Electric burn

ELECTRIC BURN-NIKITA DAS

1. CLINICAL PRESENTATION

2. Definition An electrical injury occurs when a current passes through the body, interfering with the function of an internal organ or sometimes burning tissue . Electrical injuries (electrocution, electrical shock, electrical burns , and electrical trauma) have become a more common form of trauma with a unique pathophysiology and with high mortality.

3. Basic physics Ohm’s Law: 𝐼 =𝑉/ 𝑅 I – current (Amps) V – voltage (Volts) R – resistance ( Ohms) Current = volume (or number) of electrons flowing between 2 points per second Voltage = the force that drives the electrons across the potential difference Resistance = the hindrance to flow

4. The amount and type of damage caused to the body by electricity depend on :  Type of Current (AC or DC)  Amount of current (Amperage)  Voltage  Resistance (Ohms)  Duration of event  Route of current

5. There are two Types of current :  Direct current (DC): is the unidirectional flow of electric charge. Direct current is produced by sources such as batteries .  A lternating current (AC ): is the flow of electric charge periodically reverses direction .

6. The minimum current a human can feel depends on the current type (AC or DC) and frequency. Alternative Current (AC) is more dangerous than Direct Current (DC) at lower amperage as it is more likely to cause cardiac arrhythmias.

7. Alternative Current also causes tetanic spasm of muscles of hand, preventing the victim from releasing his/her grasp. Alternative current is more likely to cause death an estimated four to six times than Direct Current .

8. Amount of current(mA) Effect 1mA Barely perceptible tingle 16 Current can be grasped and released 16-20 Muscular paralysis 20-50 Respiratory paralysis 50-100 Ventricular fibrillations >2000 Ventricular standstill

9. Voltage is a measure of the difference in electrical potential between two points and is determined by the electrical source . Electrical injuries are conventionally divided into high or low voltage using 500 or 1000 V as the most common cut point. The higher the voltage the more is tissue distruction . No fatalities with low voltage

10. Resistance (Ohms) Tendency of a material to resist the flow of electric current. Specific for a given tissue, depending on its moisture content , temperature, and other physical properties. The higher the resistance of a tissue to the flow of current, the greater the potential for transformation of electrical energy to thermal energy.

11. Nerves, muscle and blood vessels, because of their high electrolyte and water content, have a low resistance and are good conductors . Bone, tendon, and fat, which all contain a large amount of inert matrix, have a very high resistance and tend to heat up and coagulate rather than transmit current . The other tissues of the body are intermediate in resistance ( eg . dry skin)

12. Duration of contact/event The longer the duration of contact with high-voltage current, the greater the electro thermal heating and degree of tissue destruction .

13. Route of current The pathway that a current takes determines the tissues at risk, the type of injury seen, and the degree of conversion of electrical energy to heat . Current passing through the heart or thorax can cause cardiac dysrhythmias and direct myocardial damage. Current passing through the brain can result in respiratory arrest, seizures, and paralysis . Current in proximity to the eyes can cause cataracts.

14. The amount and type of damage caused to the body by electricity depend on :  Type of Current (AC or DC)  Amount of current (Amperage)  Voltage  Resistance (Ohms)  Duration of event  Route of current

15. Etiology Children- at home with extension cords (60-70%) Adult- workplace and constitute the fourth leading cause of work-related death . More than 50% of the occupational electrocutions result from power line contact , and 25% result from electrical tools or machines . Male-to-female ratio is 9:1

16. Specific causes of electrical injuries (classification)

17. Low-voltage injuries( low-tension injuries) Caused by voltage less than 1000 V. Includes most injuries caused by household current ; The child who bites into the cord producing lip, face and tongue injuries as well as occupational injuries resulting from the use of small power tools.

18. L ow-voltage injury : Representative electric field lines and isopotential lines established in the lower face during oral contact with a home power cord.

19. High-voltage injuries /high tension injuries Result of exposure to 1000 V or more. These injuries are often the result of occupational exposure to outside power lines . Commonly occur when a conductive object touches an overhead high voltage power line.

