1. Electrical Injury

2. 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

3. Electrical Injury - Epidemiology
Ages yrs.
High voltage mostly occupational injury
20% Children
Low voltage injuries in toddlers M:F 1.7:1
High voltage injuries in adolescents % male

4. Electrical Injury - Pathophysiology
Electrical – tetany, arrhythmia
Thermal – burns, coagulation
Mechanical – fractures, dislocation

5. Ohm’s Law
I= V/R
I= current V= voltage R= resistence

6. Joule’s Law
E=I²RT
E= energy I= current R= Resistence T= time

7. Electrical Injury - Pathophysiology
Current pathway defines resistence
- Vertical higher incidence of complication
- Hand – to – hand pathway
- Below symphysis, stradle pathway

8. Electrical Injury - Classification
High (>1000 Volt) vs. low (<1000 Volt) voltage
Direct (lightning) vs. alternating (50 Hz) current
Arc injury (high temperature), flashover

9. 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

10. Respiratory Involvement
Tetany of respiratory muscle
Brain stem injury
May induce hypoxia, acidosis  cardiac arrest

11. Nervous System Immediate - loss of consciousness, amnesia
Early - intracranial hemorrhage, vertebral fractures
Late - ALS, transverse myelitis, ascending paralysis
Peripheral neuropathy, RSD

12. Vascular Injury Large arteries – medial necrosis, aneurisms
Small vessels – intimal injury, coagulation necrosis
Secondary to compartment syndrome

13. Limb Injury Dislocations and fractures Coagulation of blood vessels
Muscle ischemia and edema
Compartment syndrome
Thermal injury from bone heating
Infection clostridial, streptococcal

14. Other Injuries GI – ileus, stress ulcers, direct injury
Ophthalmic – cataract, iridiocyclitis, autonomic injury
Otologic – tympanic membrane perforation, vertigo, sensoryneural injury

15. Injury Characteristics
Low Voltage
77% YO
60% extremity
40% oral commisure
No mortality
Complete functional recovery
High Voltage
76% YO
33% limb amputations
30% deep muscles
12% fasciotomy/ escharotomy
No mortality

16. Electrical Injury - Management
Combined ATLS + ACLS protocols
Cardiac monitoring for 24 hrs if LOC, ECG changes or arrhythmias
IM dT
IV H2 - blockers

17. Electrical Injury – Resuscitation
1.7 X Parkland formula or 9 ml/kg/%TBSA
Urine output ml/hour
Clearance of any pigment in urine
Bicarbonate - blood pH > 7.45
Osmotic diuresis – IV MANNITOL 25 gr

18. Electrical Injury – Wound Managemant
“True” high tension
Sharply demarcated
Always full thickness
Leathery appearence

19. Electrical injury – Wound Management
“Progressive necrosis” theory
Primary resuscitation.
Early exploration and debridment
“Second look” in hrs –definitive Tx
Primary closure
Coverage
Amputation

20. Wound Management – Extremities
Frequent envolvement of the hand
Exit point in one or both legs
Arc injury in distal fore arm or axilla

21. Wound Management – Extremities
Initial assessment usually predicts outcome:
Depth of burns
Ischemia
Anasthesia
Flexion position
Muscle viability- response to electrocautery

22. Electrical Burn - Extremities

23. Wound Management – Extremities
Exploration - large volume underlying necrotic area
Full thickness burns
Proximal periosseous myonecrosis
Retained questionable tissue may lead to contamination and further compromise

24. 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

25. Wound Management – Trunk & perineum
Suspect visceral injury
Lung – Atelectasis and edema
Abdomen – consider as penetrating wound
Perineum –urinary and bowel diversion & debridment +STSG

26. Electrical Injury -Summery
סוג הפגיעה ומיקומה
טיפול ראשוני לפי פרוטוקולים ACLS ו- ATLS
החייאת נוזלים
אקספלורציה והטרייה מוקדמים
טיפול דפיניטיבי מוקדם – בכל שיטות השחזור המקובלות