Background: Electrical injuries represent life-threatening emergencies. Evidence on differences between high (HVI) and low voltage injuries (LVI) regarding characteristics at presentation, rhabdomyolysis markers, surgical and intensive burn care and outcomes is scarce. Methods: Consecutive patients admitted to two burn centers for electrical injuries over an 18-year period (1998– 2015) were evaluated. Analysis included comparisons of HVI vs. LVI regarding demographic data, diagnostic and treatment specific variables, particularly serum creatinine kinase (CK) and myoglobin levels over the course of 4 post injury days (PID), and outcomes. Results: Of 4075 patients, 162 patients (3.9%) with electrical injury were analyzed. A total of 82 patients (50.6%) were observed with HVI. These patients were younger, had considerably higher morbidity and mortality, and required more extensive burn surgery and more complex burn intensive care than patients with LVI. Admission CK and myoglobin levels correlated significantly with HVI, burn size, ventilator days, surgical interventions, amputation, flap surgery, renal replacement therapy, sepsis, and mortality. The highest serum levels were observed at PID 1 (myoglobin) and PID 2 (CK). In 23 patients (14.2%), cardiac arrhythmias were observed; only 4 of these arrhythmias occurred after hospital admission. The independent predictors of mortality were ventilator days (OR 1.27, 95% CI 1.06–1.51, p = 0.009), number of surgical interventions (OR 0.47, 95% CI 0.27–0.834, p =0.010) and limb amputations (OR 14.26, 95% CI 1.26–162.1, p = 0.032). Conclusions: Patients with electrical injuries, HVI in particular, are at high risk for severe complications. Due to the need for highly specialized surgery and intensive care, treatment should be reserved to burn units. Serum myoglobin and CK levels reflect the severity of injury and may predict a more complex clinical course. Routine cardiac monitoring > 24 h post injury does not seem to be necessary. Keywords: Electrical injury, Burns, High voltage, Creatinine kinase, Myoglobin, Amputation Background clinical data, and LVI may cause similar damage to the Electrical injuries are rare but potentially life-threatening human body as HVI, depending on individual current emergencies. Voltage exposure is defined by industrial pathways, amperage and the duration of current expos- norms as either above or below 1000 V (high voltage in- ure. Usually, HVI causes high temperatures in tissues of juries (HVI) or low voltage injuries (LVI), respectively) greater electrical resistance, leading to extensive deep . The cutoff value of 1000 V is not supported by tissue injuries and microvascular coagulation, whereas LVI causes less invasive tissue lesions but is more likely * Correspondence: firstname.lastname@example.org to induce malignant cardiac arrhythmia and higher rates Department of Plastic and Hand Surgery, Burn Center, Bergmannstrost of neurologic long-term sequelae [1–8]. HVI and LVI Hospital, Merseburger Str. 165, 06112 Halle, Germany may both account for complex neurovascular lesions. Department of Anesthesiology and Intensive Care Medicine, University Hospital Leipzig, Liebigstr. 20, 04103 Leipzig, Germany Clinical symptoms may be considerably delayed and Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Gille et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2018) 26:43 Page 2 of 9 often require repetitive surgery. Additionally, extensive manifest AKI using continuous veno-venous hemodiafiltra- muscular necrosis and rhabdomyolysis may lead to acute tion (CVVHDF) or continuous veno-venous hemodialysis kidney injury (AKI), coagulation disorders, compartment (CVVHD). Additional vasopressors were used in order to syndrome and amputation [1–3]. The goal of this study maintain mean arterial blood pressures > 70 mmHg to was to explore differences in prehospital care, admission provide tissue oxygenation and avoid extensive fluid characteristics, burn intensive care, surgery and out- creep. Necrosectomy and split thickness skin grafting comes in patients requiring admission to a burn inten- were performed within 72 h after admission, depend- sive care unit (BICU) after HVI and LVI. ing on the patient’s individual condition. Limb ampu- tation and microvascular tissue transplantation were Methods performed in extensive muscle necrosis according to After approval of the local ethics committees, the databases the treatment protocols of the burn centers. of two neighboring burn centers in Central Germany were reviewed in order to identify patients who were admitted Statistics to the BICU for the treatment of