ORIGINAL ARTICLE
Epidemiology and Outcome of Childhood Electrical Burn Injuries at Pakistan Institute of Medical Sciences Islamabad, Pakistan Muhammad Saaiq, MBBS, FCPS
To describe the epidemiologic profile of children sustaining electrical burn injuries and assess the outcome in terms of need for amputations, hospitalization, and the associated in-hospital mortality. This case series study was performed over a 5-year period (January 2008 to December 2012) at the Department of Plastic surgery and Burn Care Centre, Pakistan Institute of Medical Sciences (PIMS), Islamabad. All children of either gender up to 15 years of age were included. They were admitted for indoor management with standard burn care protocols. The demographic profile of the child, injury characteristics, and outcome were recorded and the data analyzed statistically. Of 85 children who presented with electrical burn injuries during the study period, 89.41% (n = 76) were males and 10.58% (n = 9) were females. The age ranged from 1 to 15 years with a mean age of 10.47 ± 4.09 years. High-voltage burns were the commonest type (n = 61; 71.76%). There were 35 major limb amputations. The mean hospital stay was 6.78 ± 5.01 days (range 1–25 days). The mortality rate was 2.35%. Male children aged 10 to 15 years are the most frequent victims of electric burn injuries, and high-voltage injuries constitute the commonest form of these injuries. There is associated considerable morbidity due to inevitable major amputations of the limbs among otherwise healthy children. There is dire need for primary prevention. (J Burn Care Res 2016;37:e174–e180)
Although electrical burn injuries among children are reported from all parts of the world,1–3 their share among pediatric burn injuries is much higher in some developing countries like Bangladesh, India, and Pakistan.4–6 The spectrum of these injuries includes highvoltage burns (voltage > 1000 V), low-voltage burns (voltage < 1000 V), flash burns, and burns caused by lightning. In addition, the victim may sustain secondary injuries as a result of tetanic muscular contractions (ie, lock-on phenomenon, suffocation) and falls.7–9 The high-voltage injuries and lightning are associated with damage at the contact points and even more devastating injuries to the deeper structures, closely resembling crush injuries. As the electricity flows Department of Plastic Surgery and Burn Care Centre, Pakistan Institute of Medical Sciences (PIMS), Islamabad, Pakistan Address correspondence to Muhammad Saaiq, MBBS, FCPS, Room No 20, Medical Officers (MOs) Hostel, Pakistan Institute of Medical Sciences (PIMS), Islamabad, Pakistan. Email: [email protected] Copyright © 2014 by the American Burn Association 1559-047X/2014 DOI: 10.1097/BCR.0000000000000202
e174
through the tissues, it generates heat which causes tissue trauma. Although individual tissues offer different resistances; bone (highest), fat, tendon, skin, muscle, blood vessels and nerve (least), the majority of these act in concert as a single uniform resistor. The bone, owing to its high resistance, retains heat and delivers it to the adjacent muscle and periosteum as thermal energy, effecting even greater tissue damage compared with the overlying skin. In flash burns, there is no actual flow of current through the body and the major mechanism of injury is gas ignition or clothing catching fire, leading to thermal burns similar to those caused by flames otherwise.9–11 The current study was conducted to describe the demographic profile of children sustaining electrical burn injuries, assess the associated morbidity and mortality, and collect actionable evidence base for evolving meaningful preventive strategies to address this issue plaguing our children.
PATIENTS AND METHODS This study was a case series conducted over a 5-year period (January 2008 to December 2012) at the
Journal of Burn Care & Research Volume 37, Number 2
Department of Plastic Surgery and Burn Care Centre, Pakistan Institute of Medical Sciences (PIMS), Islamabad. PIMS is the only public sector specialist facility in the region, receiving all burn cases from a large catchment area encompassing the twin cities of Islamabad and Rawalpindi, and the adjoining provincial territories of Khyber-Pakhtunkhwa, GilgitBaltistan, and Punjab. The study included all children of either gender with electrical burn injuries who were managed during the study period. Children older than 15 years were excluded from the study. Informed consent was taken from the parents/attending adults for inclusion in the study. As the study was an observational one and did not involve any new intervention, it was conducted in accordance with the Declaration of Helsinki of 1975, as revised in 2008 and anonymity of the participants was guaranteed. The children were initially assessed and diagnosed with the help of thorough history, physical examination, and necessary investigations. They were admitted for indoor management with standard burn care protocols. Advanced trauma life support protocols were followed. Wound cleansing, application of topical antibiotics, and aseptic dressings were ensured among all cases. Prophylaxis against tetanus and analgesia was instituted. For intravenous fluid resuscitation, intravenous lines were passed and initial resuscitation was guided by Parkland’s formula (4 ml/kg/% burn) to ensure a target urine output of 1 to 2 ml/kg/hr. Cardiac and laboratory monitoring were performed among all patients. Serial radical excisions of all gangrenous tissues, fasciotomies, and carpal tunnel release were performed where indicated. Children whose wounds dictated other surgical interventions such as early amputation, flap coverage, and grafting were managed accordingly. The demographic profile of the child, cause of burns, injury distribution by anatomic regions, injury acquisition mechanisms, and outcome in terms of duration of hospitalization, amputations, and mortality were all recorded on a pro forma. Age-wise the children were stratified into three groups, ie, the infants/toddlers (0–3 years), early childhood (3.1–10 years), and late childhood (>10 years). The etiology of burn injury was stratified into high-voltage injuries (>1000 volts current), lowvoltage injuries (10 years, whereas children up to 03 years were 14 (16.47%), and those aged older than 3 to 10 years were 3 (3.52%). Table 1 shows age distribution of the children with respect to the different types of burn injuries sustained.
