Acute electrical burns: a 10-year clinical experience

We have reviewed 113 cases of electrical burns treated at the Cook County Hospital Burn Center during the past 10 years. There were 3265 acute burn admissions during this period. the incidence of electrical burns being 3.5 per cent. Low-voltage electrical burns occurred in 82 of the 113 patients (73 per cent). These were caused mostly by household electricity supplies, occurred in children, and were preventable. Arc burns of the perioral region were allowed to heal spontaneously. The surgical management of other arc burns and flash burns was similar to that for most deep burn wounds. The incidence of high-voltage electrical injuries was 27 per cent in our series. Over 50 per cent of these injuries were not work-related. These tended to occur outside the home in young adult males and were also frequently preventable. None of these patients developed acute renal failure. Early surgical debridement of devitalized tissue with allografting, followed by delayed definitive wound closure or amputation prevented septic complications. Early fasciotomy appeared to have little effect on complete limb salvage. Limb loss continues to be the major factor contributing to the high morbidity associated with these injuries. All 113 patients survived. We attribute this to early transfer of patients to our Burn Unit, aggressive fluid resuscitation, continuous haemodynamic and metabolic support, and early surgical intervention.     

The last 10 years in a burn centre in Ankara, Turkey: an analysis of 5264 cases

This is a retrospective study analysing 5264 patients treated in the burn centre at Gülhane Military Medical Academy from 1 January 1986 to 31 December 1995. Our burn centre is not only the firs, but one of the best established and supported in Turkey. Our present study has the largest patient group of other previously published studies from Turkey. Of the total patients studied, 4464 patients had minor burns and were treated on an outpatient basis and 800 patients had moderate to major burns. Although our centre is in a military area in Ankara, only 1047 (20 per cent) patients were military personnel and the military-related burn causes comprised only 6 per cent of the total. The remaining 4217 (80 per cent of the total patients) were civilians. Flame injuries were also more frequent in military patients than civilians. Minor burns were most common in the age group 0–10 years old (40 per cent) and moderate to major burns in the age group 21–30 years (54 per cent). Scalds were the main cause of paediatric burns. Male patients were dominant. The overall mortality among inpatients was 18.2 per cent and mean total body surface area (TBSA) was 57.6 per cent in patients who died. 134 patients demonstrated inhalation injury and 82 per cent of these patients died. The epidemiological pattern of our patients is similar to that in other studies from developed countries, although some ethnic causative factors could be found. Our study indicates that emergency measures should be taken to prevent flame injuries at military barracks and industrial workplaces and scalding accidents to children at home and throughout the country.     

Epidemiological survey of burns treated in Ankara, Turkey and desirable burn-prevention strategies

From 1 January 1979 to 31 December 1993, 1109 patients were admitted to our burn unit located at Hacettepe University. Of the patients, 638 (57.5 per cent) were children (under the age of 16 years). The male to female ratio was 1.4: 1 in children, and was approximately 2.6: 1 for patients over 16 years of age. Of the 638 paediatric patients, 67 (10.5 per cent) sustained electrical burns. The causes of injury in the remaining 571 cases (89.5 per cent) were hot liquids in 379 (66.4 per cent of the non-electrical burns), flame in 190 (33.3 per cent) and contact burns in two (0.3 per cent). Of the scalds, 296 (78.1 per cent of the scalds), 52 (13.7 per cent), 22 (5.8 per cent) and nine (2.4 per cent) were caused by hot water, milk, meal and oil respectively. Of the flame burns, 21 (11.1 per cent) were due to LPG explosions.