20. High-voltage injury : Approximate electric field lines when current path extends from hand to hand.

21. Lightning injuries Involve voltages higher than those of the other injuries. Involves energy with high voltage and high amperage but extremely short duration . Lightning is usually a unidirectional massive current impulse. The largest flow of current tends to jump to the ground before much of it passes through the body.

22. Rare pathognomonic “ flowerlike” branching skin lesions in persons struck by lightning. Caused by “flashover” effect of non penetrating current.

23. Other electrical injuries Intentional injuries include those due to the use of high-voltage devices for rapid incapacitation , child and or spouse abuse , and torture. Also , the use of skin electrodes in medicine can cause burn.

24. Types of electrical burns Depending on the voltage, current, pathway, duration of contact, and type of circuit, electrical burns can cause a variety of injuries through several different mechanisms . Direct contact (low and high voltage) Indirect contact a. Electric arcs b. Flame c . Flash

25. 1. Direct contact Current passing directly through the body will heat the tissue causing electro thermal burns, both to the surface of the skin as well as deeper tissues, depending on their resistance . It will typically cause damage at the source contact point and the ground contact point.

26. Indirect contact a. Electrical arcs A current spark formed between two objects of differing potential that are not in contact with each other, usually a highly charge source and a ground. Because the temperature of an electrical arc is approximately 2500 ° C, it is most destructive indirect injury. It causes very deep thermal burns at the point where it contacts the skin.

27. 2. Indirect contact B. Flame : Ignition of clothing causes direct burns from flames . C. Flash : When heat from a nearby electrical arc causes thermal burns but current does not actually enter the body.

28. Mechanism of injury Electrical energy cause direct tissue damage, alter cell membrane resting potential, and elicit tetany. Conversion of electrical energy into thermal energy , causing massive tissue destruction and coagulation necrosis . Mechanical injury with direct trauma resulting from falls or violent muscle contraction.

29. Cont.. The most common entry point for electricity is the hand; the second most common is the head. The most common exit point is the foot. A current that travels from arm to arm or from arm to leg may go through the heart and is much more dangerous than a current that travels between a leg and the ground.

30. Cont … Electrical current through the head or thorax is more likely to produce fatal injury . A current that travels through the head may affect the brain . Transthoracic currents can cause fatal arrhythmic cardiac damage, or respiratory arrest. Tissues differ in susceptibility to electrical damage.

31. Body’s response to burn Described by Jackson in 1947 . Zone of coagulation —O ccurs at the point of maximum damage. There is irreversible tissue loss due to coagulation of the constituent proteins. Zone of stasis — Characterized by decreased tissue perfusion. Zone of hyperemia — Outermost zone tissue perfusion is increased. Tissue will invariably recover unless there is severe sepsis or prolonged hypo perfusion.

32. Pattern of injury/Tissue damage Organ Tissue damage Skin Flash burns, thermal burns, arc burns, linear burns, contact electrical burns. Muscle Swelling , pain, contractions, spasms, myonecrosis , compartment syndrome. Blood vessels Blood cloths, microvascular deterioration, myoglobinemia , vasoconstriction, thrombosis, ischemia Heart Arrhythmia , asystole , ventricular fibrillation, sinus tachycardia, myocardial necrosis/infarction, cardiac arrest. Nerves Weakness , paralysis, tingling, numbness, uncontrollable loss of urine (incontinence), and chronic pain.

33. Pattern of injury/Tissue damage. Organ Tissue damage Brain Seizure, hemorrhages, poor short-term memory, unconsciousness, ischemia, personality changes, irritability, difficulty sleeping. Bones Joint dislocations, fractures, other blunt injuries Kidney Myoglobinuria , acute renal failure, acute tubular necrosis. Ears Perforation of the eardrum, hemorrhage. Eyes Cataracts

34. Clinical features Cardiovascular : asystole , Arrhythmias Respiratory : respiratory arrest( Chest wall muscle paralysis from tetanic contraction, injury to the respiratory control center of brain) Skin: A. High voltage electro thermal burns : as painless, depressed areas with central necrosis and minimal bleeding

