ELECTRICAL

BURNS
Dr Ng Siew Weng
Department of Plastic, Reconstructive and Aesthetic Surgery
Singapore General Hospital

INTRODUCTION
Electrical burns : 1000 deaths / yr in USA

(of 2 million burn injuries).

Site

of accident :

Workplace for most adults

Home for children

Lightning injury in nature

Low voltage electrical burns : leading cause of

electrical burn injuries in children and adult.

EPIDEMIOLOGY

Electricians, construction workers

Children :

Objects inserted into wall sockets eg pins, keys and fingers

Youths :

Hobbyists involving radios, computers and electrical

devices.

Ohms Law
V (voltage)

= I (Current) x R (Resistence)

Heat is generated by

electrical current through

a resistance
Power

= I2 (Current) x R (Resistence)

FACTORS DETERMINING
ELECTRICAL INJURY
Type of circuit
Resistance of tissues
Amperage
Voltage
Current pathway
Duration
Environmental factors
M. A. Cooper. Emergent Care of Lightning and Electrical Injuries. Seminars in Neurology, Volume 15, Number 3, 1995

TYPES OF CIRCUIT (DC)

Direct current (DC) :

Tends to cause a single muscle spasm

Victim can be thrown from the source
Shorter duration of exposure
Increase likelihood of traumatic blunt injury.

TYPES OF CIRCUIT (AC)

Alternating current (AC) :

3 times more dangerous than DC of the same

voltage
Continuous muscle contraction, or tetany (40-110
Hz)
Tetany occurs even at very low amperages.
United States : 60 Hz.
European countries : 50 Hz.

TISSUE RESISTANCE
least resistant (most conductive) to most

resistant (least conductive) :

Nerves
Blood

Vessels
Muscles
Wet Skin (sweating resistance)
Dry Skin
Tendon
Fat
Bone

CURRENT

VOLTAGE

PATHWAY OF CURRENT

Extent of tissue damage depends on pathway of current

Through the heart or thorax cardiac arrhythmias and

direct myocardial damage.

Through the brain respiratory arrest seizures, direct

brain injury, and paralysis.

Close to the eyes cataracts.

Mortality of high voltage burn :

Hand to hand traversing chest is 60%,

Hand to Foot 20%,
Foot to Foot 5%

MECHANISM OF ELECTRICAL
INJURY

Direct contact : The Entry/Exit Contact lesion has

three areas
Charred, Black Center
Gray,
Coagulated
Necrosis
Partial Tissue Damage

Entrance Wound: (Left) Small entrance wound (dark spot) with surrounding
burn over the abdomen.
Exit Wound: (right) Current flows through the body from the entrance point
to the exit point in the right foot.

MECHANISM OF ELECTRICAL
INJURY
Direct contact
Electrical arc :

The most destructive indirect injury

External passage of high voltage current
Ionised heated plasma with temperature 5000 to
20,000 oC.
Arcs about 1 inch for each 10,000 volt
Charred, central portions of high electrical voltage
Seen at entry and exit points burns of clothing and
secondary thermal burns.
Usually not present in household x220 voltage burns.

Arc Burn
Patient was near a power

box which exploded.

Electricity arced through the
air and entered his body.
The current was drawn to
his armpits because of
perspiration.

MECHANISM OF ELECTRICAL
INJURY

Direct contact

Electrical arc :

Flash burn :

superficial partial-thickness burns.

Thermal

MECHANISM OF ELECTRICAL
INJURY
Direct contact
Electrical arc
Flash

burn :

Thermal
Blunt injury

Victim thrown clear of source by intense muscular

contraction or fall from a height.
AC current violent muscle spasms fractures and
dislocations.

ORGAN-SPECIFIC DAMAGES
IN ELECTRICAL BURN

CARDIOVASCULAR EFFECTS

Electrical injury may affect the heart in two ways:

Direct necrosis of the myocardium

Cardiac dysrhythmias.

