.

Number of surgical interventions applied in a patient

Number of surgeries	Freq	%	Exact 95% Conf Limits
1	7	25.93%	11.11%	46.28%
2	12	44.44%	25.48%	64.67%
≥ 3	8	29.63%	13.75%	50.18%

Table XII.

Number of surgeries applied in different degrees of burns (Chi square: 3.85, P=0.426)

Number of surgeries	IIB-III degree	III degree	IV degree
1	5	2	3
2	12	3	3
≥3	6	5	3

Table XIII.

Number of surgeries applied in different BSA of burns (Chi square: 3.85, P=0.426)

Number of surgeries	0-15%	15-30%	>30%
1	5	2	3
2	7	8	3
≥3	3	8	3

Discussion

Electrical burns, although constituting a small percentage of all burns admitted to a tertiary burn center, continue to pose a heavy burden to the staff of these centers and lead to severe consequences to the patients themselves.^4,5 There exists a considerable difference in the incidence of electrical burns between developing countries and developed countries.6,7,8,9,10,11

Electrical burns differ a lot from other types of burns (scalds, chemicals, liquids, etc). The body area burned might be small, but there is often involvement of deeper structures, leading to deeper degree of burns.¹ Treatment of these burns demands special attention due to the possible risk for serious complications that might inflict almost any organ system in the human body (cardiac, renal, sepsis, bone fractures, lungs, compartment syndrome, etc).¹²

Electrical burns represent a small part of burns in Albania (only 3.8% of all burns admitted to our Burns Center are electrical - one in the last four years). It is almost the same as in other countries,⁴ which report an incidence between 4-5%. Albania is a developing country. Incidence of electrical burns in developing countries is reported to be as high as 27% of total burns, but in our country incidence is comparable to that of developed countries. Being the only Burns Center in Albania, data drawn from this survey might be extrapolated to the entire population of Albania, not limiting them only to the population of Tirana, the capital of Albania, where this Center is located as a part of the University Hospital Center Mother Theresa. According to the Census of 2021, the population of Albania is estimated to be 2.793.592 as of 1 January 2022, of which 1.387.060 are males.¹³ Our data show an almost constant number of burned patients due to electrical injury, on average 6,5 per year. This means 2,3 electrical burns per year per million inhabitants. And because all burns registered by us occurred in males, we could say that the incidence of electrical burns in males in Albania is 4,69 per million per year. Most reports found in literature show that almost 80% of electrical burns occur in males, versus 100% in our country.^5,7,10,14

Mean age of burned patients was 43.5 years old, ranging from 10 to 82. The most affected age group was that of working age (85%) of total electrical burns, with only 15% children or third age people (7.4%); and all burned patients were males. Almost all patients who sustained a HVI (high voltage injury) came from the OSSHE, which is the corporation that manages the production and transmission of electric power in our country. In all cases, failure to adhere to safety rules while working results as the cause of the accidents. This is important from the preventive point of view because increasing awareness of safety measures while working with high voltage current might further reduce the incidence of electrical burns among the workers of this corporation. The Albanian Society of Plastic Reconstructive Surgery is constantly in touch with the corporation, but still more is to be done and we are working on organizing a broad and countrywide awareness campaign with the aim of sharing information on how devastating an electrical injury can be, and how often it might lead to an amputation or even result in loss of life.

Interesting was the geographical distribution of electrical burns. Tirana, which is the capital and the most developed and industrialized city in Albania, had the highest incidence, followed by two other industrialized cities like Durres and Shkodra. Again, according to the Census of 2021, the population of Tirana constitute more than 32% of the entire population in Albania, hence most cases being from Tirana.¹³

Electrical burns occurred mostly in extremities (more than 2/3^rd of patients), explained by the fact that the contact points with the electrical current are firstly the hands.⁵ This explanation is confirmed when stratifying the incidence of burn localization in true electrical burns and electrical arc flash. Only one person had burns caused by electrical arc flash in extremities. All the others had true electrical burns.

Compared to burns caused by other agents, electrical burns usually involve a smaller percentage of BSA burned, but deeper degrees of burn.¹⁵ For the electrical burns, most of the studies from different countries report an average TBSA burned of between 20-30%.^5,8,9 In our study, more than half of the patients (55.6%) had a TBSA of 0-15%. Only 11% had a TBSA of more than 30%. Almost 75% of patients had 3rd degree or deeper burns.

Fatal results happened in 11% of patients. This is an unfavorable figure, while colleagues from developed countries report mortality as low as 2.6% in low voltage injuries,⁴ but as high as 18% for the high voltage burns.¹⁰

Compared to other studies found in literature, the treatment approach to electrical burned patients in our center results less surgical. No flaps result in the list of surgical procedures applied to our patients during this four-year period, escharectomy and skin grafting being the surgical treatment procedure on most patients. Amputations were done on only 4 patients, which means 14.8% of all the patients. Others report figures that vary from 3.8%⁵ to 12.2%¹⁶ and up to 41%⁸ in developing countries, this latter when high voltage injuries are considered.

Conclusions

Electrical burns constitute only a small part of the burned patients treated yearly at the Service of Burns and Plastic Surgery, UHC “Mother Theresa” of Tirana, yet it is a difficult situation to deal with. Most of the burns were caused by high voltage injury, in a workplace, because of neglect of safety rules while working. Mortality from electrical burns remains concerning, especially within true electrical burns, stressing the fact that this injury continues to be a serious one. More efforts should be made towards prevention, especially among workers who might come into contact with high voltage wires.