35. High voltage injury to chest

36. High-voltage injury on the chest

37. b.Arcing electric burn Arcing electrical burns through the shoe around the rubber sole

38. C. Low voltage burns

39. d. Contact burn

40. Clinical features Neurologic: transient confusion, amnesia , and impaired recall of events if not frank loss of consciousness, seizure direct spinal cord injury acute muscle tetany

41. Musculoskeletal: fractures from blunt trauma compartment syndrome ENT/head perforated tympanic membranes facial burns cervical spine injury. Clinical features

42. Classification : DEPTH Superficial (First degree) Involves only epidermis Red Painful Tender Blanches under pressure Possible swelling, no blisters Heal in ~7 days Diagnostic finding

43. CONT.. Partial Thickness (Second degree) Extends through epidermis into dermis Salmon pink Moist, shiny Painful Blisters may be present Heal in ~7 to 21 days

44. CONT… Full Thickness (Third degree) Through epidermis, dermis into underlying structures Thick, dry Pearly gray or charred black May bleed from vessel damage Painless Require grafting

45. Classification : EXTENT Rule of nines

46. Lund and Browder Method

47. Palm Method “Rule of Palm” Patient’s palm equals 1% of his body surface area

48. Classification of Burn Severity 1. Minor Burns a. Second degree adult burns less than 15% TBSA b. Second degree child burns less than 10% TBSA c. Third degree child or adult burns less than 2% TBSA 2. Moderate Burns a. Second degree adult burns involving 15 to 25% TBSA b. Second degree child burns involving 10 to 20% TBSA c. Third degree child or adult burns involving 2 to 10% TBSA

49. 3 . Major Burn a . In adults, second degree burns greater than 25% TBSA b. In children, second degree burns greater than 20% TBSA c. Third degree burns greater than 10% in an adult or a child d. Inhalation injury e. Electrical burns

50. investigations Routine labs + electrolytes + ABG RFT s & LFT s ECG (mandatory in all patients) CK ( Rhabdomyolysis + AKI) Imaging studies – Brain imaging – Cervical spine x-ray – Peripheral limbs x-ray – Chest & Pelvic radiographs (especially in previously unconscious patients)

51. Investigations Cardiac – ECG (mandatory) – Monitoring (arrhythmia / autonomic dysfunction / Haemodynamic instability) – ECG & CK-MB = poor diagnostic in myocardial affection – Troponin-I & ECHO = better diagnostic

52. EMERGENT/ RESUSCITATIVE PHASE This phase last for 24-48 hours Time required to immediate life threatening problems result from the burn injury. The phase ends when fluid mobilization and diuresis begin.

53. Management Securing the scene Power source should be turned off Denergizing the lines Triage should be concentrated on the presence of cardiac or respiratory arrest Patients require cardiac & trauma care

54. Management Standard ABCDEs of any major trauma Pulmonary Low threshold for intubation, as respiratory failure common Cardiac Serial monitoring if high V, abnormal ECG, LOC, respiratory arrest, or CV dysfunction Neuro C-spine and log-roll precautions; CT head & spine often warranted. Thorough serial neurological exams, as vessel coagulation can result in late sequel

55. ED treatment Resuscitation as per trauma guidelines, systematic physical examination ABCs , Spinal immobilisation Prolonged cardiac resuscitation following electrical injury. CVS function – assess rhythm, check pulses , ECG. Skin – inspect for burns, blisters, charred skin – specifically skin creases, areas around joints and the mouth

56. 4. Neurological function – mental status, pupillary reaction, motor function, sensation Eyes – visual acuity, anterior chamber, fundoscopy 6. Ear, nose, throat – inspect tympanic membranes, assess hearing, look for signs of smoke inhalation 7. Musculoskeletal – inspect and palpate for injuries (fractures / compartment syndrome)

