Electrical injury: electrical engineer's perspective and an historical review.
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Accidents, Occupational↗
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Electrical injuries.
Electrical injury is a relatively infrequent but potentially devastating form of multisystem injury with high morbidity and mortality. Most electrical injuries in adults occur in the work-place, whereas children are exposed primarily at home. In nature, electrical injury occurs due to lightning, which also carries the highest mortality. The severity of the injury depends on the intensity of the electrical current (determined by the voltage of the source and the resistance of the victim), the pathway it follows through the victim's body, and the duration of the contact with the source of the current. Immediate death may occur either from current-induced ventricular fibrillation or asystole or from respiratory arrest secondary to paralysis of the central respiratory control system or due to paralysis of the respiratory muscles. Presence of severe burns (common in high-voltage electrical injury), myocardial necrosis, the level of central nervous system injury, and the secondary multiple system organ failure determine the subsequent morbidity and long-term prognosis. There is no specific therapy for electrical injury, and the management is symptomatic. Although advances in the intensive care unit, and especially in burn care, have improved the outcome, prevention remains the best way to minimize the prevalence and severity of electrical injury.
Adult↗
[Electrical injury].
Electrical injury can be classified into true electrical injury, are burn. In true electrical injury, large or small, dry, dark brown necrotic wounds (electric current spots) are observed on the skin at the entrance and exit sites of the electric current, and progressive necrosis develops in surrounding tissues. As generalized symptoms, ventricular fibrillation, respiratory arrest, and loss of consciousness may be observed temporarily immediately after the injury. Necrosis also occurs in deep tissues including muscles, and pathology resembling crush injury is seen. Myoglobin released into the circulation due to muscle necrosis tissue causes myoglobinuria and increases the risk of acute renal failure. Treatment consists of emergency resuscitation and fluid supplementation with lactated Ringer's solution. However, more fluid should be administered than in cases of common burns to accelerate urinary excretion of myoglobin in the circulation. For local treatment, debridement should be performed in areas with clear third-degree burns, but in the presence of progressive necrosis, repair and reconstruction after debridement should be postponed for 2-3 weeks.
Adult↗
Burn centers should be involved in prevention of occupational electrical injuries.
Electrical injuries are uncommon, comprising 10% of our regional burn center admissions during a 9-year period. The purpose of this study was to determine the incidence, type, and location of occupation-related electrical injuries in an attempt to focus our injury prevention and outreach efforts. We retrospectively reviewed the medical records of patients with electrical injuries admitted to our burn center from January 1992 through March 2000, with focused analysis on those patients admitted with occupation-related electrical injuries. Of the 95 patients admitted for electrical burns, 81% (n = 77) were occupational injuries. This rate of injury suggests that prevention efforts should be directed at work sites and partnerships should be developed between burn centers and businesses to reduce the incidence of injuries.
Accidents, Occupational↗
Electric injury, Part II: Specific injuries.
Electric injury can cause disruption of cardiac rhythm and breathing, burns, fractures, dislocations, rhabdomyolysis, eye and ear injury, oral and gastrointestinal injury, vascular damage, disseminated intravascular coagulation, peripheral and spinal cord injury, and Reflex Sympathetic Dystrophy. Secondary trauma from falls, fires, flying debris, and inhalation injury can complicate the clinical picture. Diagnostic and treatment considerations for electric injuries are described in this article, which is the second part of a three-part series on electric injuries.
Blast Injuries↗
Limb dystonia following electrical injury.
Electrical injuries of the extremities may cause paralysis, muscle atrophy, sensory deficit, causalgia, and reflex sympathetic dystrophy (RSD). Limb dystonia has rarely been reported following electrical injury to an extremity, although it may result from cerebral hemisphere electrical trauma. Following electrical injury to the upper extremity, three patients developed limb dystonia accompanied by severe pain and sensory symptoms in two patients and features of RSD in one patient. Two patients received botulinum toxin injections without functional benefit. The mechanism of dystonia following peripheral trauma is unknown but may relate to reorganization of central synaptic connections, possibly in the spinal cord.
Adult↗
Cardiac problems associated with electrical injury.
Electrical injury is uncommon, and cardiac involvement occurs in a minority of patients who are injured. Cardiovascular complications in the electrically injured patient, however, can be devastating. Because the presentation of electrical injury to the heart can be atypical in nature, delayed in onset, or obscured by other trauma, caution must be exercised in the interpretation of initial symptoms, ECGs, monitor strips, and cardiac enzymes. Whenever there is doubt concerning the presence of cardiovascular injury, the patient should be monitored. When cardiac complications are in evidence, expectant management is generally sufficient. When specific management of cardiac arrest, other dysrhythmias, myocardial necrosis, hypertension, or conduction abnormalities is required, standard therapeutic regimens are generally appropriate. In managing apparent acute myocardial infarction, however, the possibility that the injury is not of ischemic origin must be considered. Reperfusion techniques should be applied only when occlusive coronary thrombosis is strongly suspected or angiographically confirmed. The risk of developing chronic cardiac disease after electrical injury to the heart is unknown. Patients who sustain cardiovascular injuries should be followed for at least 12 months and avoid elective surgery for 6 months after the incident.