Journal of Burn Care & Research March/April 2016
e176 Saaiq
Table 1. Distribution of the causes of burns by age groups (n = 85) Age
n
High-voltage injuries
Flash burn
Low-voltage injuries
Oral injuries
Lightning
0–3 years 3.1–10 years >10 years
14 3 68
— 2 (66.66%) 59 (86.76%)
— — 8 (11.76)
12 (85.71%) 1 (33.33%) —
2 (14.28%) — —
— — 1 (1.47%)
Injury Characteristics Observed Among the Patients Among all age groups, high-voltage electrical burn injuries were the commonest burns (n = 61; 71.76%), followed by low-voltage household injuries (n = 13; 15.29%), flash burns (n = 8; 9.41%), oral injuries (n = 2; 2.35%), and lightning (n = 1; 1.17%). (Figures 2 and 3) The commonest anatomic regions affected were hands/upper limbs (n = 79; 92.94%), followed by lower limbs (n = 65; 76.47%), trunk (n = 11; 12.94%), face, head, and neck (n = 8; 9.41%), and areas such as genitals (n = 3; 3.52%). The mechanisms involved in injury acquisition included contact with high-voltage electric wires on rooftops while playing/kite flying (n = 53), contact with high-voltage wires of street poles (n = 8), contact with household extension wires (n = 6), contact with electric appliances (n = 4), insertion of metallic objects in wall outlet sockets (n = 3), biting live extension wire (n = 2), and lightning injury (n = 1).
Surgical Procedures and Amputations The various surgical procedures undertaken among the patients included radical wound excisions/
fasciotomies/carpal tunnel releases (n = 41), major limb amputations (n = 35), finger/toes amputations (n = 19), skin grafts (n = 13), flap coverage (n = 7), commisuroplasties (n = 2), and exploratory laparotomy/ileostomy (n = 1). The rate of major amputations was significantly higher among high-voltage injured children than those with low-voltage burns. There were an overall 35 major amputations of various limbs among the 61 high-voltage injured children, constituting an amputation rate of 57.37% in this subset of the study population. The details of the amputations are summarized in Table 2 and Figure 4.
Hospital Stay The mean hospital stay ranged from 1 to 25 days with a mean of 6.78 ± 5.01 days.
Mortalities Observed There were two deaths among the hospitalized children constituting an overall 2.35% mortality rate. Both of them had sustained flash burns in excess of 50% TBSA and died during the first 24 hr of presentation to our facility. One of the deceased children was aged 13, had 60% TBSA involvement,
Figure 2. Graphic presentation of the various etiologies of electrical burn injuries among children (n = 85).
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Saaiq e177
Figure 3. Graphic presentation of the distribution of causes of burns by age groups (n = 85).
