Electrical burns

Overview

Electrical injuries represent a small but disproportionately complex subset of burn center admissions. The surface wound frequently underestimates the extent of deep tissue destruction, and the systemic effects (cardiac arrhythmias, rhabdomyolysis, neurological injury, delayed vascular thrombosis) create management challenges that persist well beyond the acute phase. Electrical burns carry the highest amputation rate of any burn mechanism.

Pathophysiology

The early clinical characterization of high-tension electrical injury by Pruitt and Mason ^[2] established that electrical burns cause tissue destruction along the path of current flow. The greatest damage occurs in tissues with the highest resistance: bone, tendon, and fascia generate heat preferentially, creating a pattern of deep injury that radiates outward from the skeleton. This "inside-out" pattern is the conceptual foundation for why surface examination is unreliable and why surgical exploration is often necessary. Baxter ^[3] further defined the management principles, recognizing that standard resuscitation formulas underestimate fluid requirements because the visible burn significantly underrepresents the total volume of injured tissue.

Moncrief and Pruitt ^[4] established the framework for electric injury as a multisystem insult requiring coordinated assessment of cardiac, renal, neurological, musculoskeletal, and vascular systems.

Assessment and management

The ABA practice guidelines authored by Arnoldo et al. ^[1] formalized recommendations for initial evaluation, cardiac monitoring, fluid resuscitation, and surgical management. These guidelines established that patients with high-voltage injury (greater than 1000V) require cardiac monitoring for at least 24 hours, aggressive fluid resuscitation targeting urine output of 1-2 mL/kg/hr to prevent myoglobin-induced renal injury, and early surgical exploration when deep tissue destruction is suspected. The guidelines also addressed the critical distinction between high-voltage and low-voltage injuries, with the latter carrying a much lower risk of deep tissue damage and systemic complications.

Kidd et al. ^[5] provided one of the few longitudinal perspectives spanning resuscitation through final impairment ratings, documenting procedures, timing, and return-to-work outcomes and demonstrating that improved resuscitation has created new challenges in reconstruction and rehabilitation.

Special populations and mechanisms

Lightning injury, a distinct subset, was reviewed by Ritenour et al. ^[6], who described the unique features including unusual symptom patterns, high mortality, and significant long-term morbidity. Lightning injuries differ from other electrical injuries in mechanism (massive brief current versus sustained contact), injury pattern (superficial flashover versus deep tissue destruction), and prognosis, requiring distinct management approaches including attention to the blast and thermal components.

Friedstat et al. ^[7] reviewed the unique challenges of chemical, electrical, and radiation injuries, emphasizing that electrical injuries require understanding of current flow pathophysiology to guide both diagnostic imaging and surgical planning. Pham and Gibran ^[8] noted that regionalized burn centers have contributed to improved outcomes through concentration of expertise.

Epidemiological shifts were documented by Aguilera-Saez et al. ^[9], who identified a new profile of electrical burn patients during economic crisis: individuals performing unauthorized electrical work outside the legal framework, often without protective equipment.

Pediatric considerations

Depamphilis et al. ^[10] reviewed surgical management and epidemiological trends in a pediatric burn center over 13 years. Foncerrada et al. ^[11] prospectively studied the effect of electrical burns on metabolic rate, body composition, and aerobic capacity in children, finding that electrical burns combined with flame burns produced measurable differences in cardiopulmonary fitness and body composition. Donelan ^[12] described reconstruction of the oral commissure following electrical burn, a common pediatric injury pattern when young children bite electrical cords. Thomas et al. ^[13] documented phantom limb pain in pediatric burn survivors who required amputation, including those with electrical injuries.

Controversies and Evidence Gaps

The optimal duration of cardiac monitoring after electrical injury remains debated. Practice guidelines recommend 24 hours for high-voltage injuries, but the evidence supporting a specific duration is limited to observational data, and late arrhythmias have been reported beyond this window. The threshold for fasciotomy (clinical examination versus compartment pressure measurement versus both) lacks standardization, particularly for injuries where deep tissue edema may develop over 24 to 48 hours. The role of advanced imaging (MRI, CT angiography) for assessing deep tissue viability before surgical exploration has theoretical appeal but limited prospective validation. The long-term neurological sequelae (peripheral neuropathy, cognitive changes, chronic pain syndromes) are well-documented but poorly understood mechanistically, limiting therapeutic options.

References

[1] Arnoldo BD et al. (2006). Practice guidelines for the management of electrical injuries. PMID: 16819345 [2] Pruitt BA, Mason AD. (1979). High-tension electrical injury. PMID: 84923 [3] Baxter CR. (1970). Present concepts in the management of major electrical injury. PMID: 4922827 [4] Moncrief JA, Pruitt BA. (1970). Electric injury. PMID: 5460366 [5] Kidd M et al. (2007). The contemporary management of electrical injuries: resuscitation, reconstruction, rehabilitation. PMID: 17471131 [6] Ritenour AE et al. (2008). Lightning injury: a review. PMID: 18395987 [7] Friedstat J et al. (2017). Chemical, Electrical, and Radiation Injuries. PMID: 28576255 [8] Pham TN, Gibran NS. (2007). Thermal and electrical injuries. PMID: 17127128 [9] Aguilera-Saez J et al. (2016). Electrical burns in times of economic crisis: A new epidemiologic profile. PMID: 27364090 [10] Depamphilis MA et al. (2020). Surgical management and epidemiological trends of pediatric electrical burns. PMID: 32245570 [11] Foncerrada G et al. (2017). Functional Exercise Capacity in Children With Electrical Burns. PMID: 27654868 [12] Donelan MB. (1995). Reconstruction of electrical burns of the oral commissure with a ventral tongue flap. PMID: 7761501 [13] Thomas CR et al. (2003). Phantom limb pain in pediatric burn survivors. PMID: 12615460