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. 2021 Dec 31;34(4):351–359.

Changing Trends In Electrical Burns From A Tertiary Care Centre - Epidemiology And Outcome Analysis

PK Arumugam 1,∗, P Thakur 1, S Sarabahi 1
PMCID: PMC8717909  PMID: 35035329

Summary

Electrical burn injuries result in significant mortality and morbidity. Most of these injuries are preventable. We conducted a retrospective analysis of various aspects of electrical injuries presenting to our center over a period of 1 year from September 2018 to August 2019. Demographic characteristics of patients along with burn characteristics and associated injuries were analysed. Outcomes including length of hospital stay, need for fasciotomy, amputation, renal failure and mortality were also analysed. A total of 6380 patients presented to our center during the study period, of which 471 (7.38%) had electrical burns. Total burn admissions were 1530, of which 283 (18.49%) patients were admitted with electrical burns. The mean age in our cohort was 25.31±12.76 years and mean TBSA was 29.22±23.81%. The most common cause of electrical burns was occupational (33.3%), followed by those that occurred on the rooftop of houses (31%). A historical comparison with data published from our center in 2011 showed a significant increase in occupational burns (18.72% vs. 33.3%) and rooftop electrical burns (8.21% vs. 31%), and a decrease in agriculture-related (42.46% vs. 9.1%) and domestic electrical burns (26.02% vs. 6.7%). There was also a significant rise in proportion of high voltage injuries (71.23% vs. 86.90%). Logistic regression analysis showed electric contact burn to be a risk factor for fasciotomy and limb gangrene. Risk factors for renal failure were age, percentage burn, electric contact burn and rural residence, and those for mortality were percentage burn and renal failure. Emphasis on preventive strategies, especially against occupational injuries and injuries occurring on rooftops, is necessary to prevent such devastating injuries

Keywords: electrical burns, epidemiology, changing trends, outcomes

Introduction

Electrical burns are devastating injuries that can lead to significant morbidity. They can occur due to direct contact or a flash burn due to arcing. Electrical contact burns, when compared to flash burns, are more dangerous as they cause deeper wounds that result in increased morbidity and mortality. Electrical burns can be classified as high voltage (>1000V) or low voltage (<1000V). There have been reports of a higher incidence of high voltage electrical burns in developing countries. Increase in industrialisation, electrification and population density make people more prone to electrical injury.1 Most of these injuries are preventable and require education of the general public to reduce the possibility of such events happening. Epidemiological analysis of electrical burns contributes to understanding the patterns of these devastating injuries and to planning further treatment strategies.

Material and methods

A retrospective chart review was conducted of all electrical burn patients admitted to our institution from September 2018 to August 2019 (12 months). Files with incomplete data or those who left against medical advice were excluded. The patient characteristics extracted were in relation to demographics, month of the year, type of electrical burn, high or low voltage, etiology of injury, total body surface area burned (TBSA), length of hospital stay, distribution of injury, fasciotomy requirement, occurrence of renal failure, amputation, associated injuries and mortality. The data were then analysed with SPSS v 23 software (IBM, USA). Categorical variables were described as percentages and continuous variables were described as mean ± standard deviation and ranges. The data were analyzed with parametric and non-parametric tests for determining statistical significance. For categorical data, comparisons were made using the Chi square/Fisher exact test, for quantitative data the t test and for non-normally distributed quantitative variables the Mann-Whitney/Kruskal Wallis test. Anova was used to test the difference between groups. Regression analysis was used to find the factors contributing to fasciotomy, limb gangrene, renal failure and mortality. P value ≤0.05 was considered significant in all statistical evaluations.

