Introduction
While burns account for 20 to 40% of hospital admissions, 5 to 27% of those are attributed
to electrical burn injuries.[1] Although it is evident that burns are common causes of morbidity and mortality in
the world, it is relatively uncommon for the neurosurgeon to be the doctor attending
to a burn victim; yet it is seldom up to anyone else to deal with the unfortunate
perils that affect the human brain, regardless of the cause.
The authors reported one such case of a patient presenting to the neurosurgical service
with a traumatic brain injury (TBI) caused due to an electrical burn.
Objectives
To highlight the possibility of electrical burns causing TBI requiring immediate neurosurgical
intervention and the association between the two entities.
To review the available data on such injuries, with special attention to the nature
of presentation, the pathophysiology of the events that arise, complications to be
expected, and the guidelines for management.
Case Report
History: A 35 year old male manual laborer from coastal Karnataka was brought to the emergency
department with polytrauma sustained due to alleged history of electrocution, followed
by fall from height while working on an electrical tower.
Physical examination: On initial assessment, the patient had a pulse rate (PR) of
64/minute, blood pressure (BP) of 90/60 mm of Hg, respiratory rate (RR) of 10/minute,
unconscious with Glasgow coma scale (GCS) score of 4/15 (E1V1M2) with decerebration
noted bilaterally, and pupils bilaterally fixed at 3 mm, nonreacting to light. An
emergency electrocardiogram (ECG) indicated atrial fibrillation.
Further physical examination revealed the following:
-
A 25 × 5 cm laceration over the right parietal region of the scalp with blackish charred
edges surrounded by hairless and hyperemic skin, with underlying open skull fracture
surrounded by haematoma, and with a circular calvarial defect measuring approximately
7 cm in diameter, beneath which was visible the underlying dura seen to be ruptured
with irregular margins along with hernia cerebri, that is, extruding gray matter:
suggestive of both a possible entry point for electrical current as well as the result
of blunt trauma as the underlying mechanism of the injury ([Fig. 1]).
-
Black charred skin over the pubis and scrotum, with superficial burns over the external
genitalia and surrounding regions of the pubis and perineum, no evident signs of urethral
injury: suggestive of a possible exit point for electrical current ([Fig. 2]).
-
Total external body surface area burnt as per the Lund and Browder chart[2]: < 10%
-
No visible bony deformities of the long bones of the limbs and negative pelvic compression
test.
Fig. 1 Entry wound at the time of presentation (as described).
Fig. 2 Exit wound at the time of presentation (as described).
Management: The patient was immediately intubated with a 7.5-mm endotracheal tube and ventilated,
cannulated with wide bore intravenous (IV) cannulas in both forearms, subclavian IV
access established, and fluid resuscitation initiated with Ringer Lactate, catheterized
with a 16F Foley catheter, and transferred for an emergency computed tomography (CT)
scan of the head, chest, and abdomen.
CT of the head ([Fig. 3]) revealed the following:
-
Right parietal scalp haematoma.
-
Open right parietal skull fracture.
-
Bifrontal pneumocephalus and subdural hygroma.
-
Right parietal contusions and corresponding contrecoup left parietal contusions.
-
Traumatic subarachnoid hemorrhage.
-
Cerebral edema, no transfalcine herniation.
Fig. 3 CT-Scan at admission.
The patient was immediately transferred to the operating theater in view of clinical,
radiological, and emergent indications, while correction of hematological and cardiac
abnormalities was initiated. The wound was thoroughly debrided—necrosed skin margins
were excised and underlying skull wound washed with saline, with least possible contact
to the ruptured dura and visible brain, which appeared contused with engorged veins.
The subdural space was packed with hemostatic gelfoam, and dura was left open, following
which the skin was approximated in a single layer with 2–0 non-absorbable nylon sutures
([Fig. 4]). The wound was bandaged and dressed with adequate padding over the site of injury.
Fig. 4 Post-operative wound.
Patient's perineum was also carefully debrided and dressed adequately, and fluid resuscitation
continued along with correction of hyperkalemia before patient was transferred to
the intensive care unit for monitoring. Postoperatively, patient had PR 68/minute,
BP 100/60, was on mechanical ventilation, and was draining adequate urine. He was
managed with IV anticonvulsants, diuretics, antiarrhythmics
The patient, who had been brought in the late hours of the evening, had physiologically
survived the night with his vital signs holding steady as was postop, with no improvement
in GCS. Unfortunately, he was discharged against medical advice the following morning,
owing to circumstances that are fairly or unfairly attributed to human beings.
Discussion
Electrical energy, apart from being the stuff of legends, natural and cosmic events,
and popular abstract connotations, interestingly also plays many physiological roles
in the human body. As students of the nervous system, we are aware that it is electrical
energy that forms the basis of the intricacies of the system, ranging from the membrane
potential to every action potential to the results of those minilightning bolts that
also include the rhythms of the cardia.