57. Treatment Fluid resuscitation Aggressive replacement if soft tissue injury Prevent Heme pigment-induced AKI Administer fluids till • Normal blood pressure • UOP ( 0.5 - 1 mL/kg/h if + ve Myoglobin // 1-2 mL/kg/h if - ve Myoglobin) • CK < 5000 U/L •negative urine for hematuria Not estimated from skin injury degree (Parkland formula) Normal Saline = best solution Monitor K level (released from damaged muscles) Over correction may lead to Abdominal Compartment Syndrome

58. Formula Parkland/Baxter Formula Lactated Ringer’s solution: 4 mL × kg body weight × % TBSA burned Half to be given in first 8 hours; half to be given over next 16 hours Modified Brooke Lactated Ringer's Solution:2.0 ml x kg body wt x % TBSA Burned Half to be given in first 8 hours; half to be given over next 16 hours

59. Evans Formula Colloids: 1 mL × kg body weight × % TBSA burned Glucose (5% in water): 2,000 mL for insensible loss Day 1: Half to be given in first 8 hours; remaining half over next 16 hours Day 2: Half of previous day’s colloids and electrolytes; all of insensible fluid replacement

60. Treatment Foley's catheter mandatory to assess urine output & level of hydration

61. Treatment Mannitol – Osmotic Diuresis to maintain UOP & prevent heme pigment deposition – 1gm/kg/day – Contraindicated if Oliguria is present – Stopped if target UOP not reached with rising plasma osmolarity Bicarbonate –– Prevent heme deposition – Give only if : • PH < 7.5 • HCO3 < 30 • No sever hypocalcemia – Stopped after 4-6 hours if urine PH not rising above 6.5 or if hyperCalcemia is present

62. Prevent Tetanus: Tetanus toxoid booster Tetanus Immunoglobulin First series of active immunization Prevent Tissue Ischemia: Elevating injuries 15* above the level of the heart. Performing active exercise. Doppler flowmeter assessment Escharotomy

63. Surgical Treatment Surgical : Fasciotomy – in Compartment syndrome ( diagnostic & therapeutic role)

64. Surgical management Limb amputation – If severely affected with persistent myoglobinuria .

65. Wound Care Immediate Care: Within 12 hours of injury, wound care consist: Covering the wound with sterile towel. Placing clean, dry sheets and blanket over the client Cleansing and gentle debridement of devitalized tissue in hydrotherapy and cart shower. Removal of any damaging agents ( e.g.: chemical tar) and application of any topical agents and a dressing. Wash with mild soap and rinse thoroughly with warm water not exceeding 104*F. Hair should be shaved to within 1inch margin around the burn wound.

66. ACUTE / INTERMEDIATE PHASE Begins with the mobilization of extra cellular fluid and subsequent diuresis. This phase ends when the burn area is completely covered by skin graft or when the wound is heal. This may take from week to months.

67. Prevent Infection: Use of gloves, caps , masks, shoe cover, scrub clothes and plastic aprons.(barrier nursing) Strict handwashing to reduce cross-contamination. Staff and visitors restrictions .

68. Provide Metabolic Support: Basal metabolic rate are 40%-100% higher than normal levels. CURRERI -- ( 25KCA X kg body weight) + (40kcal x %TBSA burn ) =25 X 44 + 40 X 7 =1380 KCAL PROTEIN REQUIREMENT 1 GM X BODY WEIGHT + 3GM X TOTAL % = 1X 44+3 X 7 = 65 GM

69. Minimize Pain and Anxiety Acute Stage Analgesic Drugs and Intravenous Doses -Tramado l (12 years and older) 1mg/kg 4-6 hours - Ketamine 0.2-0.5 mg/kg 15-25 minutes - Morphine or diamorphine 0.03-0.1 mg/kg - child 0.1 mg/kg 4-6 hours - Fentanyl 1-1,5 μ gr/kg -child 1 μ gr/kg 45-60 min - Meperidine 0.5-1 mg/kg 2-4 hours

70. Debridement: Mechanical: Careful use of scissors and forceps to lift and trim away devitalized tissue. Wet to dry dressing change. Coarse gauze dressing saturated with a prescribed solution( Parrafin or petroleum), applied to the wound and leave for 6-8hours.