and associated severe head injury secondary to fall from rooftop. He reported to our facility after 12 hr of traveling by road from a far flung area and had anuria at presentation. In addition to other resuscitative measures, he was put on ventilatory support, but did not survive. The other child who died was aged 11 years and had approximately 55% TBSA deep burns predominantly affecting head, face, and upper trunk. There was exposed cervical vertebral column. He had been referred from a remote district hospital in critical condition 7 hr after of sustaining burn injury. He also died despite instituting ventilatory support. Table 2. Amputations undertaken among the children (n = 45)
Amputations Both upper limbs One upper limb Right Left One upper plus one lower limb Traumatic penile amputation Minor amputations of hands/feet Thumb Finger Toes
High-voltage injuries n (%)
Low-voltage injuries n (%)
P
6 (100%)
-
Epidemiology and Outcome of Childhood Electrical Burn Injuries at Pakistan Institute of Medical Sciences Islamabad, Pakistan Muhammad Saaiq, MBBS, FCPS
To describe the epidemiologic profile of children sustaining electrical burn injuries and assess the outcome in terms of need for amputations, hospitalization, and the associated in-hospital mortality. This case series study was performed over a 5-year period (January 2008 to December 2012) at the Department of Plastic surgery and Burn Care Centre, Pakistan Institute of Medical Sciences (PIMS), Islamabad. All children of either gender up to 15 years of age were included. They were admitted for indoor management with standard burn care protocols. The demographic profile of the child, injury characteristics, and outcome were recorded and the data analyzed statistically. Of 85 children who presented with electrical burn injuries during the study period, 89.41% (n = 76) were males and 10.58% (n = 9) were females. The age ranged from 1 to 15 years with a mean age of 10.47 ± 4.09 years. High-voltage burns were the commonest type (n = 61; 71.76%). There were 35 major limb amputations. The mean hospital stay was 6.78 ± 5.01 days (range 1–25 days). The mortality rate was 2.35%. Male children aged 10 to 15 years are the most frequent victims of electric burn injuries, and high-voltage injuries constitute the commonest form of these injuries. There is associated considerable morbidity due to inevitable major amputations of the limbs among otherwise healthy children. There is dire need for primary prevention. (J Burn Care Res 2016;37:e174–e180)
Although electrical burn injuries among children are reported from all parts of the world,1–3 their share among pediatric burn injuries is much higher in some developing countries like Bangladesh, India, and Pakistan.4–6 The spectrum of these injuries includes highvoltage burns (voltage > 1000 V), low-voltage burns (voltage < 1000 V), flash burns, and burns caused by lightning. In addition, the victim may sustain secondary injuries as a result of tetanic muscular contractions (ie, lock-on phenomenon, suffocation) and falls.7–9 The high-voltage injuries and lightning are associated with damage at the contact points and even more devastating injuries to the deeper structures, closely resembling crush injuries. As the electricity flows Department of Plastic Surgery and Burn Care Centre, Pakistan Institute of Medical Sciences (PIMS), Islamabad, Pakistan Address correspondence to Muhammad Saaiq, MBBS, FCPS, Room No 20, Medical Officers (MOs) Hostel, Pakistan Institute of Medical Sciences (PIMS), Islamabad, Pakistan. Email: [email protected] Copyright © 2014 by the American Burn Association 1559-047X/2014 DOI: 10.1097/BCR.0000000000000202
e174
through the tissues, it generates heat which causes tissue trauma. Although individual tissues offer different resistances; bone (highest), fat, tendon, skin, muscle, blood vessels and nerve (least), the majority of these act in concert as a single uniform resistor. The bone, owing to its high resistance, retains heat and delivers it to the adjacent muscle and periosteum as thermal energy, effecting even greater tissue damage compared with the overlying skin. In flash burns, there is no actual flow of current through the body and the major mechanism of injury is gas ignition or clothing catching fire, leading to thermal burns similar to those caused by flames otherwise.9–11 The current study was conducted to describe the demographic profile of children sustaining electrical burn injuries, assess the associated morbidity and mortality, and collect actionable evidence base for evolving meaningful preventive strategies to address this issue plaguing our children.
PATIENTS AND METHODS This study was a case series conducted over a 5-year period (January 2008 to December 2012) at the
Journal of Burn Care & Research Volume 37, Number 2
Department of Plastic Surgery and Burn Care Centre, Pakistan Institute of Medical Sciences (PIMS), Islamabad. PIMS is the only public sector specialist facility in the region, receiving all burn cases from a large catchment area encompassing the twin cities of Islamabad and Rawalpindi, and the adjoining provincial territories of Khyber-Pakhtunkhwa, GilgitBaltistan, and Punjab. The study included all children of either gender with electrical burn injuries who were managed during the study period. Children older than 15 years were excluded from the study. Informed consent was taken from the parents/attending adults for inclusion in the study. As the study was an observational one and did not involve any new intervention, it was conducted in accordance with the Declaration of Helsinki of 1975, as revised in 2008 and anonymity of the participants was guaranteed. The children were initially assessed and diagnosed with the help of thorough history, physical examination, and necessary investigations. They were admitted for indoor management with standard burn care protocols. Advanced trauma life support protocols were followed. Wound cleansing, application of topical antibiotics, and aseptic dressings were ensured among all cases. Prophylaxis against tetanus and analgesia was instituted. For intravenous fluid resuscitation, intravenous lines were passed and initial resuscitation was guided by Parkland’s formula (4 ml/kg/% burn) to ensure a target urine output of 1 to 2 ml/kg/hr. Cardiac and laboratory monitoring were performed among all patients. Serial radical excisions of all gangrenous tissues, fasciotomies, and carpal tunnel release were performed where indicated. Children whose wounds dictated other surgical interventions such as early amputation, flap coverage, and grafting were managed accordingly. The demographic profile of the child, cause of burns, injury distribution by anatomic regions, injury acquisition mechanisms, and outcome in terms of duration of hospitalization, amputations, and mortality were all recorded on a pro forma. Age-wise the children were stratified into three groups, ie, the infants/toddlers (0–3 years), early childhood (3.1–10 years), and late childhood (>10 years). The etiology of burn injury was stratified into high-voltage injuries (>1000 volts current), lowvoltage injuries (10 years, whereas children up to 03 years were 14 (16.47%), and those aged older than 3 to 10 years were 3 (3.52%). Table 1 shows age distribution of the children with respect to the different types of burn injuries sustained.
