TY - JOUR
AU1 - Demir, Sabri
AU2 - Demir, Tugba Ornek
AU3 - Erturk, Ahmet
AU4 - Oztorun, Can İhsan
AU5 - Guney, Dogus
AU6 - Erten, Elif Emel
AU7 - Altinok, Metin Kaan
AU8 - Azili, Mujdem Nur
AU9 - Senel, Emrah
AB - Abstract Electrical injuries comprise 4% of cases but have higher morbidity and mortality. This study aims to share our experiences with pediatric electrical injuries and propose strategies to prevent them. The files of pediatric electrical injuries between 2010 and 2020 were reviewed retrospectively. The following were investigated: age, gender, cause, length of stay in the pediatric burn center, total burned surface area, voltage-type, and surgical procedures performed. The patients from low- and high-voltage groups were compared. Eighty-five patients were treated in the last 10 years. Seventy were males, the mean age was 9.9 years, the average length of stay in pediatric burn center was 18.2 days, and the average total burned surface area was 11.7%. Forty-three patients were injured with high-voltage and 42 with low-voltage electricity. Fasciotomy was performed in 25 patients, grafting in 40 patients, and amputation in 12 patients. The most often amputated limb was the right arm/forearm. Psychiatric disorders developed in 24 patients. One patient died. In conclusion, the incidence of high-voltage electrical injuries increases with age. They are more prevalent in males, more often accompanied by additional trauma, and have higher total burned surface area, surgical procedures are performed more often, and hospitalization times are longer. For prevention, precautions should be taken by governments and families, and education is critical. Although electrical injuries (EIs) comprise a small percentage of total admissions to major burn centers (about 4%) in both adults and children, they have higher morbidity and mortality. They are the most common cause of amputations performed in burn centers.1,2 While they occur mostly in the workplace as a result of work accidents in adults, they typically occur in children at home as home accidents.2–4 While the male to female ratio is 2:1 in children, 90% of adult cases are male.2 Since electricity was discovered in the 18th century, it has been an essential part of daily life. Today, technological developments achieved in all areas are the result of the use of electricity. However, the cost of these developments is that electricity has become an important cause of both workplace and home accidents since the 19th century. The first death owing to exposure to electric current occurred in France in 1879. Despite significant improvements in the safety standards of electrical devices, EIs remain one of the leading causes of morbidity and mortality among burn victims.5 EIs in children are mostly caused by contact with low-voltage current. Although not as often as adults, children can also be victims of high-voltage EIs.6 EIs are divided into two groups according to the magnitude of voltage: low-voltage EI (<1000 V) and high-voltage EI (>1000 V).1 In the United States, 120 V, 60-cycle alternating current (AC) electricity is used for household electricity, while in Turkey, 220V, 60-cycle AC current is used.7 Therefore, EIs occurring at home tend to be low-voltage EIs. Multiple factors determine the severity of the injury. These factors include the magnitude of the voltage (low or high voltage), the intensity of the current, the type of current (alternating or direct current), the passageway of the current, the duration of contact, the resistance of the tissues at the contact site, and personal characteristics.1 Our pediatric burn center (PBC) is located in Ankara, the capital city of Turkey. It is the countrywide final destination as a tertiary burn center for children’s burns. We admit severely burned children cases from all over the country and neighboring countries. This study aims to evaluate the 10-year data on pediatric EIs treated in our center, to examine the factors that play a role in EIs, and to propose solutions to prevent these mostly avoidable injuries. METHODS The medical files of patients who were admitted to the PBC between January 2010 and 2020 due to EIs were reviewed retrospectively. The ethics committee approval required for the study was obtained from the local ethical committee. The criteria for inclusion in the study were determined as being between the ages of 0 and 18, injured as a result of an EI, and treated in the PBC. Patients who were burned by causes other than EI or were above 18 years of age were excluded. The following were investigated: the age and gender of the victims, cause of the EI, place where the injury occurred, length of stay in the PBC, TBSA, additional trauma, type of voltage, contact points (entry and exit contact points), and whether escharotomy/fasciotomy, grafting, and amputation were performed. Additionally, it investigated whether vacuum-assisted closure (VAC) and hyperbaric oxygen therapy (HBOT) were applied in wound closure and whether psychiatric disorders developed secondary to the injury. The data were first analyzed for all patients. Afterward, the patients were divided into two groups: low-voltage and high-voltage groups, and then they were compared. Statistical analysis was performed using the Statistical Package for the Social Sciences (SPSS), version 21 (IBM, Chicago, IL) software. Categorical variables were displayed as number and percentage, and numerical variables were displayed as mean and standard deviation. For evaluating whether the numerical variables were normally distributed, the Kolmogorov–Smirnov and Shapiro–Wilk tests were used. The descriptive analysis of abnormally distributed numerical variables was performed using the Mann–Whitney U-test. Comparisons among categorical variables were made using percentages with the Pearson chi-squared test. Where some of the values of cells were “0,” the Pearson chi-squared test was applied by combining the groups. For all variables, P <.05 was considered statistically significant. RESULTS Out of 1463 patients, 85 (5.7%) were admitted to the PBC due to EIs. Seventy (82.4%) were male and 15 (17.6%) were female. The average age was 9.9 years old (min–max = 0.8–17.8; SD = 4.9). The average age of males was higher than females (10.8 and 5.9 years, respectively, P < .001) (Table 1). Table 1. Demographic features and statistical comparison of data according to the gender of the victims Variables . Male (n = 70) . Female (n = 15) . P . Age 10.8 (2.0–17.8; 4.7) 5.9 (0.8–11.8; 4.0) <.001* Voltage  Low voltage (<1000 V) 32 (45.7%) 10 (66.7%) .141**  High voltage (>1000 V) 38 (54.3%) 5 (33.3%) LOS in PBC* (day), mean (min–max; SD) 21.0 (1.0–92.0; 22.6) 4.9 (1.0–36.0; 8.9) .007* TBSA**, mean % (min–max; SD) 13.5 (0.1–70.0; 15.6) 3.5 (0.1–30.0; 8.2) .002* Place the injury happened, n (%)  At home 24 (34.4%) 9 (60.0%) .049***  Open public areas 31 (44.3%) 5 (33.3%)  At the workplace 5 (7.1%) 0  School and kindergarten 2 (2.8%) 0  On the top of the train 3 (4.3%) 0  On the balcony 3 (4.3%) 0  On the roof of house 1 (1.4%) 0  In the shopping center 0 1 (6.7%)  On the truck dumper 1 (1.4%) 0 Additional trauma  None 54 (77.1%) 15 (100%) N/A  Falling from high 12 (17.1%) 0  Head trauma secondary to falling 2 (2.9%) 0  Bone fractures secondary to falling 2 (2.9%) 0 Grafting  None 32 (45.7%) 13 (86.7%) .004**  Made 38 (54.3%) 2 (13.3%) Amputation  None 58 (82.9%) 15 (100%) N/A  Made 12 (17.1%) 0 Fasciotomy/escharotomy  None 46 (65.7%) 14 (93.3%) .033**  Made 24 (34.3 %) 1 (6.7%) Flap  None 61 (87.1%) 15 (100%) N/A  Made 9 (12.9%) 0 Developed psychiatric disorders  Not consulted 42 (60.1%) 13 (86.6%) .036***  Normal 5 (7.1%) 1 (6.7%)  Posttraumatic stress disorder 11 (15.7%) 1 (6.7%)  Depression 4 (5.7%) 0  Anxiety 8 (11.4%) 0 VAC  None 54 (77.1%) 15 (100%) N/A  Made 16 (22.9%) 0 Hyperbaric oxygen therapy  None 62 (88.6%) 15 (100%) N/A  Made 8 (11.4%) 0 Variables . Male (n = 70) . Female (n = 15) . P . Age 10.8 (2.0–17.8; 4.7) 5.9 (0.8–11.8; 4.0) <.001* Voltage  Low voltage (<1000 V) 32 (45.7%) 10 (66.7%) .141**  High voltage (>1000 V) 38 (54.3%) 5 (33.3%) LOS in PBC* (day), mean (min–max; SD) 21.0 (1.0–92.0; 22.6) 4.9 (1.0–36.0; 8.9) .007* TBSA**, mean % (min–max; SD) 13.5 (0.1–70.0; 15.6) 3.5 (0.1–30.0; 8.2) .002* Place the injury happened, n (%)  At home 24 (34.4%) 9 (60.0%) .049***  Open public areas 31 (44.3%) 5 (33.3%)  At the workplace 5 (7.1%) 0  School and kindergarten 2 (2.8%) 0  On the top of the train 3 (4.3%) 0  On the balcony 3 (4.3%) 0  On the roof of house 1 (1.4%) 0  In the shopping center 0 1 (6.7%)  On the truck dumper 1 (1.4%) 0 Additional trauma  None 54 (77.1%) 15 (100%) N/A  Falling from high 12 (17.1%) 0  Head trauma secondary to falling 2 (2.9%) 0  Bone fractures secondary to falling 2 (2.9%) 0 Grafting  None 32 (45.7%) 13 (86.7%) .004**  Made 38 (54.3%) 2 (13.3%) Amputation  None 58 (82.9%) 15 (100%) N/A  Made 12 (17.1%) 0 Fasciotomy/escharotomy  None 46 (65.7%) 14 (93.3%) .033**  Made 24 (34.3 %) 1 (6.7%) Flap  None 61 (87.1%) 15 (100%) N/A  Made 9 (12.9%) 0 Developed psychiatric disorders  Not consulted 42 (60.1%) 13 (86.6%) .036***  Normal 5 (7.1%) 1 (6.7%)  Posttraumatic stress disorder 11 (15.7%) 1 (6.7%)  Depression 4 (5.7%) 0  Anxiety 8 (11.4%) 0 VAC  None 54 (77.1%) 15 (100%) N/A  Made 16 (22.9%) 0 Hyperbaric oxygen therapy  None 62 (88.6%) 15 (100%) N/A  Made 8 (11.4%) 0 LOS, length of stay; PBC, pediatric burn centre; VAC, vacuum-assisted closure. N/A, not applicable. The chi-squared test could not be applied because one of the variables is 0. *Mann–Whitney U-test used. **Pearson chi-squared test used. ***Since some values were “0,” the chi-squared test was applied by combining groups. Open in new tab Table 1. Demographic features and statistical comparison of data according to the gender of the victims Variables . Male (n = 70) . Female (n = 15) . P . Age 10.8 (2.0–17.8; 4.7) 5.9 (0.8–11.8; 4.0) <.001* Voltage  Low voltage (<1000 V) 32 (45.7%) 10 (66.7%) .141**  High voltage (>1000 V) 38 (54.3%) 5 (33.3%) LOS in PBC* (day), mean (min–max; SD) 21.0 (1.0–92.0; 22.6) 4.9 (1.0–36.0; 8.9) .007* TBSA**, mean % (min–max; SD) 13.5 (0.1–70.0; 15.6) 3.5 (0.1–30.0; 8.2) .002* Place the injury happened, n (%)  At home 24 (34.4%) 9 (60.0%) .049***  Open public areas 31 (44.3%) 5 (33.3%)  At the workplace 5 (7.1%) 0  School and kindergarten 2 (2.8%) 0  On the top of the train 3 (4.3%) 0  On the balcony 3 (4.3%) 0  On the roof of house 1 (1.4%) 0  In the shopping center 0 1 (6.7%)  On the truck dumper 1 (1.4%) 0 Additional trauma  None 54 (77.1%) 15 (100%) N/A  Falling from high 12 (17.1%) 0  Head trauma secondary to falling 2 (2.9%) 0  Bone fractures secondary to falling 2 (2.9%) 0 Grafting  None 32 (45.7%) 13 (86.7%) .004**  Made 38 (54.3%) 2 (13.3%) Amputation  None 58 (82.9%) 15 (100%) N/A  Made 12 (17.1%) 0 Fasciotomy/escharotomy  None 46 (65.7%) 14 (93.3%) .033**  Made 24 (34.3 %) 1 (6.7%) Flap  None 61 (87.1%) 15 (100%) N/A  Made 9 (12.9%) 0 Developed psychiatric disorders  Not consulted 42 (60.1%) 13 (86.6%) .036***  Normal 5 (7.1%) 1 (6.7%)  Posttraumatic stress disorder 11 (15.7%) 1 (6.7%)  Depression 4 (5.7%) 0  Anxiety 8 (11.4%) 0 VAC  None 54 (77.1%) 15 (100%) N/A  Made 16 (22.9%) 0 Hyperbaric oxygen therapy  None 62 (88.6%) 15 (100%) N/A  Made 8 (11.4%) 0 Variables . Male (n = 70) . Female (n = 15) . P . Age 10.8 (2.0–17.8; 4.7) 5.9 (0.8–11.8; 4.0) <.001* Voltage  Low voltage (<1000 V) 32 (45.7%) 10 (66.7%) .141**  High voltage (>1000 V) 38 (54.3%) 5 (33.3%) LOS in PBC* (day), mean (min–max; SD) 21.0 (1.0–92.0; 22.6) 4.9 (1.0–36.0; 8.9) .007* TBSA**, mean % (min–max; SD) 13.5 (0.1–70.0; 15.6) 3.5 (0.1–30.0; 8.2) .002* Place the injury happened, n (%)  At home 24 (34.4%) 9 (60.0%) .049***  Open public areas 31 (44.3%) 5 (33.3%)  At the workplace 5 (7.1%) 0  School and kindergarten 2 (2.8%) 0  On the top of the train 3 (4.3%) 0  On the balcony 3 (4.3%) 0  On the roof of house 1 (1.4%) 0  In the shopping center 0 1 (6.7%)  On the truck dumper 1 (1.4%) 0 Additional trauma  None 54 (77.1%) 15 (100%) N/A  Falling from high 12 (17.1%) 0  Head trauma secondary to falling 2 (2.9%) 0  Bone fractures secondary to falling 2 (2.9%) 0 Grafting  None 32 (45.7%) 13 (86.7%) .004**  