One can endlessly list the myriad contributions of electricity to the life of the
human being, and the neurosciences, whether it be the electric chair used for criminal
executions in the yesteryears, developed by a person from the medical community, electroconvulsive
therapy (ECT) used to treat psychiatric disorders like severe depression, or investigative
roles of electroencephalogram/cardiogram/myograms (EEG/ECG/EMG) to pacemakers and
deep-brain stimulation.
It is however the bane of the same energy that could burn, causing devastating and
life-threatening injuries. Studies from different parts of the world have shown that
electrical burn injuries account for as much as 5% of admissions to burn units. Electrical
burns are responsible for as many as 1000 deaths per year in the United States. More
than 50% of all electrical burn injuries are nonintentional. While males have seen
to be more affected overall, the cause usually being occupational, electrical burns
in the household setting are the cause of such injuries among women and children.
Individuals in the age group of 18 to 40 years are more frequently affected.[1]
[3]
[4]
The major determinant for the severity of the injury is the voltage of the current
that passes through the victim's body, and the nature of the current, that is, direct
current (DC) or alternating current (AC). For this reason, electrical burns are broadly
classified as follows:
-
(i) High-voltage burns: where the voltage is 1000 V or greater. These are more common,
accounting for 57.71% of electrical burns. High-voltage burns may be “true high-voltage
burns” or there is also an entity called “flash burns,” where an arc of high-voltage
current emits heat that causes superficial burns, commonly to the hand and face.[1]
[5]
,
-
(ii) Low-voltage burns: where the voltage is less than 1000 V, as seen in domestic
burns, accounting for 42.29% of electrical burns.[1]
[5]
High-voltage injuries cause more extensive tissue damage and loss, and may involve
more systemic complications like fatal arrhythmias and renal failure or even death,
when compared with low-voltage burns. The standard classification of the degree of
severity of the burn injury, regardless of the cause, is based on the thickness or
depth of the tissue involved in the form of superficial (first degree), partial thickness
(second and third degree burns), and full thickness (fourth degree burns).[1]
Pathophysiology
What makes electrical burns interesting is the mechanism by which it acts. Any electrical
source must have an entry point through which the current enters the body: usually
the head or the hands. The current traverses through the body along the path of least
resistance before it leaves the body through an exit point, which is usually the feet.
While this is the general principle, it may not apply to an alternating source of
current where the current travels within the body.[1]
[6]
[7]
Apart from the voltage and the nature of the current, it is the duration of exposure
and the path taken by the current in the body that determines the extent of the internal
injuries, and this is where the conversation can be directed toward the nervous system,
which is affected in as much as 21% of cases. The nerves of the body, the large ones
being myelinated, and all being natural conductors of the electricity, offer low resistance,
similar to blood vessels, when compared with skin, muscle and bone, which offer high
resistance. As a result, the nerves and blood vessels favor the path of the current,
and this is responsible for the neurological and the cardiac sequelae; while muscles
and other soft tissue may suffer the direct impact of the thermal injury generated.[1]
[5]
[6]
[7]
[8]
Studies have shown that as the electrical current travels through the body, the neurological
effects are caused due to the following:
-
Electroporation: refers to the opening of pores in the cell membrane, initiating a
cascade of events that favor cellular death.
-
Vascular injury: due to spasm and release of vascular inflammatory mediators, leading
to neuronal ischemia, neuronal chromatolysis, and microglial activation.
-
Demyelination: due to alteration of the nature of the proteins and lipids.
-
Release of thermal injury, causing destruction of macromolecules.
-
Neurohumoral hypothesis: suggesting that electricity aids in circulating substances,
specifically cortisol, a stress hormone, and generation of free radicals acting at
a distance and by hyper-stimulation of glutamate receptors. The cointeraction of all
of these may also be responsible for the delayed effects in the central nervous system
(CNS) as well as peripheral nervous system (PNS).
Following the injury, due to the above mechanisms,[1]
[6]
[9]
[10] events occur that have effects at different times, which can be categorized[1]
[11] as follows:
-
Immediate and transient, for example, amnesia and loss of consciousness.
-
Immediate and prolonged, for example, hemorrhage or infarction.
-
Delayed and progressive, for example, demyelination.
-
Secondary or indirect effects, for example, TBI.
The effects may also be categorized based on the various divisions of the nervous
system affected, as presented below[1] and summarized in [Fig. 5]
[12]:
Fig. 5 Effects of electrical injuries to the different divisions of the nervous system.
-
Central Nervous System (CNS)
-
(i) TBI: possibly a direct or an indirect effect, as seen in the case above, where
the injury could have been caused due to the current entering the body, or the patient
being thrown off balance after the electrocution and sustaining a head injury, or
a combination of both. The injury may be a closed head injury or a penetrating injury
and usually requires immediate surgical intervention.
One study has reported that as much as 35% of electrical burn victims evaluated suffered
head injuries, and 9.9% of patients required neurosurgical treatment, including cranioplasty
for calvarial injuries.[4]
-
(ii) Cerebral edema: secondary to electrocution affecting the brain matter itself
and also as part of the cycle of the other listed complications.