Arrhythmias, Cardiac↗
Electrical injuries.
Electrical injuries may occur from high or low voltage contact. Low voltage injuries usually occur in the home, tetany may lead to sustained contact, and dangerous cardiac disturbances often result. High voltage injuries are usually work related and result from brief contact but may cause serious tissue destruction and secondary injuries. Both forms may be fatal. Electrical injury more closely resembles a crush injury than a thermal injury and is managed accordingly. External manifestations often belie the severity of deeper wounds.
Accidents, Home↗
Upper extremity electrical injury.
Electrical injuries to the upper extremity are far ranging in extent and vary in magnitude. Proper management requires an appreciation for the pathophysiology, clinical manifestations, and therapeutic options. Persistent neurologic and psychiatric problems further impact the high incidence of disability in the electrical injury patient. Loss is significant for victims, their families, and employers, in part because of the relative youth of those injured.
Arm Injuries↗
Cognitive decline over time following electrical injury.
Electrical injury (EI) is on the rise in the US, with more than 2400 injuries occurring annually. Consequences of EI often include diffuse neurological damage and a myriad of emotional and behavioural sequelae. While delayed onset of cognitive dysfunction is frequently alluded to in the literature, few cases have been published that document the progressive neuropsychological manifestations of EI over time. This paper offers a case study of a 49 year-old female who suffered a high voltage EI and who underwent neuropsychological evaluations at 6 and 56 months post-injury. Comparison of test results suggested a progressive pattern of global decline in cognitive functioning, with particular impairment in memory, verbal learning, abstract reasoning and sensory-motor functions. This case study illustrates the delayed onset and progression of neuropsychological dysfunction that may occur following EI, as well as the importance of long-term follow-up with patients after high voltage EI.
Adult↗
THE NEUROLOGICAL SEQUELAE OF ELECTRICAL INJURY.
Electricity is a potentially very dangerous commodity. Community safeguards, however, result in remarkably efficient control of this hazard. Mortality figures appear to be small and constant. No satisfactory morbidity figures are available with regard to general and neurological complications in non-fatal cases. Study of relevant features of such electrical phenomena as voltage level, resistance factors, current pathway, current diffusion and grounding reveals many difficulties in reconstruction of the sequence of events involved in these injuries. These features underline our frequent inability to understand the mechanisms of initiation of unconsciousness and even of differentiation between death by cardiac arrest and death by respiratory paralysis. Fourteen cases of electrical injury with a variety of neurological complications and sequelae are discussed, and the findings in these cases are compared with those of other observers. An attempt is made to present a comprehensive picture of immediate, secondary and late neurological effects, and to illustrate some of the pathological findings in electrocution material.
Accidents↗
Delayed obturator artery rupture: a complication of high-voltage electrical injury.
Electrical burns cause damage to the cardiovascular system through different mechanisms. Immediate cardiac arrhythmia is one of the common consequences. A large vessel blow out due to an electrical burn is rarely documented. It is often undetected due to its "silent" symptoms. This article reports a delayed obturator artery rupture in a 32-year-old male patient 6 weeks after he sustained severe high-voltage electrical burns. The vessel injury was treated with computed tomography (CT)-aided embolization. The patient recovered to an ambulatory status 10 weeks after the injury.
Adult↗
Thermal burn and electrical injuries among electric utility workers, 1995-2004.
This study describes the occurrence of work-related injuries from thermal-, electrical- and chemical-burns among electric utility workers. We describe injury trends by occupation, body part injured, age, sex, and circumstances surrounding the injury. This analysis includes all thermal, electric, and chemical injuries included in the Electric Power Research Institute (EPRI) Occupational Health and Safety Database (OHSD). There were a total of 872 thermal burn and electric shock injuries representing 3.7% of all injuries, but accounting for nearly 13% of all medical claim costs, second only to the medical costs associated with sprain- and strain-related injuries (38% of all injuries). The majority of burns involved less than 1 day off of work. The head, hands, and other upper extremities were the body parts most frequently injured by burns or electric shocks. For this industry, electric-related burns accounted for the largest percentage of burn injuries, 399 injuries (45.8%), followed by thermal/heat burns, 345 injuries (39.6%), and chemical burns, 51 injuries (5.8%). These injuries also represented a disproportionate number of fatalities; of the 24 deaths recorded in the database, contact with electric current or with temperature extremes was the source of seven of the fatalities. High-risk occupations included welders, line workers, electricians, meter readers, mechanics, maintenance workers, and plant and equipment operators.