Made 38 (54.3%) 2 (13.3%) Amputation  None 58 (82.9%) 15 (100%) N/A  Made 12 (17.1%) 0 Fasciotomy/escharotomy  None 46 (65.7%) 14 (93.3%) .033**  Made 24 (34.3 %) 1 (6.7%) Flap  None 61 (87.1%) 15 (100%) N/A  Made 9 (12.9%) 0 Developed psychiatric disorders  Not consulted 42 (60.1%) 13 (86.6%) .036***  Normal 5 (7.1%) 1 (6.7%)  Posttraumatic stress disorder 11 (15.7%) 1 (6.7%)  Depression 4 (5.7%) 0  Anxiety 8 (11.4%) 0 VAC  None 54 (77.1%) 15 (100%) N/A  Made 16 (22.9%) 0 Hyperbaric oxygen therapy  None 62 (88.6%) 15 (100%) N/A  Made 8 (11.4%) 0 LOS, length of stay; PBC, pediatric burn centre; VAC, vacuum-assisted closure. N/A, not applicable. The chi-squared test could not be applied because one of the variables is 0. *Mann–Whitney U-test used. **Pearson chi-squared test used. ***Since some values were “0,” the chi-squared test was applied by combining groups. Open in new tab While only 33 of the EIs (38.8%) occurred inside the home, the other 52 (61.2%) occurred outside the home. These included streets, playgrounds, workplaces, schools, kindergartens, train stations, home balconies, rooftops, shopping malls, and on truck dampers. Since the electrical source was wires passing through outside, victims who were injured by high-voltage contact on the balcony of their home were considered outside the home. In three boys (4.3%), the EI occurred by extending metal bars from the balconies of their homes toward high-voltage transmission lines passing near the balcony (Table 1). In 16 of the victims (18.8%), additional trauma occurred due to falling from a height. Twelve (17.1%) of these had general body trauma, two (2.9%) had head injuries, and two (2.9%) had bone fractures. Grafting was performed in 40 patients (47.1%), escharotomy/fasciotomy in 25 (29.4%), amputation in 12 (14.1%), and flap surgery in 9 (10.6%). VAC therapy was performed in 16 patients (18.8%) and HBOT in 8 patients (9.4%), who were likely to require amputation (Table 1). Psychiatric disorders developed in 24 (28.2%) victims. Posttraumatic stress disorder (PTSD) was the most common psychiatric disorder (Table 1). One victim (1.2%) who was injured by high-voltage contact died. The EI occurred while he was traveling on the damper of a truck and passing under a high-voltage transmission line crossing the road. Along with the flame burns occurring on the skin, third-degree burns occurred in the trachea. He died due to rapidly developing acute respiratory distress syndrome. Comparison According to the Type of Voltage Forty-three (50.6%) victims were injured by high voltage and 42 (49.4%) by low voltage. The average age of the high-voltage group was significantly higher than that of the low-voltage group (11.8 and 7.9 years, respectively, P = .001). High-voltage EIs were more common in boys than in girls (38 vs 5, P = .012) (Table 1). In the low-voltage group, 32 of 42 patients were boys and 10 were girls. Although there were more boys in both groups, there was no statistically significant difference between the groups (P = .141) (Table 2). Table 2. Statistical comparison of data according to the magnitude of the electrical voltage (low voltage <1000 V, high voltage >1000 V) Variables . Low voltage (n = 42) . High voltage (n = 43) . P . Age, mean year (min–max; SD) 7.9 (0.8–17.3; 5.3) 11.8 (3.9–17.8; 3.5) .001* Gender, n (%)  Male (n = 70) 32 (76.2%) 38 (88.4%) .141**  Female (n = 15) 10 (23.8%) 5 (11.6%) Length of stay in PBC* (day), mean (min–max; SD) 5.3 (1–52; 9.8) 30.7 (1–92; 22.9) <.001* TBSA, mean % (min–max; SD) 3.2 (0.0–40; 7.1) 20.1 (1.0–70.0; 16.1) <.001*** Place the injury happened, n (%)  At home 32 (76.2 %) 0 <.001***  Open public areas, parks, streets, etc. 5 (11.9 %) 32 (74.4%)  At the workplace 2 (4.8 %) 3 (7.0%)  School and kindergarten 2(4.8 % 0  At the train station, on the top of the train 0 3 (7.0%)  On the balcony 0 3 (7.0%)  On the roof 0 1 (2.3%)  In the shopping center 1 (2.0%) 0  On the truck dumper 0 1 (2.3%) Additional trauma  None 42 (100%) 27 (62.8 %) N/A  Falling from high 0 12 (27.98%)  Head trauma secondary to falling 0 2 (4.7%)  Bone fractures secondary to falling 0 2 (4.7%) Grafting  None 34 (81.0%) 11 (24.6%) <.001**  Made 8 (19.0%) 32 (74.4%) Amputation  None 42 (100%) 31 (72.1%) N/A  Made 0 12 (27.9%) Fasciotomy/escharotomy  None 47 (95.9%) 13 (36.1%) <.001**  Made 2 (4.1%) 23 (63.9%) Flap  None 42 (100%) 34 (79.1 %) N/A  Made 0 9 (20.9 %) Developed psychiatric disorders  Not consulted 40 (95.2%) 15 (34.9%) <.001***  Normal 1 (2.4%) 5 (11.6%)  Posttraumatic stress disorder 0 12 (27.9%)  Depression 0 4 (9.3%)  Anxiety 1 (2.4%) 7 (16.3%) VAC  None 41 (97.6%) 28 (65.1%) <.001**  Made 1 (2.4%) 15 (34.9%) Hyperbaric oxygen therapy  None 42 (100%) 35 (81.4%) N/A  Made 0 8 (18.6%) Variables . Low voltage (n = 42) . High voltage (n = 43) . P . Age, mean year (min–max; SD) 7.9 (0.8–17.3; 5.3) 11.8 (3.9–17.8; 3.5) .001* Gender, n (%)  Male (n = 70) 32 (76.2%) 38 (88.4%) .141**  Female (n = 15) 10 (23.8%) 5 (11.6%) Length of stay in PBC* (day), mean (min–max; SD) 5.3 (1–52; 9.8) 30.7 (1–92; 22.9) <.001* TBSA, mean % (min–max; SD) 3.2 (0.0–40; 7.1) 20.1 (1.0–70.0; 16.1) <.001*** Place the injury happened, n (%)  At home 32 (76.2 %) 0 <.001***  Open public areas, parks, streets, etc. 5 (11.9 %) 32 (74.4%)  At the workplace 2 (4.8 %) 3 (7.0%)  School and kindergarten 2(4.8 % 0  At the train station, on the top of the train 0 3 (7.0%)  On the balcony 0 3 (7.0%)  On the roof 0 1 (2.3%)  In the shopping center 1 (2.0%) 0  On the truck dumper 0 1 (2.3%) Additional trauma  None 42 (100%) 27 (62.8 %) N/A  Falling from high 0 12 (27.98%)  Head trauma secondary to falling 0 2 (4.7%)  Bone fractures secondary to falling 0 2 (4.7%) Grafting  None 34 (81.0%) 11 (24.6%) <.001**  Made 8 (19.0%) 32 (74.4%) Amputation  None 42 (100%) 31 (72.1%) N/A  Made 0 12 (27.9%) Fasciotomy/escharotomy  None 47 (95.9%) 13 (36.1%) <.001**  Made 2 (4.1%) 23 (63.9%) Flap  None 42 (100%) 34 (79.1 %) N/A  Made 0 9 (20.9 %) Developed psychiatric disorders  Not consulted 40 (95.2%) 15 (34.9%) <.001***  Normal 1 (2.4%) 5 (11.6%)  Posttraumatic stress disorder 0 12 (27.9%)  Depression 0 4 (9.3%)  Anxiety 1 (2.4%) 7 (16.3%) VAC  None 41 (97.6%) 28 (65.1%) <.001**  Made 1 (2.4%) 15 (34.9%) Hyperbaric oxygen therapy  None 42 (100%) 35 (81.4%) N/A  Made 0 8 (18.6%) PBC, pediatric burn centre; VAC, vacuum-assisted closure. N/A, not applicable. The chi-squared test could not be applied because one variable is 0. *Mann–Whitney test used. **Pearson chi-squared test used. ***Since some values were “0,” the chi-squared test was applied by combining groups. Open in new tab Table 2. Statistical comparison of data according to the magnitude of the electrical voltage (low voltage <1000 V, high voltage >1000 V) Variables . Low voltage (n = 42) . High voltage (n = 43) . P . Age, mean year (min–max; SD) 7.9 (0.8–17.3; 5.3) 11.8 (3.9–17.8; 3.5) .001* Gender, n (%)  Male (n = 70) 32 (76.2%) 38 (88.4%) .141**  Female (n = 15) 10 (23.8%) 5 (11.6%) Length of stay in PBC* (day), mean (min–max; SD) 5.3 (1–52; 9.8) 30.7 (1–92; 22.9) <.001* TBSA, mean % (min–max; SD) 3.2 (0.0–40; 7.1) 20.1 (1.0–70.0; 16.1) <.001*** Place the injury happened, n (%)  At home 32 (76.2 %) 0 <.001***  Open public areas, parks, streets, etc. 5 (11.9 %) 32 (74.4%)  At the workplace 2 (4.8 %) 3 (7.0%)  School and kindergarten 2(4.8 % 0  At the train station, on the top of the train 0 3 (7.0%)  On the balcony 0 3 (7.0%)  On the roof 0 1 (2.3%)  In the shopping center 1 (2.0%) 0  On the truck dumper 0 1 (2.3%) Additional trauma  None 42 (100%) 27 (62.8 %) N/A  Falling from high 0 12 (27.98%)  Head trauma secondary to falling 0 2 (4.7%)  Bone fractures secondary to falling 0 2 (4.7%) Grafting  None 34 (81.0%) 11 (24.6%) <.001**  Made 8 (19.0%) 32 (74.4%) Amputation  None 42 (100%) 31 (72.1%) N/A  Made 0 12 (27.9%) Fasciotomy/escharotomy  None 47 (95.9%) 13 (36.1%) <.001**  Made 2 (4.1%) 23 (63.9%) Flap  None 42 (100%) 34 (79.1 %) N/A  Made 0 9 (20.9 %) Developed psychiatric disorders  Not consulted 40 (95.2%) 15 (34.9%) <.001***  Normal 1 (2.4%) 5 (11.6%)  Posttraumatic stress disorder 0 12 (27.9%)  Depression 0 4 (9.3%)  Anxiety 1 (2.4%) 7 (16.3%) VAC  None 41 (97.6%) 28 (65.1%) <.001**  Made 1 (2.4%) 15 (34.9%) Hyperbaric oxygen therapy  None 42 (100%) 35 (81.4%) N/A  Made 0 8 (18.6%) Variables . Low voltage (n = 42) . High voltage (n = 43) . P . Age, mean year (min–max; SD) 7.9 (0.8–17.3; 5.3) 11.8 (3.9–17.8; 3.5) .001* Gender, n (%)  Male (n = 70) 32 (76.2%) 38 (88.4%) .141**  Female (n = 15) 10 (23.8%) 5 (11.6%) Length of stay in PBC* (day), mean (min–max; SD) 5.3 (1–52; 9.8) 30.7 (1–92; 22.9) <.001* TBSA, mean % (min–max; SD) 3.2 (0.0–40; 7.1) 20.1 (1.0–70.0; 16.1) <.001*** Place the injury happened, n (%)  At home 32 (76.2 %) 0 <.001***  Open public areas, parks, streets, etc. 5 (11.9 %) 32 (74.4%)  At the workplace 2 (4.8 %) 3 (7.0%)  School and kindergarten 2(4.8 % 0  At the train station, on the top of the train 0 3 (7.0%)  On the balcony 0 3 (7.0%)  On the roof 0 1 (2.3%)  In the shopping center 1 (2.0%) 0  On the truck dumper 0 1 (2.3%) Additional trauma  None 42 (100%) 27 (62.8 %) N/A  Falling from high 0 12 (27.98%)  Head trauma secondary to falling 0 2 (4.7%)  Bone fractures secondary to falling 0 2 (4.7%) Grafting  None 34 (81.0%) 11 (24.6%) <.001**  Made 8 (19.0%) 32 (74.4%) Amputation  None 42 (100%) 31 (72.1%) N/A  Made 0 12 (27.9%) Fasciotomy/escharotomy  None 47 (95.9%) 13 (36.1%) <.001**  Made 2 (4.1%) 23 (63.9%) Flap  None 42 (100%) 34 (79.1 %) N/A  Made 0 9 (20.9 %) Developed psychiatric disorders  Not consulted 40 (95.2%) 15 (34.9%) <.001***  Normal 1 (2.4%) 5 (11.6%)  Posttraumatic stress disorder 0 12 (27.9%)  Depression 0 4 (9.3%)  Anxiety 1 (2.4%) 7 (16.3%) VAC  None 41 (97.6%) 28 (65.1%) <.001**  Made 1 (2.4%) 15 (34.9%) Hyperbaric oxygen therapy  None 42 (100%) 35 (81.4%) N/A  Made 0 8 (18.6%) PBC, pediatric burn centre; VAC, vacuum-assisted closure. N/A, not applicable. The chi-squared test could not be applied because one variable is 0. *Mann–Whitney test used. **Pearson chi-squared test used. ***Since some values were “0,” the chi-squared test was applied by combining groups. Open in new tab Length of stay in the PBC was much higher in the high-voltage group than in the low-voltage group (30.7 vs 5.3 days, respectively, P < .001). Similarly, the TBSA of the high-voltage group was much greater (20.1% and 3.2%, respectively, P < .001). While all the high-voltage EIs occurred outside, most of the low-voltage injuries (32/42; 76.2%) occurred at home. While no additional trauma was observed in the low-voltage group, it was observed in 44.4% of the victims in the high-voltage group. The rates of grafting (74.4% vs 19.0%), amputation (27.9% vs 0.0%), and escharotomy/fasciotomy (63.9% vs 4.1%) were much higher in the high-voltage group. Thus, it can be seen that the amputation rate was substantial in the high-voltage group, while there were no amputations in the low-voltage group. Psychiatric consultation was requested for a total of 30 victims (35.3%): 28 from the high-voltage group and 2 from the low-voltage group. While a psychiatric disorder developed in only 1 (2.4%) victim in the low-voltage group, 23 (53.5%) victims in the high-voltage group developed psychiatric disorders. Out of these 23 victims, PTSD occurred in 12, anxiety disorder in 7, and depression in 4. The rate of developing psychiatric disorders in the high-voltage group was much higher (P < .001). Also, VAC and HBOT application rates were higher in the high-voltage group (Table 2). Contact Points Some authors suggest using the term “contact points” for both entry and exit points.1,2,8 However, to distinguish both of them, we termed the part of the body where contacts the electricity source as “the entry contact point” and where contacts the ground and the current exits the body as “the exit contact point.” Contact entry points were detected in 79 victims (n = 85, 92.9%); 38 (n = 42, 90.5%) from the low-voltage group and 41 (n = 43, 95.3%) from the high-voltage group. In the low-voltage group, all of the victims’ contact entry points except one were in their upper extremity. In the high-voltage group, the contact entry points of 31 (72.1%) victims