The type of electrical burn was classified as electrical contact burn, electrical flash burn or a combination of both. Voltage of electricity was categorised into high when voltage was more than 1000V and low when it was less than 1000 V. Renal failure was defined based on the following criteria (KDIGO): increase in serum creatinine by 0.3mg/dL or more within 48 hours or increase in serum creatinine to 1.5 times baseline or more within the last 7 days or urine output less than 0.5 mL/kg/h for 6 hours.2 Patients were admitted to the Burns Intensive Care Unit. Fluid resuscitation was done based on institutional protocol to maintain a urine output of 1-2ml/kg/hr for contact burns and 0.5-1 ml/kg/hr for flash burns.3

Results

Total burns treated during the study period were 6380. Total burn admissions were 1530. The proportion of electrical burns treated during the study period was 471 with 283 admissions. The proportion of electrical burns out of the total burns was 7.38% and burn admissions was 18.49%. Data were collected from 252 inpatients after excluding incomplete files and those who left against medical advice (Fig. 1). Overall the ages ranged from 1 to 68 years (Table I). The mean age was 25.31±12.76 years. The mean TBSA burned was 29.22±23.81%. There was a male preponderance of 90.47%. The majority of patients were in the age group 21-25 years (22.2%) and the second most affected was the age group 16-20 years (Fig. 2). The month of June had the maximum number of patients (16.66%) and the least numbers were seen during the month of December (3.57%) (Fig. 3). Electrical contact burn was the most common type of burn injury (40.87%) followed by a combination of electrical contact and flash burns (31.74%). The most common cause of electrical burns was occupational (33.3%), followed by electrical burns that occurred on the rooftop of houses (31%). Occupational injuries included those working as an electrician, working on high tension wires, working on transformers or working on construction sites. Agricultural and accidents within the house accounted for 9.1% and 6.7%, respectively. There were more cases from rural areas, consisting of 59.12%. Overall most of the injuries were high voltage, making up 90.07%. The upper limbs were the most commonly involved body part (77.8% and 74.6% - right and left upper limb, respectively) followed by the trunk (74.2%). The face was involved in 54.4% of cases. Twenty-five percent of the cases required emergency fasciotomy for compartment syndrome. Renal failure occurred in 12.7% of cases. Overall mortality rate was 24.6%.

Fig. 1. Flow chart showing study design.

Fig. 1

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Table I. Demographics and characteristics of electrical burns.

Table I

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Fig. 2. Electrical burn distribution by age group.

Fig. 2

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Fig. 3. Electrical burn distribution by month.

Fig. 3

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The five most common causes of electrical burns (occupational, rooftop, agriculture, domestic and falling of live wire on a person) were analysed further (Table II). Male:female ratios were most skewed for occupational burns with a value of 83:1 (p<0.001). Age group analysis showed children less than 10 years were maximally affected due to rooftop electrical injuries. The most common cause in the age group 11-20 years was also rooftop electrical injuries. In the age groups 21-30 years, 31-40 years and 41-50 was occupational (p<0.001). Rooftop electrical burns and live wire falling on a person occurred more in urban areas, while the other etiologies occurred more in rural areas (p=0.03). High voltage injuries were predominant in all groups except for the domestic electrical burns, where the distribution was almost equal (p<0.001). TBSA, length of hospital stay, renal failure and mortality were not significant between the groups. A total of 56 patients underwent amputations. The amputation rate was 22.22%. The most common site was below the elbow amputation, followed by below the knee amputation (Table III). Associated injuries were seen in 36 patients. Head injury was seen in 17 patients, and included parenchymal contusion, intracranial hemorrhage, subdural hematoma, extra dural hematoma and associated fractures. Spinal injury (2 patients) included D7, D8 fracture and a case of D10 fracture. Chest injuries (4 patients) included rib fractures with hemothorax. Abdominal injuries (2 patients) involved a case of hemoperitoneum and a case of abdominal defect with intestinal evisceration. Urogenital injury (6 patients) included 4 cases of penile amputation and 2 urethral injuries. There were 4 cases of corneal injury and one radial nerve injury. A historical comparison was done with a study from the same institution carried out in 2011 by Duggirala et al.4 (Table IV). There has been a drop in electrical burns in children 5 years or younger, from 7.3% to 2.8% (p=0.013). The other age groups had a similar distribution. A male preponderance has increased from 84.25% to 90.47% in the present study (p=0.021). Agriculture as a cause of electrical burns was most common in 2011 (42.46%): this has reduced to 9.1% in the present study (p<0.001). Occupational burns have increased to 33.3% from 18.72% in 2011 (p<0.001). Of note, there has been a spike in the number of electrical burns occurring on the rooftops of homes. This is 31% in the present study, an alarming increase from 8.21% in 2011 (p<0.001). Domestic electrical burns have dropped from 26.02% to 6.7% (p<0.001). The proportion of high voltage injuries has increased to 86.9 from 71.23 (p<0.001).

