Electrical Injury Anne Lambert Wagner, MD, FACS Burn & - PowerPoint PPT Presentation

Electrical Injury Anne Lambert Wagner, MD, FACS Burn & Frostbite Center Medical Director Associate Professor of Surgery University of Colorado Hospital Aurora, CO

Objectives • Discuss differences between electrical injuries • Lightening strikes • Case presentation

UCH Bur urn n Cen enter ter – Estab tablished lished 19 1978 78 • On site burn clinic open 5 days/week • >500 admission/year

Renamed in 2018 Burn & Frostbite Center at UCHealth • 3 burn fellowship & surgical critical care trained and boarded surgeons – g • ABA verified burn center since 1998 • 19 bed unit • Only Level 1 Trauma hospital with an ABA verified burn center • Accepts patients ages 12 & up or >40 k

Only ABA Verified Burn Center in Colorado Since 1998 1998

Community Education and Prevention and Advocacy Frostbite Prevention for the Homeless Electrical Company It Happens in Seconds Injury Prevention Training for Firefighters SOAR ABLS (Advanced (Survivors Offering Burn Life Support) Assistance in Recovery)

Community Education and Prevention and Advocacy Rwanda Frostbite Prevention for the Burn Homeless Electrical Company It Happens in Seconds Scholarship Injury Prevention Training for Firefighters 1 Resident & 1Attending SOAR ABLS (Advanced (Survivors Offering Burn Life Support) Assistance in Recovery)

Community Education and Prevention and Advocacy Rwanda Frostbite Prevention for the Burn Homeless Electrical Company It Happens in Seconds Scholarship Injury Prevention Training for Firefighters 1 Resident & 1Attending SOAR ABLS (Advanced (Survivors Offering Burn Life Support) Assistance in Recovery)

Introduction • Burns – 1.25 million, 80% minor – Approximately 450,000 seeking treat – 45,000 hospital admissions • Admissions – 44% fire/flame, – 33% scald – 9% contact – 4% electrical • 27% developing countries – 3% chemical • Electrical vs thermal burns – Higher morbidity – Longer hospital LOS – Consume far more resources

Introduction • Kids – 3 rd most common injury causing death – Greatest length of stay (7.8 days) • Scalds very common – <2 years age – Account for 65% hospital admissions

Mo Mort rtality ality • 3400 people die/year • 75% die at the scene • 50% decline burn related deaths – 50% for 49% TBSA – 50% for > 90% TBSA • 97.1% survival rate • 1.2% mortality rate • 98.8% survival rate

Electrical Injury • Adult population – Work-related – 3% work related deaths – 90% male • Kids – 2:1 male:female – Most commonly around their home – Kids < 6 low voltage – Kids > 6 high voltage – 70 % occur at home with adult supervision.

Electrical Injury • DC – 1/31/2018 – 13 yo male – Electrical arc burn – 59% TBSA – 30 foot fall resulting in • right frontal EDH • left temporal contusion • SAH • right frontal bone fracture • right retrobulbar hematoma • right grade IV kidney laceration • right iliac and superior rami fractures – ICU days: 73 – LOS: 85 days – – –

Electrical Injury • DC – 1/31/2018 – ICU days: 73 – Vent days 27 – 15 total operative procedures – LOS: 85 days – Acute rehab – ICU days: 73 days – Vent days: 27

Electrical Injury • 97% of electricians have been shocked or injured on the job • Every 30 minutes during a normal work day – A worker suffers an electrically injury that requires time off the job for recovery • Electrocution is the 4 th leading cause of work-related deaths in the US – Few people perform “electrical work” as part of their job. • Only 5.4% patients with high tension were able to return to their previous occupation

Electrical Injury • Handschin, et al – June 2009 • Compared thermal burns to electrical – Operations – 3.3 vs 5.2 – Amputations – 1.5% vs 19.7% – Escharotomy/fasciotomy – 21% vs 47 % – LOS 32 days vs 44 days – Mortality 11% vs 13.2% • Only 5.4% patients with high tension were able to return to their previous occupation

Pathophysiology • Electrical current passing through tissues has multiple distinct mechanisms – Direct action on cell proteins and cell membranes – Direct tissue injury from heat generation • Severity multifactorial – Voltage – Current – Type of current – Path of the flow – Duration of contact • High voltage > 1000V • Low voltage < 1000V