71. Enzymatic debridement: Application of commercially prepared proteolytic and fibrinolytic topical enzyme ( eg . Papain) to the burn wound. Surgical Debridement: Tangential excision – very thin layers of devitalized tissue are sequentially shaved until viable tissue is reach . .

72. Grafting Autograft : Coverage of the burn wound with a graft of the patient’s own skin ( autograft ). Biologic dressings Homograft - Homograft are skin obtained from living or recently deceased humans. Heterografts - Heterografts consist of skin taken from animals (usually pigs )

73. Care of Donor Site A moist gauze dressing is applied at the time of surgery to maintain pressure and to stop any oozing. The donor site may be treated in several ways , from single-layer gauze impregnated with petrolatum, scarlet red, or bismuth to new biosynthetic dressings such as Biobrane or BCG Matrix .

74. Donor sites must remain clean, dry, and free from pressure. Because a donor site is usually a partial-thickness wound, it will heals spontaneously within 7 to 14 days with proper care . Donor sites are painful, and additional pain management must be a part of the patient’s care. Care of Donor Site

75. Care of the Patient with an Autograft Occlusive dressings are commonly used initially after grafting to immobilize the graft. Immobilize newly grafted areas to prevent dislodging the graft. Homografts , heterografts , or synthetic dressings may also be used to protect grafts. The graft may be left open with skin staples to immobilize it, which allows close observation of progress. The first dressing change is usually performed 3 to 5 days after surgery , or earlier in the case of purulent drainage or a foul odor .

76. If the graft is dislodged, sterile saline compresses will help prevent drying of the graft until the physician reapplies it . The patient is positioned and turned carefully to avoid disturbing the graft or putting pressure on the graft site . If an extremity has been grafted, it is elevated to minimize edema. The patient begins exercising the grafted area 5 to 7 days after grafting. Care of the Patient with an Autograft

77. Biosynthetic and synthetic dressings   BIOBRANE - composed of a nylon, Silastic membrane combined with a collagen derivative.   BCG Matrix - This dressing combines beta-glucan, a complex carbohydrate, with collagen in a meshed reinforced wound dressing. Other synthetic dressings used for burn wounds include Tegaderm , N- Terface , and DuoDerm .

78. Topical Antimicrobial Treatment Open Method : After application of antimicrobial cream, it is left open without gauze dressing and reapplied as needed. Closed Method: Gauze dressing is impregnated with antimicrobial and applied to the wound. Wrap from the most distal to proximal direction . Temporary wound coverings.

79. Antimicrobial Bacitracin –Interruption of cell wall synthesis. Cerium Nitrate Silver Sulfadiazine- S imilar to that of silver sulfadiazine or silver nitrate Gentamicin -Binds irreversibly to the 30s ribosome and inhibits protein synthesis

80. Antimicrobial Mafenide Acetate -antibacterial activity against most Gram-positive species, including clostridia. Mupirocin (Bactroban) - inhibition of protein synthesis. Nitrofurazone - it inhibits several bacterial enzymes involved in carbohydrate metabolism. It is bactericidal.

81. Antimicrobial Povidone Iodine (Betadine) Silver Nitrate 0.5% - Bacteriostatic at lower concentrations (0.5%) and bactericidal at higher concentrations (10%). Silver Sulfadiazine - Impair bacterial DNA replication

82. Maximize Function Therapeutic Positioning Range of motion exercise Splinting Client and Family education Ambulation Stretching Exercise

83. REHABILITATION PHASE Goal: Maximize functional capacity, minimize functional loss and maximize emotional recovery. The rehabilitation for patients with burn injuries starts from the day of injury, lasting for several years and requires multidisciplinary efforts. A comprehensive rehabilitation programmed is essential to decrease patient’s post traumatic effects and improve functional independence.

84. PRINCIPLES OF BURN REHABILITATION The program should start early, preferably the day of injury. A program of care should be avoid prolonged periods of immobility, and any body parts that is able to move freely should be moved frequently. Range of motion exercise should be started the day of injury. There should be planned program of daily activity and rehabilitative care. The plan should be reviewed daily as rehabilitative needs change.

