Summary
Electrical injuries are very aggressive pathological lesions with heavy functional and aesthetic consequences. The primary cause of their gravity is the progressive tissue necrosis that occurs with the continuous extension of wound necrosis, even leading to loss of the entire injured extremity. The goal of this study is to analyse the role of the inefficiency of the electric energy system in the incidence of electrical injuries in Kosovo during the period December 2000 to 2007 suffered by a total number of 182 patients treated in the Department of Plastic and Reconstructive Surgery, Pristina, Kosovo. Electrical injuries accounted overall for 17.25% of all patients admitted with burns; 35.72% of the burns were due to high voltage and 64.28% to low voltage; among the patients with contact burns the amputation rate was 28.58%, and four patients (7.14%) died. These results suggest that the aggravation of the electric energy system led to an increase in the number of patients with electrical injuries.
Keywords: ELECTRICAL, BURN, INJURIES, EIGHT-YEAR, REVIEW
Abstract
Les lésions d'origine électrique constituent des pathologies très agressives qui provoquent de lourdes conséquences fonctionnelles et esthétiques. La principale cause de leur gravité est la nécrose tissulaire progressive qui se produit avec l'extension continuelle de la nécrose de la lésion, qui conduit même à la perte de l'entière extrémité lésée. L'objectif de cette étude est d'analyser le rôle joué par l'inefficacité du système de l'énergie électrique dans l'incidence des lésions d'origine électrique au Kosovo pendant la période décembre 2000-2007 subies par un nombre total de 182 patients traités dans le Département de Chirurgie Plastique et Reconstructrice, Pristina, Kosovo. Les patients qui présentaient des lésions d'origine électrique constituaient globalement 17,25% de tous les patients brûlés hospitalisés, atteints dans respectivement 35,72% et 64,28% des cas par la haute ou par la basse tension; parmi les patients atteints de brûlures dues au contact le taux d'amputation était 28.58%, et quatre patients (7.14%) sont décédés. Ces résultats font penser que l'aggravation de la situation de l'énergie électrique au Kosovo a provoqué une augmentation du nombre de patients atteints de lésions d'origine électrique.
Introduction
Human life has changed rapidly since the introduction of electric energy for commercial requirements. The life of man today, without electric energy, would be empty. However, the benefits of this "good" energy in stable conditions can be transformed into destructive agents for the human organism. Electrical injuries occur when the human body comes into contact with an electric arc, due to electricity passing through the human body.
Electrical burns have usually been more frequent in undeveloped countries with an inefficient electric energy system and a low social and economic level, as in our country, Kosovo. The consequences of the Kosovo war (1998-June 1999) included the destruction of the country's production infrastructures and the disruption of the electricity supply system. With the deterioration of the electricity supply system in Kosovo, the number of patients with electrical injuries increased, with the highest rate in Europe. In Kosovo the electricity supply system consists of two old power stations that are unable to satisfy all needs for electric current, as is normally the case with outdated electricity distribution systems.
The passage of electric energy through the human body triggers some very complex reactions in the body's tissues and organs. These reactions, on the one hand, affect the organism's anatomical, histological, and biochemical structural composition and, on the other, give rise to a series of electrotraumas. 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. Electrical injuries cause necrosis of the skin and deep tissue structures, and the necrosis may lead to decreased function of the affected limb or its complete loss, as also to life-threatening complications such as renal failure and sepsis. The treatment of electrical injuries therefore presents many complex multilevel problems and thus requires a proactive approach and up-todate treatment. Electrical injuries are very aggressive pathological lesions which result in heavy functional and aesthetic consequences. The primary cause of their gravity is the progressive tissue necrosis that occurs with the continuous extension of wound necrosis, even leading to loss of the entire injured extremity. The goal of this study was to analyse the role of the inefficiency of the electric energy situation in the incidence of electrical injuries in Kosovo during the period December 2000 to 2007. This involved a total number of 182 patients treated in the Department of Plastic and Reconstructive Surgery, Pristina, Kosovo. Electrical injuries accounted overall for 17.25% of all patients admitted with burns; 35.72% of the cases were due to high voltage and 64.28% to low voltage; among the patients with contact burns the amputation rate was 28.58%, and four (7.14%) died. These results suggest that the aggravation of the electrical energy system increased the number of patients with electrical injuries.