were in the upper extremities, and the contact entry points of 4 (9.3%) victims were on their heads. One of these four victims’ contact entry point was on the lateral edge of the right eye (Figure 1A). This patient developed bilateral cataracts and secondary vision loss. The most common entry point in both groups was the right hand. Figure 1. Open in new tabDownload slide (A) Male patient with an entry hole in the lateral right eye as a result of direct contact with a high-voltage source. Cataracts developed in this patient’s eye. (B) Developing necrosis of the right forearm as a result of high-voltage electrical injury. (C). The appearance of the same patient’s amputated forearm and hand. (D) The appearance of the amputation stump. Figure 1. Open in new tabDownload slide (A) Male patient with an entry hole in the lateral right eye as a result of direct contact with a high-voltage source. Cataracts developed in this patient’s eye. (B) Developing necrosis of the right forearm as a result of high-voltage electrical injury. (C). The appearance of the same patient’s amputated forearm and hand. (D) The appearance of the amputation stump. In 37 victims (43.5%), including 30 (71.4%) in the low-voltage group and 7 (16.3%) in the high-voltage group, no contact exit point was detected. The most common contact exit point in both groups was the lower extremities and feet. There was no difference between the groups in terms of contact entry points (P = .055). On the other hand, there was a difference in terms of contact exit points (P < .001). Amputations A total of 23 amputation procedures were performed on 12 patients in the high-voltage group. Of these, eight patients underwent major amputations, and four only had toe amputations. Right arm/forearm amputations were performed in six of eight patients who underwent major amputations. Of these six, four patients underwent amputations below the right elbow (Figure 1B–D), and the right arm was amputated above the elbow in two patients. In addition, both the left and right forearms were amputated below the elbow in one patient, and the left leg was amputated above the knee in one patient. Therefore, the most amputated limb was found to be the right arm and forearm (n = 7). Together with the patient whose left forearm was amputated entirely, eight upper limb amputations were performed in seven patients. All amputations are shown in detail in Table 3. Table 3. The list of amputated extremities and organs of victims and number of amputations and comparison of psychiatric evaluation in patients with and without amputation Amputated extremities/organs . Mechanism of injury . Number of patients (%) . Number of amputations (%) . Left foot thumb High voltage 4 (33.3) 4 (17.5) Right arm upper the elbow High voltage 2 (16.7) 2 (8.7) Right forearm under the elbow High voltage 2 (16.7) 2 (8.7) Both forearms under elbow High voltage 1 (8.3) 2 (8.7) Right foot thumb High voltage 1 (8.3) 1 (4.3) Left leg above the knee High voltage 1 (8.3) 1 (4.3) Right forearm under the elbow and bilateral all toes High voltage 1 (8.3) 11 (47.8) Total 12 23 Amputated extremities/organs . Mechanism of injury . Number of patients (%) . Number of amputations (%) . Left foot thumb High voltage 4 (33.3) 4 (17.5) Right arm upper the elbow High voltage 2 (16.7) 2 (8.7) Right forearm under the elbow High voltage 2 (16.7) 2 (8.7) Both forearms under elbow High voltage 1 (8.3) 2 (8.7) Right foot thumb High voltage 1 (8.3) 1 (4.3) Left leg above the knee High voltage 1 (8.3) 1 (4.3) Right forearm under the elbow and bilateral all toes High voltage 1 (8.3) 11 (47.8) Total 12 23 Open in new tab Table 3. The list of amputated extremities and organs of victims and number of amputations and comparison of psychiatric evaluation in patients with and without amputation Amputated extremities/organs . Mechanism of injury . Number of patients (%) . Number of amputations (%) . Left foot thumb High voltage 4 (33.3) 4 (17.5) Right arm upper the elbow High voltage 2 (16.7) 2 (8.7) Right forearm under the elbow High voltage 2 (16.7) 2 (8.7) Both forearms under elbow High voltage 1 (8.3) 2 (8.7) Right foot thumb High voltage 1 (8.3) 1 (4.3) Left leg above the knee High voltage 1 (8.3) 1 (4.3) Right forearm under the elbow and bilateral all toes High voltage 1 (8.3) 11 (47.8) Total 12 23 Amputated extremities/organs . Mechanism of injury . Number of patients (%) . Number of amputations (%) . Left foot thumb High voltage 4 (33.3) 4 (17.5) Right arm upper the elbow High voltage 2 (16.7) 2 (8.7) Right forearm under the elbow High voltage 2 (16.7) 2 (8.7) Both forearms under elbow High voltage 1 (8.3) 2 (8.7) Right foot thumb High voltage 1 (8.3) 1 (4.3) Left leg above the knee High voltage 1 (8.3) 1 (4.3) Right forearm under the elbow and bilateral all toes High voltage 1 (8.3) 11 (47.8) Total 12 23 Open in new tab Four of the 12 patients who underwent amputation were brought to our hospital on the same day they were injured in the rural areas in the vicinity of our center. Three of these patients underwent escharotomy/fasciotomy in our center on the same day. Of these, the right forearm was amputated below the elbow in only one patient. On the other hand, eight patients were referred to our center from outside the province. Two of these patients were underwent fasciotomies successfully in the hospital where they were referred. However, although it was necessary it was found that three patients had not undergone emergency fasciotomies, and fasciotomies were made insufficiently in the other three patients. These fasciotomies were performed or revised in our PBC as delayed on the second day of the burn. According to this, only one (25.0%) of the four patients who were referred to our center at close range and underwent fasciotomy in a timely manner underwent major amputation, while five of the eight (62.5%) who were referred from outside the province and had not undergone their fasciotomies on time required major amputations. Mechanism of Injury The most common cause of low-voltage EI was direct contact with an electrical wire at home (20/42, 