85. DISORDERS OF WOUND HEALING

86. Hypertrophic Scar These are Characterized by an over abundant formation of matrix, especially collagen, in wounds that heal by granulation.

87. Keloids A large heaped-up mass of scar tissue, a keloid may develop and extend beyond the wound surface

88. Failure to heal Failure of the wound to heal result from many factors, including infection, an underlying disease process, shearing, pressure or inadequate nutrition.

89. Contractures The burn wounds tissue shortens because of the force exerted by the fibroblasts and the flexion of muscles in natural wound healing.

90. RECONSTRUCTION SURGERIES The surgical plan involves recreating the initial tissue loss and then adding appropriate tissue. The techniques are - Direct closure Grafts Flaps Expanded skin

91. DIRECT CLOSURE Direct closure in burn reconstruction is the simplest form of scar revision following excision of the scar.

92. SKIN GRAFTING Split or partial thickness graft -includes epidermis and part of dermis Full thickness graft - includes epidermis and full thickness of the dermis Composite graft- includes the full thickness of the skin and a portion of the underlying tissue such as subcutaneous tissue, muscle, cartilage or bone.

93. FLAPS A skin flap is a segment of skin and subcutaneous tissue which is transferred from its original position on the body to another site while maintaining its own inherent vasculature for nourishment.

94. Common post burn contractures and the respective anti- contracture position of nursing. The flexion contracture of the neck can be avoided by having a pillow under the shoulder and nursing with the neck in extension

95. The Extension contracture of the neck can be avoided by sitting with head in flexion and lying with pillows behind the head.

96. Clawing of fingers can be avoided by keeping the M.P joints in flexion. IP joints in extension, thumb mid palmer radial abduction.

97. The thumb and palm deformity is avoided by keeping the wrist extended with minimal MCP flexion and keeping the fingers extended and thumb abducted .

98. Flexion contracture of knee can be avoided by keeping the legs extended in lying and sitting and by using knee extension splints.

99. Dorsal contracture at the ankle can be prevented by keeping ankles at 90 degrees

100. Massage

101. Exercise and Stretching

102. Pressure Garments

103. Silicone Silicone is another modality used to treat hypertrophic scarring. It is likely to influence the collagen remodeling phase of wound healing.

104. PSYCHOLOGICAL IMPACT Reassurance Demonstrate genuine empathy and compassion Active listening Providing adequate information Answering their questions

105. Social rehabilitation Individuals should be encouraged in order to re-establish themselves in their social and vocational lives as soon as they are able to, and their family members should be encouraged to promote this behavior . Life after a burn injury, particularly a major injury can take some significant adjusting to however with the right support and rehabilitation, burn injured patients can lead a full life.

106. Acute pain related to destruction of skin and tissue as evidenced by pain score of 4. Hyperthermia related to infection as evidenced by temperature of 101.1 degree F, moderate pus cells, scanty growth in wound swab, TLC of 18.900 thousands. Fluid volume deficit related to loss of fluid through burn wound , restricted oral intake as evidenced by tachycardia, dry lips, dry skin. Imbalanced nutrition less than body requirement related to hyper metabolic state, protein catabolism as evidenced by negative protein and calorie balance, deranged LFT.

107. Impaired skin integrity related to disruption of skin surface as evidenced by absence of viable tissue. Impaired physical mobility related to limb immobilization, restrictive therapies as e videnced by limited ROM. Risk for electrolyte imbalance related to muscle and tissue breakdown. Risk for infection related to destruction of skin barrier, environmental exposure. Risk for ineffective tissue perfusion related to interruption of arterial and venous blood flow.

108. Anxiety related to threat of disfigurement, hospitalization. Risk for ineffective airway clearance, pneumonia related to prolonged bed ridden . Disturbed body image related to dependent client role, traumatic event . Risk for complications ( compartment syndrome, local infection, neurologic injury, DVT, arrhythmia) related to electric injury. Knowledge deficit regarding the treatment regimen.

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