Necrosis involves : (1) myocardium, (2) nodal tissue,

(3) conduction pathways, and the (4) coronary
arteries

AC produce greater damage than DC for any given

voltage

CARDIAC MANIFESTATIONS

Cardiac standstill and ventricular fibrillation

Sinus tachycardia
Nonspecific ST- and T-wave changes.
Conduction defects e.g. (1) various degrees of heart blocks,
(2) bundle-brunch blocks, and (3) prolongation of the QT
interval, are also common.
Supraventricular tachycardias, premature ventricular
contractions, and atrial fibrillation.
Depression of the right and left ejection fractions
Increase creatine kinase (CK) MB fraction spurious
diagnosis of myocardial infarction

CUTANEOUS EFFECTS

Entry and Exits

Most common sites of contact for current : hands and skull.

The most common areas of ground (exit): the heels.

Potential for deeper burns :

Deeper burn may occur because of (1) high voltage or (2) moisture on
the skin which lowers resistance and allow transmission of current to
deeper tissue
Heat generated by bone massive coagulation and necrosis of deep
muscles and other tissues (almost completely sparing the skin)
Severity of the skin burns cannot be used to assess the degree of
internal injury in an electrical accident with low voltage
TBSA cutaneous involvement may not accurately reflect fluid
requirement for resuscitation.

CUTANEOUS EFFECTS
Burns over flexure

creases :

Kissing burn : occurs at the flexor creases as the

electric current arcs causing arc burns on both
flexor surfaces.
Extensive underlying tissue damage often present
because current became concentrated in its
passage.

CNS EFFECTS
Acute

Respiratory arrest, seizures, mental status changes,

coma, amnesia, quadriplegia and localized paresis.
Current through skull coagulation of brain
parenchyma, epidural and subdural hematomas and
intraventricular haemorrhages.
Peripheral neuropathy

Late

Ascending paralysis, transverse myelitis amyotrophic

lateral sclerosis

EFFECTS ON EXTREMITIES
EXTREMITIES :

Fracture / dislocations including spinal injury

Compartment syndrome :
Loss of intravascular fluid ; Inelastic fascial
compartments
interstitial pressure capillary perfusion
pressure, perfusion hypoxia extravasation
interstitial pressure of compartment.
PotentialSigns - pain, pallor, paresis and
pulselessness
Reversible before 6 hrs.

Electric burn while holding

a tool. The entrance wound
with thermal wound shown.

Same hand a few days later,

with deeper tissue
involvement.

OPHTHALMIC EFFECTS
Cataracts :

Head & ceck electrical injuries

> 1000 volts
4 to 6 months after accident

Other effects : corneal lesions, uveitis,

iridocyclitis, vitreous hemorrhage, optic

atrophy, retinal detach, and chorioretinitis

OTHER ORGAN EFFECTS

RENAL :

Similar to crush injuries; myoglobinuria

Myoglobin acute renal failure

VASCULAR INJURY :

Direct result of current flow

Secondary due to surrounding tissue damage

OTHER ORGAN EFFECTS

Ear Effects :

Typanic membrane rupture frequently found in

lightning patients and
Disruption of the ossicles may occur
Cerebrospinal fluid otorrhea hematympanic and
permanent deafness.

Electrical Burn Management

Make sure current is off

Lightning hazards
Do not go near patient until current is off

ABCs

Ventilate and perform CPR as needed

Oxygen
ECG monitoring

Treat dysrhythmias

Management

MANAGEMENT

Specifically for patients admitted to ICU :

Thorough evaluation for hidden injury (especially spinal cord

injury) and for blunt thoracic or abdominal trauma.
Serial evaluation of liver, pancreatic, and renal function for
traumatic and anoxic/ischemic injury (in case of
cardiorespiratory arrest),
Appropriate imaging studies (e.g., computed tomography or
abdominal sonogram) as necessary.
CT scan of the head is indicated in all severe cases of lightning
injury, of injuries due to a fall, and if there are persistent
abnormal findings in the neurologic examination.
Preventive treatment for stress ulcers.
Psychiatric assessment and support as soon as the patient is
conscious and hemodynamically stable.

MANAGEMENT
Patients with high-voltage :

Evaluation for rhabdomyolysis and myoglobinuria

(uncommon in lightning injury).
Evaluation of the limbs for compartment syndrome
- may require fasciotomy (rare in lightning injury).
Nutritional support due to increased energy
expenditures.
Ophthalmologic and otoscopic evaluation
(common in cases of lightning injury).

PREVENTION
Home and workplace :

Households electrical cords, wall sockets,

extension cords
Exposed high tensions electrical installation

Thank You