Of the 471 adult patients (over 16 years), 159 (33.8 per cent) were injured by electricity. The causes of non-electrical burn injuries were: hot liquid in 25, flame in 274, chemical agents in four, contact in four, and other causes in four. Although our centre is located in Central Anatolia, 41.8 per cent of all patients were referred from the other six regions of Turkey. Of the 1109 inpatients, 645 (58.2 per cent) were injured in Central Anatolia, 279 (25.2 per cent) in the Black Sea Region, 55 (5.0 per cent) in the Mediterranean Region, 18 (1.6 per cent) in the Marmara Region, 34 (3.1 per cent) in the Aegean Region, 52 (4.7 per cent) in Southeastern Anatolia and 26 (2.3 per cent) in Eastern Anatolia. Approximately two-thirds of the patients (419) required one or more surgical interventions, including debridement and grafting, as well as amputation. The most important early complications were acute renal failure (148 patients −13.3 per cent), sepsis (660 patients −59.5 per cent) and gastrointestinal haemorrhage (seven patients −0.6 per cent). The overall mortality rate was 34.4 per cent. The epidemiological pattern of the burns showed that emergency measures should be taken to prevent scalding accidents to children throughout the country, and for electrical burns in adults, particularly those living in the Black Sea Region. In establishing, implementing and directing prevention programmes, regional differences should be taken into consideration.     

Electrical burns in Kuwait: A review and analysis of 64 cases

Sixty-four patients with electrical burns were admitted to the Department of Plastic Surgery, Ibn Sina Hospital, Kuwait during the past 6 years. There were 1202 admissions during this period, the incidence of electrical burns being 5.3 per cent. Sixty-nine per cent of the patients sustained injury from direct contact with live electrical wire, the remaining 31 per cent sustained flash burns. The incidence of low voltage injury was much higher as compared to high voltage. Forty-four per cent of these injuries were not work related. Less than 10 per cent of the body surface area was involved in about 80 per cent of the patients. A total of 65 operations was carried out in 39 patients. Twenty of these patients had repeated debridements until the wound was ready for coverage. All 64 patients survived.     

Retrospective evaluation of admission criteria for paediatric electrical injuries

In the medical community, the practice of admitting all electrical burns for 24–48 h of observation, monitoring and laboratory evaluation is widespread. This retrospective review of paediatric electrical burns was conducted to determine which patients may safely be treated as outpatients.

Retrospective analysis of all paediatric burns admitted between 1980 and 1991 identified 35 patients with electrical injuries. Patients were divided into two groups for analysis: those burned by exposure to household voltages (120–240 V; n=26) and those exposed to high voltages, in excess of 1000 V (n=9).

The majority of household electrical injuries occurred secondary to contact with the household 120 V (21/26). Contact with an extremity accounted for the largest number of these injuries (18/26). The mouth was the second most frequent site of injury (7/26). Most of these patients (20/26) had < 1 per cent BSA burn. No patient in the household-voltage group had an arrythmia that required treatment, nor were there any identified examples of compartment syndrome or other vascular complications. Seven patients did require minimal skin grafting. No deaths occurred in either group.

The patients in the household-voltage group were significantly younger. High-voltage electrical injuries occurred in an older patient population and required more aggressive care and surgical intervention. This was evident at the time of initial evaluation. Based on these data, healthy children with small partial-thickness electrical burns and no initial evidence of cardiac or neurovascular injury do not appear to need hospital admission.     

Paediatric burn injuries in New England, USA

The authors analysed a subset of data from the New England Regional Burn Program (NERBP) to describe the epidemiology of burn injuries for children aged from birth to 19 years in the six-state New England area of the USA. The subset of the NERBP data analysed pertained to residents of the six New England states who were admitted to hospital for the treatment of a burn injury sustained between 1 July 1978 and 30 June 1979. Analysis of the data revealed that 1128 (41 per cent) of the 2742 hospitalized burns identified occurred to persons between the ages of birth and 19 years, yielding an overall burn incidence rate of 30.7 burns per 100,000 person-years. Children aged from birth to 2 years sustained a higher burn rate, 96.7 burns per 100,000 child-years, than did children in any other age category. The burn rate for males was higher than the rate for females in each age category, as were the rates for black children compared to white children. Children in Massachusetts experienced the highest overall burn rate among the six New England states; the lowest rate occurred in New Hampshire. Overall, 63 per cent of the burns occurred in a residential setting. The most common activities related to burn injury were food preparation and food consumption, which accounted for 471 (42 per cent) of the burn injuries.     