Electrical Injury • 3 types of electrical injury 1. Flow of current burns • Contact points 2. Arc (flash) injury 3. Flame injury from ignition 4. Lightning strikes

Power (J[Joules])=I 2 (Current) x R(Resistance) • Electric current leads to Joule heating • Tissue resistance – Nerves->blood vessels->muscle->skin- >bones • Animal models – Body acts as a single uniform resistance – Injury is inversely proportional to the cross-sectional area of the involved body part • Deep tissues retain heat • Both macro and microvascular injury – Irreversible – Rationality for serial debridement's

Acute Management • Initial management – Follow current ATLS protocols • Specific electrical injury issues: 1. Cardiac monitoring 2. Compartment syndromes 3. Fluid resuscitation

Cardiac Monitoring • Card iac abnormalities & myocardial damage – both low & high voltages • Non-specific ST-T changes – most common ECG abnormality • Atrial fib – Most common dysrhythmia • Myocardial damage &/or dysrhythmias will manifest quickly • ALL pts should be monitored – Enroute – ED

Cardiac Monitoring • Indications for cardiac monitoring: – Loss of consciousness – ECG abnormality – Documented dysrhythmia – CPR in the field – Other standard indications • No evidence regarding length of time – Generally 24-48 hours

Myoglobinuria • Indication of significant muscle damage • Possible indication of ongoing ischemia • Generally want to maintain a UO – 1-2 cc/hour adults – 2 cc/hour peds • Consider alkalinization

Trauma • 15% electrical burns sustain traumatic injuries • Falls • Being thrown • Tetanic muscle contractions • Compression fractures

Compartment syndrome • High voltage injuries • Compartment pressures • Decision to operate is generally clear cut and early • Carries significant morbidity – Avoid prophylactic releases – Clear signs of a developing compartment syndrome • Nerve dysfunction • Failure to resuscitate • Marker for increased injury severity – 7.5% develop DVT – 49% require amputations

Lightning • 2 nd leading cause of weather related death in the world • 1 st in the US • 80 deaths/year • Florida #1 • 25.3 lightning strikes/square mile • 1.45 million strikes/year

NWS Storm Data from 1989-2018 • According to the U.S. has averaged 43 reported lightning fatalities/year. • Approximately 10% of people who are struck by lightning are killed • 90% are left with various degrees of disability. • More recently, in the last 10 years the U.S. has averaged 27 lightning fatalities. Peter Hawkes • 7/20/2016 • Golfing Arvada around 6:00 pm • Hid under a tree with a friend • Less than 2 ft apart

Lightning • Large TBSA is rare • Spectrum of injury is extremely varied • Pathognomonic sign • Dendritic, arborescent or fern- like branching • Extravasated blood • Full thickness burns on the tips of the toes

Lightening • 10% strikes fatal • 1/3 of high voltage deaths • Repiratory & cardiac arrest • Dilated or NR pupils & GCS • Not reliable • Not predictive • Careful ear exam • Ruptures tympanic membranes • Middle & inner ear destruction • Sensorineural hearing loss • Increased lifetime risk vertigo

Lightening • Neurologic complications • Common • Unconsciousness • Seizures • Paresthesias • Paralysis • Can develop several days after the initial injury • Keraunoparalysis (temporary paralysis) • Transient weakness in limbs following a lightning strike, often associated with cold, mottled skin.

Lightening • Repiratory & cardiac arrest • Dilated or NR pupils & GCS • Not reliable • Not predictive • Neurologic complications common • Unconsciousness AB 38 y.o. male • Seizures • Struck by lightning in cemetary • Cardiac arrest on the scene with bystander • Paresthesias CPR with resumption of a normal heart rhythm with a perceptible pulse • • Paralysis Subsequently intubated for airway protection. 3% TBSA involving chest, left thigh, bilateral • Develop over days feet Discharged hospital day 4 • • Better prognosis Primarily c/o chest pain • Optho exam negative • Extubated HD 2 • Cardiology – mild hypokinesia, elevated trop

Low-Voltage Burns • Localized to points of contact • Oral cavity burns most common • Young children • Chewing on cords • Most serious complication • Bleeding from the labial artery • 10-14 days after injury

Complications • Cataract formation • 5-20% patients • Pathopysiology unknown • Cornea & lens most frequently affected ocular tissue • Series published by Saffle • 77% progressed to surgical therapy • Interval time of presentation can range from • 3 weeks to 11 years