47.6%), and the second most common cause was insertion of a metal object into an electrical wall socket (10/42, 23.8%). The most common causes of high-voltage EIs were extension of a metal bar toward transmission line wires (15/43, 34.9%) and climbing up transmission line poles (10/43, 23.2%). The mechanisms of injury are shown in detail in Table 4. Table 4. The mechanisms of the injuries . n (%) . High-voltage group (n = 43)  By the extension of metal bars towards the transmission line wires 15 (34.9)  Climbing up an electric pole 10 (23.2)  Contact with a transformer 7 (16.3)  On the top of a train wagon 3 (7.0)  Playing under the high voltage line 7 (16.3)  Passing under high voltage line on the truck dumper 1 (2.3) Low-voltage group (n = 42)  Contact with wall socket via inserting a metal object 10 (23.7)  An electrical leakage from electrical devices at home 7 (16.7)  An electrical leakage from electrical devices at work 1 (2.4)  Electrical leakage from game machines in the playground 2 (4.8)  Direct contact to the electric wire at home 20 (47.6)  Biting the electric wire 1 (2.4)  Electric leakage from the escalator at the shopping center 1 (2.4) . n (%) . High-voltage group (n = 43)  By the extension of metal bars towards the transmission line wires 15 (34.9)  Climbing up an electric pole 10 (23.2)  Contact with a transformer 7 (16.3)  On the top of a train wagon 3 (7.0)  Playing under the high voltage line 7 (16.3)  Passing under high voltage line on the truck dumper 1 (2.3) Low-voltage group (n = 42)  Contact with wall socket via inserting a metal object 10 (23.7)  An electrical leakage from electrical devices at home 7 (16.7)  An electrical leakage from electrical devices at work 1 (2.4)  Electrical leakage from game machines in the playground 2 (4.8)  Direct contact to the electric wire at home 20 (47.6)  Biting the electric wire 1 (2.4)  Electric leakage from the escalator at the shopping center 1 (2.4) Open in new tab Table 4. The mechanisms of the injuries . n (%) . High-voltage group (n = 43)  By the extension of metal bars towards the transmission line wires 15 (34.9)  Climbing up an electric pole 10 (23.2)  Contact with a transformer 7 (16.3)  On the top of a train wagon 3 (7.0)  Playing under the high voltage line 7 (16.3)  Passing under high voltage line on the truck dumper 1 (2.3) Low-voltage group (n = 42)  Contact with wall socket via inserting a metal object 10 (23.7)  An electrical leakage from electrical devices at home 7 (16.7)  An electrical leakage from electrical devices at work 1 (2.4)  Electrical leakage from game machines in the playground 2 (4.8)  Direct contact to the electric wire at home 20 (47.6)  Biting the electric wire 1 (2.4)  Electric leakage from the escalator at the shopping center 1 (2.4) . n (%) . High-voltage group (n = 43)  By the extension of metal bars towards the transmission line wires 15 (34.9)  Climbing up an electric pole 10 (23.2)  Contact with a transformer 7 (16.3)  On the top of a train wagon 3 (7.0)  Playing under the high voltage line 7 (16.3)  Passing under high voltage line on the truck dumper 1 (2.3) Low-voltage group (n = 42)  Contact with wall socket via inserting a metal object 10 (23.7)  An electrical leakage from electrical devices at home 7 (16.7)  An electrical leakage from electrical devices at work 1 (2.4)  Electrical leakage from game machines in the playground 2 (4.8)  Direct contact to the electric wire at home 20 (47.6)  Biting the electric wire 1 (2.4)  Electric leakage from the escalator at the shopping center 1 (2.4) Open in new tab DISCUSSION EIs can present as a wide range of injuries, from minor skin rashes at the entry and exit points to life-threatening injuries.9 These injuries constitute 2% to 10% of the patients who are admitted to PBCs.10 In our study, it was found to be 5.7%. As in other injuries, EIs are more common in boys. In our study, the male:female ratio was found to be 4.66. Unlike adults, the literature reports that low-voltage injuries occur more frequently than high-voltage injuries in children.11,12However, it has been reported that the frequency of high-voltage injuries in children has been increasing in developing countries, while it has been decreasing in developed countries over the years. Depamphilis et al reported the high-voltage EI rate as 19% in children in the United States, while Srivastava et al reported that 80% of the EIs in children in India occurred with high-voltage.10,13 A study conducted in Turkey reported that 63% of EIs in children happened with high voltage.14 In our study, 50.6% of the cases occurred with high-voltage electricity. Our PBC is a nationwide tertiary burn center that is the end point for childhood burn cases among 55 burn units and centers in Turkey, and we admit the most severe cases. Most mild EIs that occur with low-voltage are usually treated in burn units in the periphery. Major burns must be referred to a burn center according to Turkey’s national burn algorithm.15 For this reason, we predict that most EIs in children in Turkey are caused by low-voltage electricity. It has been reported in the literature that high-voltage EIs are more common in children older than 12 years of age.4 In our study, 26 (n = 43, 60.5%) of the victims injured with high voltage were older than 12 years old; these results are similar to the literature. EIs are mostly seen as work accidents in adults, while they mostly occur as household accidents in young children. In adolescents, EIs mostly occur outside by climbing on electricity poles, contacting or climbing transformers, touching the wires of electric transmission lines and transformers with metal rods, and climbing on trains. EIs that occur due to reasons such as climbing electricity poles and climbing on trains are accompanied by falling from heights and additional trauma.16 As stated by Celik et al., EIs occurring on the balcony are characteristic of our country.14 Especially on hot summer days, family members spend most of their time on the balcony. In recent years, electricity transfer lines have been brought underground in large cities, but