Fig. 4. High-voltage wires running dangerously close to the rooftop of houses.

Fig. 4

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Table II. Analysis of etiology of electrical burns.

Table II

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Table III. Amputation distribution in electrical burns.

Table III

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Table IV. Comparing parameters of present study to study from the same centre in 2011.

Table IV

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Logistic regression analysis for fasciotomy showed electrical contact burn and workplace injuries to be a significant risk factor in univariable analysis, but on multivariable analysis only electrical contact burn was an independent risk factor (Table V). A risk factor for limb gangrene was electrical contact burn in both univariable and multivariable analysis (Table VI). The risk factors contributing to renal failure were increasing age, increasing TBSA, electrical contact burn and rural place of residence on multivariable analysis (Table VII). The risk factors for mortality were increasing TBSA and renal failure on multivariable analysis (Table VIII).

Table V. Regression analysis for fasciotomy.

Table V

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Table VI. Regression analysis for limb gangrene.

Table VI

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Table VII. Regression analysis for renal failure.

Table VII

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Table VIII. Regression analysis for mortality.

Table VIII

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Discussion

Electrical burns are devastating injuries that are debilitating.5 The incidence of electrical burns in the western world is reported to be 4-5%.6 In the developing world the percentage of electrical burns has been reported to be up to 27%. In the present study the proportion of electrical burns out of the total burn admissions was 17.5%, similar to many observations from developing countries.7

Predominantly males were affected: 90.9% in our study. A similar trend was also observed in 2011 (84.25%). This is probably due to men working in highly dangerous jobs such as linemen working on high-tension lines and transformers. Such male predominance has been seen in many reports of electrical burns.8,9 No difference in outcomes between males and females have been reported, however females have higher early mortality than men.10

Specific age groups were found to be prone to electrical burn injuries. Most of the injuries in our study occurred in the age group 21 to 30 years, followed by 11 to 20 years. A similar preponderance of electrical burns in the 21 to 30 years age group has been reported in other studies.9 This is the age group which is most commonly employed in high-risk electrical work. Adolescents in the 11 to 20 years group are commonly involved in outdoor activities exposing them to high-tension electrical wires.

We noted an increase in cases during the months from June to September. A similar trend was observed in the year 2011 in our institute. The increase in cases from June corresponds to the onset of monsoon season in India. The wet environment in the monsoon months predisposes to electrical burns.

High voltage injuries constituted the majority in our study, with 86.90% of all cases. Low voltage injuries made up 13.09%, nearly half of which occurred in the domestic setting. Based on other studies, high voltage injuries make up 38 to 50%, and low voltage injuries make up 20-44.7%.11,12 The proportion of high voltage injuries presenting to our centre has increased to 86.90 from 71.23% in 2011.4

The most common etiology in this study was occupational, constituting 33.3% of all cases. They included working on high-tension wires, transformers and construction sites. The mortality rate in this group was 26.19%. A study evaluating the outcome of occupational electrical injuries among French electrical company workers over a period of ten years showed a mortality rate of 3.2%. Significant morbidity was seen in these patients (32.5%).13 Amputation rates in our study are comparable to other studies from India.14 Similar amputation rates have been reported in other series.15 Electrical injuries are the fourth most common cause of work-related death due to the inherent hazardous nature of working with electricity (5–6% of all workers’ deaths).16 The overall mortality rate in occupational electrical burns has varied from 3-15%.17 There is an immediate and necessary need to put into place safe workplace practices to prevent such debilitating injuries from occurring.