Burn injuries in the Jeddah area of Saudi Arabia: a study of 319 cases

Three hundred and nineteen patients with different types of burns were studied at King Fahd Hospital, Jeddah, Saudi Arabia over a 2-year period (December, 1985 to December, 1987). Scalding was the most common cause (56.4 per cent) of burn injuries compared with 41.4 per cent of patients who sustained flame injury; 84.6 per cent of the thermal injuries occurred at home, with children (less than or equal to 18 years of age) being affected most frequently (61.8 per cent). The overall mortality was 9.4 per cent.     

Occupational burn injuries

The epidemiology of occupational burns injuries in a well-defined population is analysed. Although a total of 371 persons sustained an injury, only a few were inpatients and just one required anti-shock treatment. The mean burn surface area was 0.66 per cent and 14 patients had full thickness burn injuries. There were no deaths. Men were found to be more prone than women to injury, especially young workers. The distribution by categories of work and causes of burn are illustrated. Scalds and contact burns were dominant, particularly in restaurants. The work by the National Labour Inspection is acknowledged.     

Electrical burns--incidence and prognosis in Western Scotland

A 10-year review of all patients admitted to the West of Scotland Regional Burns Unit with serious electrical burns indicated an incidence of only 2.6 cases per million of the population served by the Unit per year. Injuries following electrocution or electric flash, but excluding injuries caused by grasping the hot heating element of an electric fire, were suffered by 70 patients, 52 of whom sustained electrocution which was not immediately fatal. Ninety-one per cent of the patients were male. The patients who died in hospital did so as a result of sepsis rather than as a direct result of the electrical injury. All those patients who had ECG changes on admission recovered completely. In view of the very deep injuries, the amputation rate was high with 12 out of 52 patients (23 per cent) with electrocution injury requiring one or more amputations. The events preceding the serious electrical injury in our patients suggest that, 57 per cent of all the injuries could have been prevented, and in patients under 20 years of age this percentage rose to 91.     

Epidemiological pattern of adult burn injuries

An epidemiological survey of 411 patients over a period of five and a half years is analysed. There were no yearly trends but there was a slight increase in the number of female burns during the survey. There were 293 males, 71.3 per cent and 118 females, 28.7 per cent. The majority of the burns occurred in the younger age groups and reflect the cause of the injury. Approximately one-half of the injuries were burns of less than 10 per cent and three-quarters were of less than 20 per cent. The most extensive burns were caused by petrol and clothes fires. Predisposing conditions were present in 23.8 per cent of the patients, with alcohol abuse figuring prominently. Epilepsy was present in 2.7 per cent of the patients. The major predisposing conditions, causes and complications of the burn injuries are discussed. Burn infection occurred in 18.2 per cent of the patients and septicaemia in 3.5 per cent. There was a mortality rate of 8.3 per cent and the average length of hospital stay was 22.9 days. While these burns are mainly preventable it is difficult to see how this can be fully achieved.     

Burn injuries in the Dong Bei area of China: a study of 12,606 cases.

This survey analyses data from nine Chinese burn units with respect to age, causes, severity of burn injury, and survival or death of patients admitted to hospital during the past 10 years (from January 1980 to December 1989). Of 12,606 burned patients treated, 3391 were children (26.9 per cent) and over half the children (52.3 per cent) were up to 4 years old. Almost 60 per cent of the 12,606 patients treated were in the young adult group (15-44 years), and 86.9 per cent of 12,606 patients sustained thermal injuries mainly from fire flames followed by scald injuries (40.7 per cent). About 93 per cent of the patients had burns covering less than 50 per cent of the body surface area. The overall mortality rate was 1.24 per cent. The LD50 for the 12,112 patients less than 60 years old was a burned surface area exceeding 80 per cent of the total body surface area.     

