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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 51  |  Issue : 1  |  Page : 9-14

Analysis of electrical injury in a Level I southern Taiwan trauma center


1 Department of Plastic Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taiwan
2 Department of General Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taiwan
3 Department of Trauma Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taiwan

Date of Submission21-Apr-2017
Date of Decision24-Jul-2017
Date of Acceptance29-Sep-2017
Date of Web Publication09-Feb-2018

Correspondence Address:
Dr. Ching-Hua Hsieh
No. 123, Ta-Pei Road, Niao-Song District, Kaohsiung City 833
Taiwan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/fjs.fjs_60_17

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  Abstract 


Background: Electrical injuries are potentially devastating in many ways. This study aimed to profile the epidemiologic characteristics and outcome of these patients in a Level I trauma center in Southern Taiwan.
Methods: A retrospective review of 34 (1.9%) patients with electrical injuries and admitted to the Kaohsiung Chang Gung Memorial Hospital Burn Center from 2009 to 2015 from all 23,705 hospitalized patients registered in the trauma registry system. The information such as patient's profile, injury characteristics and severity, description of the burn injury, associated injuries, expenditures, and outcomes were gathered.
Results: There were 33 males and one female with an average age of 37.1 ± 10.4 years old. Twenty-eight cases (82.3%) were work related. The average total body surface area burned was 5.26%. The mean injury severity score was 9.8 with the median, and interquartile ranges (Q1–Q3) being 4 and 3.3–9.3. The average hospital length of stay (LOS) was 16.6 ± 14.3 days. Twenty-one patients required Intensive Care Unit (ICU) admission, and the average ICU LOS was 20.1 ± 16.2 days. Fourteen patients underwent operations with each patient averaging 2.5 operations. There were two cases of mortality (5.9%). Although the expenditure seemed to be higher in dealing with the electrical burn patients (n = 34) than the nonelectrical burn patients (n = 1727), there were no significant differences of the average total expenditure as well as the costs of operation, examination, and pharmaceuticals between the electrical burn patients and nonelectrical burn patients.
Conclusions: Most of the electrical burn injuries are work related and may associated with injuries to different body regions. With a high incidence of ICU admission and the requirement of frequent operations, the electric burn injuries still carry high morbidities with the risk to mortality.

Keywords: Electrical injury, expenditure, injury severity score, mortality


How to cite this article:
Sudario-Lumague R, Yang JC, Lin CC, Hsu SY, Hsieh CH. Analysis of electrical injury in a Level I southern Taiwan trauma center. Formos J Surg 2018;51:9-14

How to cite this URL:
Sudario-Lumague R, Yang JC, Lin CC, Hsu SY, Hsieh CH. Analysis of electrical injury in a Level I southern Taiwan trauma center. Formos J Surg [serial online] 2018 [cited 2018 Feb 25];51:9-14. Available from: http://www.e-fjs.org/text.asp?2018/51/1/9/225132




  Introduction Top


There is a trend of increased incidence of electrical injuries due to rapid industrialization in some areas [1] and the lack of corresponding safety information in some agricultural populations.[2] In some countries, the reported incidence of electrical injuries consisted as high as 30.9% of all burn cases.[2],[3] In Taiwan, electrical burns accounted for just 6% of all burn cases, while scald burns (49.9%), flame burns (19.6%), and burns from explosion (11.8%) made up the majority of the burn cases.[4] With damage to deeper tissues and the associated injures such as cardiogenic shock, the electrical injuries can be the most damaging among all types of burn injuries.[5] Based on the available literature, the hospital course of electrical injury patients has been studied extensively, and the unpredictability of the injury had been pointed out because the visible cutaneous injury does not truly represent the actual intrinsic tissue damage. These deep tissues have been shown to retain heat from the electric current, often causing a more severe injury than those that can be seen on the superficial skin.[5] In addition, the patient outcomes are often compounded by the accompanying trauma that comes with the electrical injury. These include falls from height, bone injuries on the upper and lower limbs, and blunt abdominal injury.[6] This study aimed to profile the epidemiologic characteristics and the outcomes of these patients in a Level I trauma center in Southern Taiwan to provide more valuable information about patients with electrical burns, including information on the associated injuries and related expenditures.


  Methods Top


Ethics statement

This study was preapproved by the institutional review board (IRB) of the Chang Gung Memorial Hospital (approval number: 201600100B0D001). Informed consent was waived according to IRB regulations.