in rural settlements and villages, transmission lines are still overhead and passing through houses and close to balconies (Figure 2A). High-voltage EIs occur by extending metal bars toward the electrical transmission wires from balconies and from the terrace or roof of the houses close to these wires. Figure 2. Open in new tabDownload slide (A) Especially in rural areas and in some cities, electricity transmission line wires pass over streets and very close to balconies. (B) Electricity transmission line wires that cross transversal to roads are common in rural areas and on village roads. (C) Transformer with a step-shaped pole suitable for climbing located in an outdoor open area in a village. Children come into contact with electricity either by opening the lid of the box close to the ground or by climbing up the pole like climbing a ladder. (D) In most large cities, electrical transformers within the city are secured in safe buildings. One of these transformers is seen in the photo. (E) View of train catenary systems. High-voltage electrical injuries take place as a result of direct contact or as arc burns, due to children standing on train wagons. (F) The view of very high-voltage transmission lines inside residential areas as a result of irregular and rapid urban expansion. High-voltage electrical injuries occur as a result of children playing under these wires, climbing their poles, or extending a metal stick onto the transmission line. Figure 2. Open in new tabDownload slide (A) Especially in rural areas and in some cities, electricity transmission line wires pass over streets and very close to balconies. (B) Electricity transmission line wires that cross transversal to roads are common in rural areas and on village roads. (C) Transformer with a step-shaped pole suitable for climbing located in an outdoor open area in a village. Children come into contact with electricity either by opening the lid of the box close to the ground or by climbing up the pole like climbing a ladder. (D) In most large cities, electrical transformers within the city are secured in safe buildings. One of these transformers is seen in the photo. (E) View of train catenary systems. High-voltage electrical injuries take place as a result of direct contact or as arc burns, due to children standing on train wagons. (F) The view of very high-voltage transmission lines inside residential areas as a result of irregular and rapid urban expansion. High-voltage electrical injuries occur as a result of children playing under these wires, climbing their poles, or extending a metal stick onto the transmission line. Overhead high-voltage transmission lines are passed diagonally above roads in most places. In addition, especially in rural areas, the wires of electrical transmission lines pass roadsides and sometimes cross the road (Figure 2B). There is a risk of EI when tall vehicles pass under these wires. Such injuries can be prevented by passing the wires of electricity transmission lines underground where they intersect with roads. Transformers are used for purposes such as raising and lowering current and voltage in an electrical circuit, transmission of electrical energy, and distribution of electrical energy. Although transformers are located inside special buildings along the street in most of the metropolitan cities in Turkey, they are still found outside in the streets and open spaces in rural areas (Figure 2C and D). In our study, 15 victims were injured as a result of extending a metal bar onto overhead transmission wires. Of these 15 victims, 11 had extended the metal bars from the street toward the wires, 3 from the balconies of their houses, and 1 from the roof of his house. Ten victims were injured as a result of climbing on electricity poles on the streets, and seven were injured by a metal rod or hand coming in contact with transformers on the streets. Thus, a total of 32 victims were injured as a result of extending metal bars toward electrical wires, climbing electricity poles, and contacting transformers on the streets. It may be possible to prevent these injuries by relocating overhead transmission wires below ground and housing electrical transformers in special reinforced buildings. Recently, it has become common to take selfies in dangerous places, especially among adolescents, such as on train wagons at stations. Such cases, some of which have resulted in death, have been reported worldwide.11,17 Today, the electrical energy of both commuter trains and high-speed trains is provided by power lines called catenary systems (Figure 1E). There is high-voltage electric current (>1000 V) in the new generation of high-speed train catenary systems. In Turkey and most countries, 25 kV 50 Hz AC is used in high-speed train catenary systems. Three patients were injured by climbing onto train wagons that were at rest at the station. Two of them climbed onto the wagons to take selfies. It is critical to eliminate these accidents through precautions that the government could take (such as increasing security precautions at train stations) and to provide education and raise awareness among families on television, social media, and in schools. Another serious problem is that the high-voltage transmission lines previously located outside the city were left between the houses as a result of unplanned urban expansion (Figure 2F). Eight of our patients were injured by climbing on the poles of these lines, extending metal bars toward wires, or just playing under them. These lines should be relocated out of the city according to new city plans. Especially in high-voltage EIs, permanent tissue damage that usually requires surgical intervention, such as escharotomy or fasciotomy, occurs in the forearm and hands.18 High-voltage EIs often result in limb amputations.19,20 According to Joule’s law, the amount of heat (Joule) created by a current passing through tissue is directly proportional to the tissue resistance and duration of the current. The electric current generates heat as it passes through the tissues throughout the body. Since the tissue