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Acute electrical injury: A systematic review

*Corresponding author: Hamid Karimi, Motahary Burn Hospital, School of Medicine, Burn Research Center, Iran University of Medical Sciences, Yasemi Alley, Vali Asr Ave., Tehran 19637, Iran. Tels: +98 912 6466875 (NA Latifi); +98 912 3179089 (H Karimi) Fax: +98 21 88770048 (H Karimi) E-mails: dr.noorahmadlatifi@yahoo.com (NA Latifi); hamidkarimi1381@yahoo. com (H Karimi) The journal implements double-blind peer review practiced by specially invited international editorial board members.


Introduction
Electrical injuries, though uncommon, are among severe burn injuries and have multiple organ involvement. Multi-specialty treatment group is needed in order to have good and reasonable results [1][2][3][4][5].
Several complications and sequel have been reported after electrical injury [6][7][8][9][10]. These should be in the mind of attending physicians to prevent and treat the special complications that may happen for the patients. Kidney, heart, nervous system, musculoskeletal system, eyes and ears are among the organs that may be affected during the process of injury [11][12][13][14][15][16].
In this report, we systemically surveyed all articles about electrical injury during last 40 years and some of the important guidelines will be provided for the physicians who treat electrical injury patients.

Results
We found 247 papers and some of them were not relevant.
Objective: To review low-voltage, high-voltage and lightening electrical burns in adults and children, identify novel areas that are not recognized and improve treatments results and outcome. Methods: An extensive literature search on electrical burn injuries was performed using Ovid Medline, PubMed and Embase databases from 1976 to 2016. Studies related to electrical injury in the adult and children (< 15 years of age) population were included in our study. Fifty-one research papers and review articles were identified and included in this study. Results: Total occurrence of electrical injury among burn injuries ranged from 3.5% to 15.0%. Most of them were low voltage (73%) and one fourth were high voltage and percentage of lightening injuries were very low around 2%-4% of total cases of electrical injury. Mortality is somehow higher among high voltage electrical injuries and lightening. Most of complications of them were morbid in kidney, heart, extremities (including amputations) and nervous systems. Long-term psychological problems were reported with greater incidence rates in highvoltage injuries. Psychological and posttraumatic stress disorders were also reported. Mortality rates from electrical injuries were 2.6% in low voltage and 5.2% in high voltage. Conclusions: High-voltage injury leads to greater morbidity and mortality than low-voltage one. Lightening has mortality of about 32%, higher rates of complications and specialty longterm complications. Strict multi-specialty treatment and rehabilitations are required for proper treatment of electrical injuries. The rate and percentage of low voltage injury was 73%.
Mortality was higher in lightening and high voltage groups.
Morbidity was higher in high voltage group comparing with morbidity in low voltage group [18][19][20]. Cardiac electrical injury and dysrhythmia were higher in low voltage group [4,6,21].
Cardio-respiratory arrest was higher in lightening group. Most of electrical injury was reported out of home and in workplace.
Although in children below 6 years old it is reported in home and low voltage, in adolescence it is reported during summer, during leisure activities and out of the home, in open areas.
Electrical injury has been reported mostly in spring and summer with wet body either due to working and sweating or due to heavy rain [22][23][24][25][26]. Lightening is reported mostly in summer and heavy rain, near a tree or tall structure or in open space, when having a metallic object in hand or near the bare body and in 15% cases multiple victims are affected [17,20,[27][28][29][30].
Direct electricity has been reported to have higher burn injuries specially in extremities [4,5,7,8]. High-voltage injury has more extremities and muscle injuries, but low-voltage injuries cause more cardiac dysrhythmia, although both can be seen in both injuries [2,11,13,19,21].

Discussion
Electrical injuries have many adverse effects and have several direct, immediate and long-term or indirect sequels. In process of treatment and caring for electrical injuries, several important guidelines are recommended.
First, the electricity should be discontinued (safety of the medical personnel). Second, the patient should be removd from the site of injury. Third, as a severe trauma patient, he should be cared and treated. Airway, breathing, circulation and diagnosis are important and cannot be emphasized further [1][2][3][4].
If there is cardio-respiratory arrest, this should be attended first then removing the clothes and evaluation of the burn injury will be done [4,[21][22][23].
Sites of electrical injury (input and output sites) are obvious as they are a 3rd or 4th degree burns with complete necrosis of the skin and sometimes necrosis of the tissues below the skin such as fascias, nerves, muscles, tendons, vessels and bones.
Normally surface of these areas are very small and not more than 1% of total body surface area. But in the path of the current, most of the deep muscles and sometimes even superficial muscles have been burnt due to extreme heat that are produced with high resistance of the bones and voltage of the current. The heat produced is directly related to resistance of that part of body and second exponential of voltage. So in high-voltage injuries, we have much more extensive muscle injuries and burns [4,17].
Necrosis of muscles will have two consequences: release of myoglobin that may produce renal shutdown, and severe edema in the compartments that will result in compartment syndrome and require escharotomy and fasciotomy.
Electrical injury will have injury to conduction system of heart and will produce arrhythmias from the first seconds of the injury, In lightening group, cardio-respiratory arrest would be seen frequently and long term resuscitation and cardio-pulmonary resuscitation are recommended (sometimes more than 1 h), as most of these patients will recover from the arrest [18,19,31,32].
Lightening are in different types such as ribbon lightening, flash lightening, and bolt lightening, and so on. And one of the main pathognomonic sign of this injury is Lichtenstein figure or Lichtenstein tree that can be seen over the patient's skin [18,19,31].
In these cases, internal organ burn is not present and most of the burns are from 1st and 2nd degree.

Conclusion
Electrical injuries are uncommon, but the complications are severe. Mortality, morbidity and amputation rates are higher among high-voltage and lightening injuries.
Lightening, though very rare, has a high mortality rate and high rate of complications.