Epidemiology of industrial burns in Brisbane

A retrospective epidemiological study of industrial burns admitted to the Royal Brisbane Hospital was conducted over a period of 7 years. A total of 182 patients were included in this survey--173 males (95 per cent) and 9 females (5 per cent). The proportion of industrial burns has decreased from 31.5 per cent to 18.5 per cent of total admissions to the burns unit over the past 10 years. Fifty per cent of the burns occurred in males less than 30 years old. The average age was 31 years. Two-thirds of the burns covered less than 10 per cent of the body and 84 per cent covered less than 20 per cent. While scalds were the commonest cause of industrial burns in our study (19.4 per cent), flame burns with clothing ignited caused the most extensive burns. Face and hands were the most common sites involved. Burns to these regions were mainly caused by flame and electrical burns. Eye burns comprised 5.5 per cent of the sample and were due to chemicals, gas explosions and electric flash. Twenty-six patients (14 per cent) suffered respiratory injury. Only one patient out of our series of 182 died. Progress has been made in industrial safety in the past few years but carelessness and human error still take their toll.     

Epidemiology of burns in Bergen, Norway.

We organised a prospective series to study, the epidemiology and causes of burns in the city of Bergen, Norway. We included 361 patients treated during one year at the casualty centre or at the burn centre at the hospital. Thirty-six per cent (n = 131) of the patients were less than 15 years old, and 9% (n = 33) were over 60. The incidence of burns was 17/10,000 inhabitants, 0.7 for patients who were admitted and 17 for outpatients. Burns were most common among male subjects aged 40 years or less, while women were more at risk in the older age groups. Almost half the injuries were caused by scalds, and 92 (26%) were from contact with hot surface. Scalds were more common among women than among men, while firework and flame burns were more common among men. Burns occurred at home in 227 patients (63%), at work in 58 (16%), and during leisure activities in 76 (21%). The mean surface area burned was 3.5% total body surface area (TBSA); patients who were admitted had a TBSA of 18% compared with 1.8% among those treated as outpatients.     

An analysis of 1704 burn injuries in Hong Kong children

Over a 12-month period, 1704 children less than 15 years old with burn injuries seen in the accident and emergency departments of seven major regional hospitals in Hong Kong were analysed with respect to their epidemiological data. The age group with the highest risk for injury was 0-4 years (57 per cent) and with a maximum at 1-2 years of age. Boys showed a significantly higher incidence of burns than girls at any age. Ninety-three per cent of the accidents occurred at home and 92 per cent were scalds caused by hot water and other fluids. In the great majority of patients the total body area of burn did not exceed 5 per cent. Younger children had a higher incidence of burns involving the head, face and anterior trunk, 39 per cent of the 0-4 year age group required hospital admission. During the winter months, the children tended to suffer from deeper burns.     

Hand burns in children under 5 years of age

In order to evaluate the epidemiology and functional results of hand burns in young children, 92 consecutive patients (126 hand burns) under age 5 years admitted to a Burn Center were reviewed. Scald burns (49 per cent) were most common, followed by flame (34 per cent), contact (14 per cent) and electrical burns (3 per cent). The child was left unattended by an adult in 53 per cent of cases and documented abuse was present in 6 per cent. The mean total body surface area (TBSA) burned was 17 per cent, and 77 patients (85 per cent) had additional burns in other areas (arms 34 per cent, legs 31 per cent, chest 29 per cent and face 27 per cent).

Palmar burns occurred in 24 hands (19 per cent), dorsal in 41 (33 per cent), while both surfaces were burned in 61 (48 per cent). Joints involved included the MP in 96 (76 per cent). PIP in 87 (69 per cent) and DIP in 80 (63 per cent). The depth was superficial partial thickness in 53 (47 per cent), deep partial in 55 (44 per cent), and full thickness in 18 hands (14 per cent); a total of 29 hands were grafted (15 deep partial and 14 full thickness). Escharotomies were required in 12 hands (9 per cent) (9 flame and 3 scald) and partial amputation of digits was required in 3 (2 per cent).