This necrosis may contribute to the decreased function or loss of the affected limb and even life-threatening complications such as renal failure and sepsis. The treatment of electrical injuries is thus a complex multi-level problem, requiring a very active up-to-date and more modern treatment. An important role is played by immediate decompression-fasciotomy and early necrectomy in the treatment and prevention of acute complications of electrical burns, which can be fatal.
Materials and methods
In our retrospective study we analysed the records of 182 patients with electrical burns treated in the Department of Plastic and Reconstructive Surgery, Surgery Clinic, University Clinic Centre of Kosovo, Pristina, Kosovo, during the period from December 2000 to 2007.
The following variables were considered: age, sex, tension of current (voltage), mechanism of the injury, and the incidence over the years. Depending on their voltage electrical burns can be of two types: low-voltage electrical burns, below 1000 V, induced by electrical cabling in the home, and high-voltage electrical burns, ranging from 1000 to 50000 V, from overhead electrical cabling. Depending on the mechanism of the injury, this may be classified as a flash or arc burn, which is usually a superficial burn, or a contact or touching burn, which is caused by the passage of electric current through the human body. However, electrical injury is classified in the fourth degree of burns.
Electrical injuries are treated with immediate cardiopulmonary resuscitation and the administration of intravenous fluids. For fluid administration we always use the following modified Parkland formula: TBSA (percentage) x body weight (kg) x 8-10 = ml Ringer's lactate during the first 24 h - urine output is considered adequate at a rate of 30-50 ml/h and, if myoglobinuria is present, intravenous fluids are titrated to a targeted urine output of 100 ml/h. If myoglobinuria persists despite fluid resuscitation, mannitol can be administered and urine alkalinization performed to prevent precipitation of myoglobin in the kidney tubules.
Early surgical management of electrical injuries should focus on the need for fasciotomy or compartment release. Progressive sensory and motor loss, severe pain, loss of arterial circulation, and increased compartment pressure are possible indicators of the need for fasciotomy. The ideal time to determine the presence of myonecrosis is typically three days post-burn. On day 3 all unhealthy necrotic tissue can be debrided and definitive wound closure can be achieved. In cases of extensive limb injury, a free tissue transfer may be necessary to provide wound coverage or to preserve limb length for optimal prosthesis fitting.
Results
The annual incidence of electrical injuries showed a notable increase in the first four years after the war in Kosovo (1998-99). In the year 2000 the percentage of electrical burns out of all burn admissions was 9.55% and in 2007 as high as 23.81%. The overall number of 149 admissions to our ward in 2002 included 31 patients with electrical injury (20.80%) while in the year 2003 35 patients (20.95%) out of the total number of 167 burn patients had electrical injury. In the years 2004 and 2005 there was a decrease from 12% to 9% (Table I).
Table I. Annual distribution of patients with electrical injury.
Among the cases of electrical burns, 171 involved males and 11 females. The commonest age group, with 44 cases, was that aged 40-49 yr (24.17%), followed by the 30-39 yr group, with 42 cases (23.07%), and the 20 29 yr group with 38 cases (20.88%). The youngest patient was two years old and the oldest 67, and the mean age was 33.6 yr.
A total number of 182 patients were admitted for treatment in the Division of Plastic Surgery, Clinic of Surgery, University Clinical Centre of Kosova, Pristina, in the years 2000-2007; 126 cases (69.23%) were electrical arc flash burns and 56 (30.77%) were electrical contact burns. Among the 56 patients with contact burns, 36 had lowvoltage electrical injuries (below 380 V) and 20 high-voltage (ranging from 1000 to 200,000 V (Table II).
Table II. Distribution of patients by mechanism and voltage of injury.
Sixteen patients out of the 56 with contact burns had amputations (amputation rate, 28.6%) (Table III).