-
(iii) Ischemia (stroke): as a consequence of vasospasm. Strokes following electrocution
have been reported in specific individual instances as well.[12]
-
(iv) Seizures: due to electrical stimulation, occurring both as immediate and delayed
consequence.
-
(v) Cerebellar syndromes: due to electrocution and subsequent ischemia or hemorrhage.
-
(vi) Hydrocephalus requiring shunt insertion.
-
(vii) IV thrombosis: also known to be related to seizures itself.
-
(viii) Myelopathy and spinal cord transection due to the course of the current, and
a possibility of a Brown–Sequard-like presentation, with a combination of upper motor
and lower motor neuron signs.
-
(ix) Amyotrophic lateral sclerosis (ALS): delayed sequelae.
-
(x) Movement disorders: delayed sequelae.
-
Peripheral Nervous System (PNS)
-
(i) Mononeuropathy commonly affecting, but not limited to, the nerves of the upper
limb, as they are usual entry points. Median and ulnar neuropathies have been commonly
reported. They could also be secondary to fracture of the long bones.
-
(ii) Polyneuropathy
-
(iii) Polyradiculopathy where there are multiple entry points.
-
(iv) Cranial nerve dysfunction where the head and its orifices are entry points. Patients
have been found to have sensorineural hearing loss and associated symptoms like vertigo
and tinnitus, apart from presentations attributed to the damage of individual nerves
or a combination of more than one.
-
Autonomic Nervous System (ANS)
-
(i) Autonomic cardiovascular complications are well-known and cannot be ignored. Arrhythmias
are a direct result of electrical injuries, and intensive and sequential cardiac monitoring
is indicated in all electrical burn victims.[13]
-
(ii) Horner syndrome.
-
(iii) Bladder dysfunctions.
-
(iv) Sexual dysfunctions.
-
(v) Complex regional pain syndrome.
-
(vi) Reflex sympathetic dystrophy.
-
(vii) Keraunoparalysis is also known as Charcot's paralysis where the patient has
temporary limb paralysis, pallor and pulselessness following a surge of catecholamine
release.
It is for the management of the above-listed sequelae and complications that the neurosurgeon
has a key role to play in the immediate and future care of the electrical burn victim
alongside a multidisciplinary team to treat the individual as a whole, which we subsequently
discuss.
-
(i) Arrhythmia: Atrial and ventricular fibrillation are common and ST changes in the ECG have also
been reported. It is also essential to monitor cardiac enzymes.[13]
-
(ii) Rhabdomyolysis and myoglobinuria with raised creatine phosphokinase levels, further
leading to:
-
(iii) Acute renal failure.
-
(iv) Electrolyte abnormalities, with special attention to potassium levels that have
definite association to the cardiac rhythm abnormalities as a result of the thermal
injuries and fluid loss that requires rigorous resuscitation.
-
(v) Spinal injuries and fractures or dislocation of long bones and also of the commonly
encountered thoracic and lumbar spine.
-
(vi) Ocular injuries and their sequelae-like cataract and keratoconjunctivitis.
-
(vii) Abdominal visceral injuries have been widely documented and includes a wide
spectrum from mild injuries requiring conservative management as well as severe cases
where laparotomy and exploration is doubtlessly indicated and where mortality has
been significant.[6]
-
(viii) Sepsis and subsequent multiorgan dysfunction syndrome (MODS).
Management
Management of any burn victim, electrical or not, is to be rigorous from the time
the patient is wheeled into the emergency room. All possible injuries, immediate as
well as delayed, must be imagined from the initial assessment itself. Following emergency
management (airway breathing and circulation [ABC]), the patient must receive fluid
resuscitation as per the formulae adopted by the center, the Parkland formula still
being the standard. The patient must undergo thorough and regular investigations,
the most important of which is the ECG, before bloodwork including cardiac enzymes
and creatine phosphokinase (CPK) levels, and CT scan of the head and neck, thorax
and abdomen, to rule out the extent of potential internal injuries.[1]
[4]
[6]
[13]
For the neurosurgeon, the authors reiterate the need for a comprehensive neurological
assessment and evaluation for the need for surgery. Open head injuries must be managed
acutely with the high-risk of infection in mind, and all other pathologies must be
urgently excluded, regardless of the condition of the pupils that may be misleading
as a result of autonomic dysfunction, as described. Immobilization of the spine must
never be overlooked.[1]
[6] Measures must be taken to ensure that morbidity and mortality arising, due to a
neurosurgical pathology, is avoided at all costs.
Burn victims inevitably require to undergo multiple plastic surgical interventions
like debridement, skin grafting, chronic wound dressing, contracture releases, etc.
apart from the constant medical treatment needed, making them chronic patients, bearing
all the burden that comes with it, such as the complications of being bedridden, who
later also require intensive rehabilitation.[1]
[6]
The most important step in the management of burns remains the prevention of burns,
and the doctor plays a tremendous role in educating the public about the causes, effects,
and management of burns.
Conclusion
It is possible for electrical injuries to have direct or indirect but certainly far-reaching
effects on the nervous system; hence, awareness on the subject and appropriate approach
is critical for the neurosurgeon/neurologist in saving the life of the patient.