that is most resistant to electric current is bone tissue, the highest heat in EIs occurs in bones. Therefore, necrosis occurs in muscle tissues adjacent to bones.2,19 Since the damage caused by electric current in one organ or part of the body is inversely proportional to the cross-sectional area, more damage occurs in relatively narrow areas, such as the wrists and ankles.21 Compartment syndrome may develop in the extremities secondary to the injury, and if the intervention is not performed on time, amputations of the extremities may be required. Therefore, if necessary, early escharotomy/fasciotomy for decompression should be performed.19 In order to evaluate the circulation of the limbs, Doppler ultrasound is recommended together with palpation of the peripheral pulses and neurological examination.22 Nonetheless, despite these measures, more amputations are performed for EIs than for other burn types. In the literature, the most frequently amputated limbs have been reported to be the upper extremities. Our results for major amputations are similar to the literature, as the upper limbs were the most often amputated (Table 3). Not performing or insufficient escharotomy/fasciotomy for decompression increases the amputation rate.23 While the rate of major amputation was 25.0% in victims who were transferred to our center from nearby soon after injury, it was found to be as high as 62.5% in patients who were transferred late from distant areas and had not undergone fasciotomy or had undergone insufficient fasciotomy. In order to prevent this, it is important to train doctors who make the first intervention with EI victims, and early intervention by surgeons where the injury occurred should be performed. As with other causes of severe burns, psychiatric disorders frequently develop in EI victims.24 After EIs in adults, 57.5% to 78.5% of victims have been reported to develop psychiatric disorders (such as substance abuse, anxiety disorders, PTSD, and depression). The most commonly diagnosed psychiatric disorders in these patients are depression and PTSD.25–27 In the English literature, we could not find a detailed study of psychiatric disorders that develop after EIs in children. A total of 24 victims (24/85, 28.2%) were diagnosed with psychiatric disorders, including one from the low-voltage group and 23 from the high-voltage group. Medical treatment was started for these patients. Pliskin et al suggested that the frequency of depression and other psychiatric disorders increases after 3 months in adult patients exposed to EIs.28 Therefore, we predict that the rate of developing a psychiatric disorder will increase in the long-term psychiatric follow-up of these victims. The incidence of psychiatric disorders is much higher in amputated victims. Psychiatric disorders were observed in 10 of 12 (83.3%) patients who underwent amputation. Therefore, it is important to continue long-term follow-up of all victims by a psychiatrist, especially those who are likely to undergo amputation or have been amputated. Limitations There are some limitations to this study. One potential limitation is being a retrospective study. Another potential limitation is that it is based on data from a single center. Since our PBC is a tertiary center, much more severe patients are referred to us, so the actual low-voltage and high-voltage ratios are not fully known. In addition, in severe EIs, victims are often deceased at the scene, in peripheral hospitals, or during transfer before being admitted to specific burn centers. In our study, the mortality rate was found to be low because only patients who died in our center were considered. To reveal the true death rates, studies involving peripheral hospitals and ambulance services nationwide should be conducted. CONCLUSIONS EIs in children often occur as a result of preventable accidents, therefore in order to prevent these injuries, besides education, it is critical for governments in public areas and families at home to take precautions, for instance the rates of high-voltage EIs in children have been decreased by education and precautionary measures in developed countries, such as the United States and Austria.13,29 Some of the precautions the government could take include the following: relocating city electrical transmission lines underground, not placing electricity poles close to house balconies, passing electrical transmission lines so as not to cross roads, moving high-voltage lines that pass through cities to outside the city, securing transformers located on roadsides and outdoors in rural areas in closed buildings, and increasing security measures at train stations to prevent access by adolescents. Low-voltage EIs occurring inside and outside the home can also be prevented by simple measures, such as eliminating wires at home, using safety cover sockets, and keeping electrical devices away from children. Ensuring the performance of emergency interventions such as escharotomy/fasciotomy in the early period of injury in patients who need decompression in centers where trauma occurs may also contribute to lowering high amputation rates. Finally, it is also very important to follow up on victims of pediatric EIs in terms of developing psychiatric disorders, especially those who undergo amputations. Conflict of interest statement. None declared. Funding: No funding was received for this study. REFERENCES 1. Arnoldo BD , Purdue GF. The diagnosis and management of electrical injuries . Hand Clin 2009 ; 25 : 469 – 79 . Google Scholar Crossref Search ADS PubMed WorldCat 2. Bernal E, Arnoldo BD . Electrical injuries. In: Herndon DNMDF, editor. Total burn care 2018 . p. 396 – 402.e2 . 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TI - Electrical Injuries in Children: A 10-Year Experience at a Tertiary Pediatric Burn Center
JF - Journal of Burn Care & Research
DO - 10.1093/jbcr/irab012
DA - 2021-01-23
UR - https://www.deepdyve.com/lp/oxford-university-press/electrical-injuries-in-children-a-10-year-experience-at-a-tertiary-by7dGfOrad
SP - 1
EP - 1
VL - Advance Article
IS - 
DP - DeepDyve
ER -