Follow-up was available in 46 hands from 7 to 120 months (mean 39 months). Partial thickness burns (34) healed with normal (32) or near-normal (2) hand function and developmental delay occurred in one patient. Hand function in 12 full thickness burns was normal in 9, decreased in 3 with developmental delay in 2 patients. The number of reoperations required per hand burned after hospital discharge varied with age (2 years and under 1.2 vs. over 2 years 0.6), depth (deep partial 0.4 vs. full thickness 1·6) and surface involved (palmar 1.3 vs. dorsal 0.1 vs. both 1.5), indicating that children under 2 years with full thickness palmar burns are at increased risk of developing burn scar deformities requiring surgical correction. Although 24 total reoperations were required in 25 deep partial and full thickness hand burns, residual burn scar deformities were present in only 2 hands at follow-up (1 boutonniere and I web space contacture).

It is concluded that the overall outcome of hand burns in this age-group is good and developmental delay is rare with proper acute management and prompt surgical correction of burn scar deformities.     

Profile of the paediatric burn patient in a Canadian burn centre.

Five hundred and eighty-three children (0-18 years old), consisting of 33.4 per cent of all burn inpatients, were admitted to the University of Alberta Hospitals over an 11-year period (January 1978 to December 1988). Demographic and outcome variables, in addition to aetiological factors, were examined. 48.4 per cent of burns occurred in children less than 4 years of age, with males predominating in every age group (P less than 0.001). Children had smaller burns, a higher incidence of scalds, less inhalation injuries and a lower mortality compared to adult burn patients admitted over the same time period (P less than 0.05). There was a low incidence of confirmed child abuse by burns (1.4 per cent). High-risk environments identified were the home (74.6 per cent of burns) and recreational settings (12.4 per cent of burns), mainly occurring around campfires. Native children were overrepresented in the burn population compared to the general population by a factor of approximately 10:1. Scald prevention, high-risk environments (home and recreational), high-risk populations (male and natives) and unsafe practices with flammable liquids (petrol in particular) should be emphasized in paediatric burn prevention programmes.     

Long-term psychosocial adjustment in patients with severe burn injuries: a follow-up study.

An investigation of the long-term psychosocial adjustment of patients with severe burn injuries is presented. In the selected 13-year period (1968-80) 46 patients fulfilled the entry criteria: burns covering more than 30 per cent body surface area (deep dermal or full skin thickness). Seventeen patients died early and one later. Of the remaining 28 patients, contact was made with 25 (89.3 per cent) who all participated. The observation time ranged between 7 and 21 years. The patients received a semi-standardized interview adjusted for age at the time of burn injury, a psychiatric interview and a physical examination to assess the permanent character and functional loss. The principal findings were: no correlation could be found between degree of disfiguration/function loss and the long-term psychosocial adaptation after severe burn injuries. The determinant factor was the premorbid psychiatric/psychological integration and, to some extent, support from staff and relatives.     