Study design

This retrospective study reviewed data of all 23,705 hospitalized patients registered in the trauma registry system of a Level I trauma center from January 1, 2009, to December 31, 2015. All patients (n = 1761) with a burn injury and hospitalized for treatment were included in the study. Among these patients, there were 34 (1.9%) patients with an electrical burn injury and 1727 (98.1%) patients with a nonelectrical burn injury. Case histories were reviewed, and the following information was gathered age, sex, electrical voltage, Glasgow coma scale scores on arrival at emergency department (ER), burn of total body surface area (TBSA), presence of cardiogenic shock at ER, associated injuries, hospital length of stay (LOS), admission in Intensive Care Unit (ICU), operation, inhospital mortality, and total expenditure which included the costs of operation (operation fee and operation supply fee), examination (physical examination, hematology testing, radiography and pathological examinations, electrocardiography (ECG) examination, echocardiogram, endoscopy, electromyography, cardiac catheterization, and electroencephalography monitoring), the cost of pharmaceuticals (medical service, medicines, and narcotics), and other related expenditures (fee for registration, administrative tasks, wards, nursing, blood and plasma tests, hemodialysis, anesthesia, rehabilitation treatment, special material costs, and personal expenses). These expenditures were compared between those electrical burn and nonelectrical burn patients and were expressed as cost/victim in New Taiwan Dollars (NTD). In this study, we also used the abbreviated injury scale (AIS) and injury severity score (ISS) to describe the injuries of the patients. The AIS is a numerical system for grading specific tissue trauma to six body regions (head/neck, face, thorax, abdomen, extremities, and external). Each region is graded according to the severity of the injury with a grade of 1 being minor injury to a grade of 6 which is considered a fatal injury. The ISS scores of each patient were determined using the formula such that ISS is the sum of the squares of the highest AIS grade in each of the three most injured areas. The AIS and ISS is the most widely used anatomic severity index which has been the standard for the prognosis of patient outcomes in traumatic injuries.[7]


  Results Top


A total of 34 patients were included in the study [Table 1]. There were 33 males (97.1%) and one female (2.9%). The average age of the patients was 37.1 ± 10.4 years old [Table 2]. Twenty-eight cases (82.3%) were work related. There were 8 high-voltage (23.5%) and 26 low-voltage (76.5%) injury cases. The average percentage of TBSA burned was 5.26%. The mean ISS score was 9.8 with the median, and interquartile ranges (Q1–Q3) being 4 and 3.3–9.3. Based on ISS, there were three patients who scored ≥25 (deemed as very severely injured), one patient who scored 16–24 (severely injured), five patients who scored 9–15 (moderately injured), and 25 patients who scored 1–8 (mild injury). Based on AIS, the injury regions located on external, extremity, and head/neck comprised 91.2% (n = 31), 20.6% (n = 7), and 8.8% (n = 3) of all patients with electrical injuries, respectively. In addition, one (2.9%), three (8.8%), and five (14.7%) patients had a ≥3 AIS injury in the thorax, extremity, and external, respectively. The average hospital LOS was 16.6 ± 14.3 days. Twenty-one patients (61.8%) required ICU admission, and the average ICU LOS was 20.1 ± 16.2 days. Fourteen patients underwent operations, each patient averaging 2.5 operations. There were two cases of mortality (5.9%) overall. Although the expenditure seemed to be higher in dealing with the electrical burn patients than the nonelectrical burn patients, there were no significant differences of the average total expenditure (NTD 176,504 ± 183,019 and 123,020 ± 241,213, P = 0.199), the costs of operation (10,735 ± 18,262 and 7957 ± 25,231, P = 0.523), examination (6055 ± 8293 and 3138 ± 9955, P = 0.090), and pharmaceuticals (9658 ± 16,182 and 8440 ± 32,158, P = 0.826) in the electrical burn patients (n = 34) and the nonelectrical burn patients (n = 1727), respectively.
Table 1: List of patients with electrical injury included in the study

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Table 2: The characteristics of the injuries and the outcomes for the patients with electrical injury

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  Discussion Top


In this study regarding electrical injuries in Taiwan, males are still the most commonly injured (97.1%) and the most accidents occurred at work (82.3%). Electrical injuries occurring mostly in the workplace have been reported in the literature (67.5%–81%).[1],[8],[9],[10] This is due to the fact that jobs involving electrical equipment are almost always assigned to males in the workplace. The average age (37.1) of patients in this study is also consistent with the working age reported in other areas.[6],[11],[12],[13],[14] A report by Brandt showed that 81% of all electrical injuries are occupation related, and the average age is also 37.1 years old. They postulated that at this age, the workers may have already been employed for some time, hence may have developed complacency in handling the electrical equipment. They recommended a targeted continuing safety education in the workplace to reduce the risk of electrical injury.[10] However, notably, a different report by Luz from Brazil shows a slight predominance of electrical injuries among children and adolescents who play near the high-tension lines.[15]