Journal of Burn Care & Research March/April 2016
e176 Saaiq
Table 1. Distribution of the causes of burns by age groups (n = 85) Age
n
High-voltage injuries
Flash burn
Low-voltage injuries
Oral injuries
Lightning
0–3 years 3.1–10 years >10 years
14 3 68
— 2 (66.66%) 59 (86.76%)
— — 8 (11.76)
12 (85.71%) 1 (33.33%) —
2 (14.28%) — —
— — 1 (1.47%)
Injury Characteristics Observed Among the Patients Among all age groups, high-voltage electrical burn injuries were the commonest burns (n = 61; 71.76%), followed by low-voltage household injuries (n = 13; 15.29%), flash burns (n = 8; 9.41%), oral injuries (n = 2; 2.35%), and lightning (n = 1; 1.17%). (Figures 2 and 3) The commonest anatomic regions affected were hands/upper limbs (n = 79; 92.94%), followed by lower limbs (n = 65; 76.47%), trunk (n = 11; 12.94%), face, head, and neck (n = 8; 9.41%), and areas such as genitals (n = 3; 3.52%). The mechanisms involved in injury acquisition included contact with high-voltage electric wires on rooftops while playing/kite flying (n = 53), contact with high-voltage wires of street poles (n = 8), contact with household extension wires (n = 6), contact with electric appliances (n = 4), insertion of metallic objects in wall outlet sockets (n = 3), biting live extension wire (n = 2), and lightning injury (n = 1).
Surgical Procedures and Amputations The various surgical procedures undertaken among the patients included radical wound excisions/
fasciotomies/carpal tunnel releases (n = 41), major limb amputations (n = 35), finger/toes amputations (n = 19), skin grafts (n = 13), flap coverage (n = 7), commisuroplasties (n = 2), and exploratory laparotomy/ileostomy (n = 1). The rate of major amputations was significantly higher among high-voltage injured children than those with low-voltage burns. There were an overall 35 major amputations of various limbs among the 61 high-voltage injured children, constituting an amputation rate of 57.37% in this subset of the study population. The details of the amputations are summarized in Table 2 and Figure 4.
Hospital Stay The mean hospital stay ranged from 1 to 25 days with a mean of 6.78 ± 5.01 days.
Mortalities Observed There were two deaths among the hospitalized children constituting an overall 2.35% mortality rate. Both of them had sustained flash burns in excess of 50% TBSA and died during the first 24 hr of presentation to our facility. One of the deceased children was aged 13, had 60% TBSA involvement,
Figure 2. Graphic presentation of the various etiologies of electrical burn injuries among children (n = 85).
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Figure 3. Graphic presentation of the distribution of causes of burns by age groups (n = 85).
and associated severe head injury secondary to fall from rooftop. He reported to our facility after 12 hr of traveling by road from a far flung area and had anuria at presentation. In addition to other resuscitative measures, he was put on ventilatory support, but did not survive. The other child who died was aged 11 years and had approximately 55% TBSA deep burns predominantly affecting head, face, and upper trunk. There was exposed cervical vertebral column. He had been referred from a remote district hospital in critical condition 7 hr after of sustaining burn injury. He also died despite instituting ventilatory support. Table 2. Amputations undertaken among the children (n = 45)
Amputations Both upper limbs One upper limb Right Left One upper plus one lower limb Traumatic penile amputation Minor amputations of hands/feet Thumb Finger Toes
High-voltage injuries n (%)
Low-voltage injuries n (%)
P
6 (100%)
-