Epidemiology of adults' and childrens' burns in a Turkish burn center

From 1 January 1979 to 1 January 1985, 4094 patients were treated for burn injury in our centre. Of these, 84.9 per cent were treated as outpatients and 617 (15.1 per cent) were hospitalized. Of the 617 patients, 56.7 per cent were under 15 years of age (birth to 6 years: 67.7 per cent; 7-15 years, 32.3 per cent) and 43.3 per cent were over 15 years. The causes of burns in the over 15 years group were: flame, 36.3 per cent; electrical, 28.0 per cent; scalding, 18.4 per cent; liquefied petroleum (LP) gas explosion, 11.0 per cent; and others, 6.3 per cent. The burn cases in the under 15 years group were: scalding, 58.0 per cent; flame, 24.6 per cent; electrical, 10.0 per cent; hot meals, 5.2 per cent; and others, 2.0 per cent. After being resuscitated, these patients were treated with systemic antibiotics, local chemotherapy and silver-nitrate-incorporated amniotic membrane. Despite all medical efforts, 217 (35.7 per cent) of the hospitalized patients died as a result of various complications. At the same time, 3477 patients were treated as outpatients: 72.0 per cent of these were under 15 years old (birth to 6 years, 82.9 per cent, 7-15 years, 18.8 per cent) and 28.0 per cent patients were over 15 years of age. The causes of burn injury in these patients were: hot liquids, 61.7 per cent; flame, 17.0 per cent; hot meals, 8.4 per cent; hot metal, 5.8 per cent; electrical, 3.6 per cent; and chemical, 1.7 per cent.     

Thermal injury in the elderly: when is comfort care the right choice?

The factors contributing to a higher mortality rate in elderly thermal injury victims are not well delineated. The purpose of this study is to determine the impact of the initial injury, medical comorbidities, and burn size on patient outcome and to determine a level of injury in this population when comfort care is an appropriate first choice. Individual medical records of patients over 65 years of age admitted to our burn center over a 10-year interval were reviewed for patient demographics, mechanism of injury, total body surface area (TBSA) burned, medical comorbidities, use of Swan-Ganz catheters, evidence of inhalation injury, level of support, and patient outcome. The mechanisms of thermal injury were flame (68%), scald (21%) and electrical or chemical contact (11%). Twenty-six preventable bathing, cooking, and smoking-related injuries were seen (33%). The average TBSA was 25 per cent. Average length of stay varied depending on outcome. The overall mortality rate for this group was 45 per cent. Patients older than 80 years with 40 per cent or greater TBSA burned had a 100 per cent mortality rate despite aggressive treatment. Burn wound size correlated better with probability of poor outcome than age. Thermal injuries in the elderly are becoming more important with the aging of our population. Underlying medical problems--specifically chronic obstructive pulmonary disease--do play a role in increased patient morbidity and mortality. This study shows that age greater than 80 years in combination with burns greater than 40 per cent TBSA are uniformly fatal despite aggressive therapy. We believe that delaying the start of comfort-only measures in this situation only prolongs the pain and suffering for the patient, the family, and the physician.     

Quality of life and return to work following electrical burns

To investigate the psychosocial outcomes following electrical burns, a cross-sectional survey of electrical burn patients was done using three outcome tools: the Burn Specific Health Scale brief version (BSHS-B), the Coping with Burns Questionnaire (CBQ), and the Pain Patient Profile (P3). Questionnaires were mailed to electrical burn patients discharged from an adult regional burn centre, and also distributed to attendants of an electrical utility conference in Toronto. Twenty-six of 88 patients who were discharged from the regional burn centre during the study period with updated residential information were contacted and 14 (54%) completed the questionnaires. Twenty questionnaires were also distributed at the conference and 8 (40%) were completed; leaving a total of 22 (48%) patients for the study. The average patient age was 44.0+/-11.7 years; 21 (96%) were men, and the average time from injury to survey completion was 5.3+/-4.9 years. Five (23%) of the 22 patients returned to the same work duties, 10 (45%) changed duties, and 7 (32%) did not return to work. BSHS-B scores were low for all patients. Participants with high voltage burns (>1000 V) had worse sexuality scores (p<0.05), while those with larger burns (>10% TBSA) had worse physical scores (p<0.05). Patients surveyed >5 years from injury showed improvement in physical scores. CBQ scores indicated that optimism was the most commonly used coping strategy. P3 showed significant levels of emotional distress in all patients, with anxiety being more common in high voltage injuries (p<0.05). The data suggests that electrical burn patients may have a limited ability to return to work and an overall poor quality of life. Emotional distress is the dominant feature influencing long-term outcome in these patients. Further studies are warranted to validate these findings.