Absenteeism↗
Adjunctive hyperbaric oxygen therapy contributes healing in electrical injury: a case report of high voltage electrical injury.
In electrical injuries, new treatment modalities and guidelines are needed for improving clinical outcome and the survival of damaged tissue. Although there is no published study about hyperbaric oxygen (HBO) therapy for electrical injury in the literature, it is indicated in conditions, which may contribute to the clinical presentation of electrical injury such as thermal burns, crush injuries, necrotizing soft tissue infections, problematic wounds and compromised skin grafts and flaps. An 11-year-old child with high voltage electrical injury treated with adjunctive hyperbaric oxygen for 90 minutes twice a day at 2,4 ATA for one week, then once a day for six days for a total of 20 sessions was presented to demonstrate the beneficial effects of hyperbaric oxygen therapy initiated before irreversible damage had taken place. Although hyperbaric oxygen therapy was initiated rather late, when the most effective window for intervention had already past, HBO was effective in fighting against necrosis, infection and tissue loss. Adjunctive HBO therapy is suggested for electrical injuries for its contribution to healing. In order to see the favourable effects of HBO, it is better to start the treatment within the first 24 hours following injury.
Child↗
Determination of tissue viability in experimental electrical injuries.
Electrical burns or ischemia (induced by vascular ligation) were produced in the legs of 15 anesthetized dogs to study evolution of tissue changes compared with impedance alterations. After the application of 1-ampere currents at 60 Hz, animals were monitored from 1 to 4 days. Muscle impendance was measured with frequency sweeping to determine tissue destruction. Nuclear magnetic resonance spectroscopy (phosphorus 31) was used to assess metabolic activity, and results were compared to impedance measurements. In burned limbs, 70% reduction in muscle impedance was seen, which corresponds to decreased metabolic activity (absent organic phosphates) and suggests necrosis. Visually viable tissue had impedance decreases of 25% and levels of organic phosphates slightly lower than normal. Relaxation frequencies in dogs with severe burns exceeded 80 kHz; in viable tissue, 30 to 40 kHz (normal: 30 kHz). In ischemic muscle, organic phosphates decreased rapidly (1 to 2 hours); impedance changes evolved more slowly (1 day), but they ultimately reached the same degree of severity. Measurement of impedance may be a valuable adjunct in the evaluation of electrical burns, since significant changes strongly suggest nonviability.
Animals↗
Electrical injury mechanisms: electrical breakdown of cell membranes.
Electric fields are capable of damaging cells through both thermal and nonthermal mechanisms. While joule heating is generally recognized to mediate tissue injury in electrical trauma, the possible role of electrical breakdown of cell membranes has not been thoroughly considered. Evidence is presented suggestive that in many instances of electrical trauma the local electrical field is of sufficient magnitude to cause electrical breakdown of cell membranes and cell lysis. In theory, large cells such as muscle and nerve cells are more vulnerable to electrical breakdown. To illustrate the significance of cell size and orientation, a geometrically simple model of an elongated cell is analyzed.
Arm↗
Auditory and neuropsychiatric behavior patterns after electrical injury.
Major electrical injury causes widespread tissue destruction. Slow and incomplete functional recovery after electrocution-type injury has led clinicians to suspect residual brain damage. One hundred and one consecutive patients who were admitted to the hospital because of electrical injury were studied. Forty-eight had electric-current injury. The other 53 had flash, contact, or arcing burns (electrical injury without passage of current). A primary study cohort of 16 patients with electric-current injury and 18 patients who had electrical injury without passage of current received specialized trauma-based psychiatric treatment, which was coordinated with serial auditory and neurologic studies. This strategy served to highlight discrepancies between preinjury and postinjury performance. Twelve of 16 patients with electric-current injury showed neurobehavioral (organic) dysfunction after 1 year, which implied brain damage; eight showed persistent auditory changes. Four of 18 patients who had electrical injury without passage of current met criteria for post-traumatic stress disorder after 1 year; none had neurobehavioral or auditory dysfunction. These findings indicate that patients with electric-current injury are at risk for permanent auditory dysfunction and brain damage, whereas those with other types of electrical burns are not.
Adult↗
Rhabdomyolysis following electrical injury.
Severe electrical injury is often associated with acute rhabdomyolysis, evident from massively elevated serum creatine (CK) levels, along with presence of other muscle fiber constituents in the serum and urine, resulting specifically in hyperkalemia, hyperphosphatemia, and myoglobinuria. The acute medical care of the patient with electrical injury must include addressing supportive therapy for the rhabdomyolysis (more fully reviewed in other articles in this issue of Seminars), but understanding the underlying pathophysiology of rhabdomyolysis may allow for the future development of improved therapeutic modalities.
Animals↗