The mean TBSA of only 5.26% is lower than that of other reports of electrical injury patients who had 10.5%–30.3% TBSA.[6],[9],[14],[15],[16],[17] However, due to the mechanism of electrical injury, the variability in these reported cutaneous burns may not correspond with the actual deep tissue damage, which is more important to understand during the management of patients. In fact, 25 of our study patients out of 34 only sustained 0%–2% TBSA cutaneous burns mostly on the hand (contact point) but were still managed similarly with those who had actual deep tissue damage to avoid possible sequels, namely, myocardial damage, neurologic deficits, and renal damage. Unlike in the underdeveloped countries where high-voltage injuries are more common, the electrical low-voltage injuries were more common in this study (76.5%).[3],[9],[11],[16],[17] It had been reported that when the chest is situated along the electric current path that connects the entrance and exit points, the current passages can lead to cardiac injury.[18] The documented cardiovascular effects of an electrical shock include arrhythmias, acute myocardial necrosis, myocardial ischemia, heart failure, hemorrhagic pericarditis, and anomalous nonspecific ECG changes.[19] While exposure to high voltage or direct current will most likely cause ventricular asystole, even low-voltage alternating current can cause sudden cardiac death by ventricular fibrillation,[20] and delayed ventricular arrhythmias have been also reported.[21] In this study, three patients (8.8%) had presented with cardiogenic shock and one patient (2.7%) had arrhythmia, which is comparable with a recent study that has recorded significant arrhythmias in only 3% of monitored patients.[22]

The high incidence of falls among electrical injury patients can be explained by alternating current causing tetanic muscle contractions which may throw the victims away from the electrical source.[5] Falling from a height is the most common associated injury with electrical injuries, and it was reported in as high as 25.6% of all electrical injury patients.[6] In this study, seven patients had a history of fall (20.5%) which is similar to the reports in the literature (25.6%).[6] Thorough history taking, particularly on the history of falling from a height, is very important during the initial evaluation to prevent the miss of the associated injuries. A study by Chen and Yangreported that head injuries occurred in 8 out of 249 (3.2%) electrical injury patients, with all victims presenting a history of falling from a height while working near an electrical source.[23] All of these patients had a computed tomography scan <24 h after injury. Six patients had an intracerebral hematoma or epidural hematoma, three patients underwent craniotomy and evacuation of the hematoma, and one patient underwent debridement secondary to a depressed skull fracture. It is, therefore, recommended to highly suspect significant head injury among electrical injury patients with a history of fall.[23]

The ISS score, a guide for the evaluation of trauma care and a valuable tool for studies, is used as a predictor of morbidity and mortality.[24] In this study, the average ISS score was 9.8. This score of <10 means low mortality rate; in addition, most of our patients only sustained a low-voltage injury. High-voltage injuries are more devastating, and patients have higher complications, resulting in amputations, operations, longer hospital stays, and even mortality.[1],[6],[15],[25],[26] In this study, there were three patients with an ISS score of ≥25 and two (66.6%) of these three patients did not survive. The mortality rate of 5.9% in this study is comparable with other reports of mortality rates being 1.6%–9.1%.[1],[4],[6],[9],[11],[13],[15],[16],[27],[28] The ISS can, therefore, provide valuable information to describe the severity and possible hospital course of patients with electrical injuries. When treating an electrical burn victim as a trauma patient, meticulous examination should always be performed to avoid missed injuries.

The average LOS at the hospital was 16.6 days which was also comparable to those seen in other reports ranging from 14 to 34 days.[9],[11],[15],[16],[17],[28] In general, the main contributory factor to prolonged hospital stay is the need for operations, which may often be numerous. In this study, 41% of the patients needed an operation, with each patient requiring average 2.5 operations as multiple debridements before a definitive skin grafting can be performed. In this study, although the expenditure seemed to be higher in dealing with the electrical burn patients than the nonelectrical burn patients, there were no significant differences of the average total expenditure as well as the costs of operation, examination, and pharmaceuticals between the electrical burn patients and the nonelectrical burn patients. However, comparison of these values to other reports may be difficult due to the differences in economies and insurance policies among institutions in different countries. In addition, the numbers relating to cost do not reflect other losses such as lost income due to lost days at work, the cost of subsequent therapy and rehabilitation efforts, and the need for possible future treatments in the case of long-term complications.


  Conclusions Top


In this study, we present the epidemiologic characteristics and outcome of electrical burn patients in a Level I trauma center in Southern Taiwan together with information on associated injuries and expenditures. Most of the electrical burn injuries are work related and may associated with injuries to different body regions. With a high incidence of ICU admission and the requirement of frequent operations, the electric burn injuries still carry high morbidities with the risk to mortality. Thus, it is still imperative to educate the population about the dangers and hazards associated with improper use of electrical devices.

Financial support and sponsorship

This research was supported by a grant from CMRPG8F0801.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

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