Table III. Amputation rate and level.
About twothirds of the amputations involved the upper limbs. Only one patient underwent shoulder disarticulation (Figs. 1, 2).
Fig. 1a. Patient with total gangrene of upper extremity.
Figs. 2a. Reconstruction of defects with abdominal flap and skin graft.
Fig. 1b. Shoulder disarticulation.
Figs. 2b. Reconstruction of defects with abdominal flap and skin graft.
Of all injuries, 85.7% (48/56) were in the upper extremities, 7.1% (4/56) in the lower extremities, 3.6% (2/56) in the head and/or neck, and 3.6% (2/56) in the trunk. To cover the wound we mainly used partial- or full-skin grafting (38.46% of cases), flaps (local, abdominal, cross-finger, and fasciocutaneous) (19.24%), and direct closure of the amputation stump (25%) (Fig. 2). The mean number of operating procedures was three per patient.
In the eight-year period of study, there were four deaths among the patients (7.14%) (due to the high voltage of the electric current).
Discussion
Electrical injuries are very frequent in the everyday practice of plastic surgery clinics all over the world. The increasing incidence of electrical burns is due to the increasing use of electric current in everyday life and an increasing population. In our study, electrical burns after the war in Kosovo accounted on average for 17.25% of all admissions due to burns. This electrical burns incidence of 17.25% in Kosovo is higher than in other reports in this region and 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%. This increasing incidence of electrical burns is a consequence of the war in Kosovo (1998-1999), the low social and economic level of the population, the inefficiency of the electricity network, the amortization of electricity network dispersions, the misuse of electric current, and repair work on the electricity network done by non-professionals. A marked relationship was found between inefficient electric energy supply and the incidence of electrical injuries.
With regard to such accidents, the distribution by age group and sex was similar to that of certain other studies.1-3 Our results showed a higher proportion of patients with injuries caused by electric current than that due to electric arc (69.23%), while electrothermal contact burns accounted for 30.77%. Also, in our study, low-voltage electrical injuries were more frequent (64.28%) than high-voltage (35.72%), a figure that is not consistent with the results of other researchers. These results are a consequence of the population's low social-economical level and of electricity network repair work being performed by non-professionals. Progressive necrosis of tissues damaged by electrical injury was caused not only by high but also by low voltage (220 V), as for example when an electric wire held between two fingers as the conduction distance was too short.2 We also treated patients with amputations not only of fingers but also at forearm level, caused by low-voltage current.
Problems in the management of such cases arise in the assessment of the extent and depth of the lesions, which are usually much more severe than is externally visible. Early surgical management should focus on the need for fasciotomy-compartment release, which should be performed within the first 12 h post-injury. Sheridan and Martin reported that treated patients who had a fasciotomy within 12 h of the onset of increased compartment pressure had normal function in 68% of cases, but when surgery was performed after 12 h only 8% of patients had normal function.4 Early necrectomy and amputation should be performed three days post-injury in order to eliminate the negative effects of necrotic tissue. The amputation rate in our study was 28.58%, higher than that reported by Mann (10%),5 Zhu (9%),2 and Sinha (4.5%).1 Our amputation rate was high because we still do not have a burns centre, the patients or their parents refuse amputations, and fasciotomy is not performed within first 12 hours.
The overall mortality rate from electrical burns has been reported to be between 3 and 20% (Sinha 3.7%,1 Escudero 4.3%,6 Koller 8.3%,7 Haberal 19.6%3).8-13 The mortality rate in our study was 7.14%.
Conclusion
On the basis of the results of our study we can conclude that:
electrical burns are deep tissue lesions caused by the passage of electric current in the human body that are characterized by higher morbidity and invalidity than burns of any other aetiology. They constitute one of the severest medical problems in our country;
the high incidence of electrical burns in Kosovo (17.25%) is typical of an undeveloped country, reflecting the inefficiency of the electric energy system and the population's low social and economic level;
the high electrical burn amputation rate (28.58%) is a reflection of the lack of a burns centre in our Department.
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