Rooftop electrical injuries (injuries occurring on the roof of residential buildings) were seen in our patients. Some of the common mechanisms while on the roof were accidentally touching high-tension wires, a metal object the person was holding coming into contact with these wires, and children playing on the roof and coming into contact with the wires. This is probably due to an increase in electrification, urbanization and increased population density in urban areas. A major cause of these injuries has been attributed to overhead high-tension wires that in many cases are dangerously close to the rooftops of houses. Similar reports of electrocution from rooftops have been reported by other authors.18,19

However, the percentage of patients sustaining injuries from rooftops in our study has been alarmingly high. The high-tension wires originate from generating stations and consist of voltages ranging from 140 kV (kilovolts) to 700 kV. These lines reach the substation and further distribution occurs at voltages ranging from 2.4 kV to 33kV. These lines are present along streets and can be found to run overhead above houses (Fig. 4A and B). There exists the danger of sustaining electrical burns at these very high voltages. These lines end in transformers that are in close vicinity to houses and the final electricity supply to homes occurs at 240V.18 In our study, most high voltage injuries sustained were of 11kV. Transformers near houses contributed to 2.3% of cases in 2019. Additionally, we also found a rise in electrical burns due to flying kites on rooftops that come into contact with high-tension wires. Cases due to flying kites have increased to 4.9% in 2019 from 1.5% in 2011.

Domestic electrical injuries made up 6.7% of total electrical burns, which is similar to other reports. 20 Electrical sockets, wires within the house, and attempts at changing a fuse led to most of these injuries in our study.

Electricity has helped to improve productivity in the rural farming sector. However, its improper use can result in injury and death. Farming areas tend to have a damp environment, predisposing the people working there to an increased risk of electrical injury. The number of agricultural electrical burns has reduced to 9.1% compared to 42.46% in 2011.4

Electrical burns can cause massive necrosis of skeletal muscles causing rhabdomyolysis and leading to renal failure. Rhabdomyolysis has been demonstrated in 14-42% of electrical burns.21 The rate of renal failure in electrical burns ranges from 1.5% to 7.5%.22 Renal failure occurred in 12.7% of our cases. Similar rates of renal failure have been reported in a study from India.23

We identified electrical contact burn as an independent risk factor for fasciotomy requirement and limb gangrene. As for renal failure, increasing age, increasing TBSA and electrical contact burn were risk factors. Additionally, persons presenting from rural areas were also found to be at risk for renal failure, probably due to the increased time for obtaining primary care. Mortality in electrical burns has been reported to be 2.4-10%.5,24-26 We had a higher mortality rate of 24.6%. Regression analysis showed increasing TBSA and renal failure to be factors that predict mortality. Other factors such as cardiovascular complications, ICU requirement, erythrocyte transfusion requirement, fresh frozen plasma (FFP) requirement, albumin requirement, admission serum albumin level <3.5 mg/dl and admission hemoglobin level <12 mg/dl have been additionally identified by other studies.27,28

These are preventable injuries and education regarding this type of injury should be stressed. Social media and televised awareness programs help dissemination of preventive strategy to the general public. Care should be taken during the construction of houses to make sure there are no high-tension wires in the vicinity. Furthermore, adequate protective gear and regulations for persons involved in working on high-tension wires should be followed.

Limitations of the study

The retrospective nature of the study is a limitation. Furthermore, this is from a single centre and may not reflect the picture across the country.

Conclusion

Electrical burns form a significant part of burn admissions in our country. Most injuries are high voltage injuries that result in high rates of amputation (22.2%) and morbidity. Mortality rates in our study were as high as 24.6%. Most of these injuries occurred in the workplace and on the rooftop of homes. These injuries are preventable and measures must be put in place to reduce their occurrence. Educating the general public regarding the dangers of high-tension wires could help prevent rooftop injuries. Furthermore, occupational exposure to electricity should occur with all safety precautions in place and with protective gear to prevent such debilitating injuries.

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