electrical injuries between Data are presented as the mean ± standard deviation and 01/1998 and 12/2015. Electrical injuries were defined as counts (percentage). Statistical comparisons between sur- direct electrical injuries, electric arc burns and concomitant vivors and non-survivors were performed using the χ2test burns due to HVI or LVI. Both centers were comparable for qualitative data and Student’s t test or Mann-Whitney regarding infrastructure, staff and adherence to national U-test for quantitative data. The alpha level of significance recommendations. The catchment areas of both centers (p) was set at 0.05. All tests were two-tailed. Univariate are coordinated by the regional emergency dispatching ser- analysis was performed to identify possible predictors of vices and by the national burn depository of the fire dis- mortality. Variables tested included demographic data, patching center of the City of Hamburg. The distance of burned total body surface area (TBSA), emergency airway the two burn centers is 40 km and together, they have a management, cardiac arrhythmia electrocardiography and catchment area of 3 federal states involving approximately time, admission temperature, serum myoglobin, creatine 8.5 million inhabitants. The burn center in Leipzig provides kinase (CK) and troponin levels over the course of four six BICU beds and six intermediate care beds whereas the PID, intensive care, surgical procedures and outcomes. burn center in Halle provides eight BICU beds. Logistic regression analysis was performed to identify in- dependent predictors of mortality. Data were obtained General management from paper-based and electronic charts. Patients were admitted to the burn resuscitation room from the trauma scene or were secondarily transferred Results from other hospitals. The indications for BICU admission During the study period, 4075 patients were admitted to comprised surgical burn wound management, potential the two BICUs; 162 (3.9%) of these patients met the risk for rhabdomyolysis and cardiac arrhythmia. Emer- inclusion criteria and thus were subject of the study gency measures included tracheal intubation in case of (Fig. 1). Of the 162 patients, 11 patients (6.8%) were progressive airway edema or respiratory insufficiency, aged below 18 years (range 12–17 years). HVI was central venous and arterial access, urinary catheterization, present in 82 patients (50.6%) (Tables 1, 2 and 3). Most electrocardiography and cardiac monitoring. If HVI com- patients were male (94.4%), and the mean age was 37.7 promised limb circulation, pulse oximetry was routinely ± 15.5 years (Table 1). Emergency tracheal intubation applied to detect peripheral perfusion deficits. In cases of was required in 74 patients (45.6%) (Table 2). The need progressive edema and compartment syndrome, decom- for tracheal intubation was significantly associated with pression escharotomy or fasciotomy was performed imme- mortality (p < 0.001). Cardiac arrhythmia was observed diately. Fluid resuscitation was initiated using lactated or in 23 patients (14.2%), including seven patients who acetated Ringer’s solution according to Parkland formulas required cardiopulmonary resuscitation (CPR) at the and target urinary outputs of 0.5 ml/kg/h. A more aggres- scene of whom five survived until BICU discharge to sive approach (estimating a urinary output of 2 ml/kg/h) rehabilitation (Table 1). Four patients (2.5%) presented was performed in the presence of relevant myoglobinemia cardiac arrhythmias after hospital admission. All ar- (serum myoglobin level > 1000 μg/l). Application of di- rhythmias were self-limiting without compromising the uretics was avoided within the first 24 h. Pharmacological patient. In one patient, arrhythmia attributable to the strategies, such as application of mannitol or alkalization electric injury was observed > 24 h after admission. by adding sodium bicarbonate to the intravenous solution, HVI patients required significantly more extensive burn were not performed routinely but were considered in cases intensive care and surgery than LVI patients (Table 2). with severe rhabdomyolysis (serum myoglobin > 3000 μg/l). Admission serum myoglobin and CK levels were signifi- Renal replacement therapy (RRT) was initiated only in cantly associated with HVI, TBSA, BICU length of stay Gille et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2018) 26:43 Page 3 of 9 Fig. 1 Study flow chart Table 1 Demography, clinical presentation, cardiac arrhythmia and trauma context of patients with electric injury Total (n = 162) > = 1000 V (n = 82) < 1000 V (n = 80) p value Age, years; mean (SD) 37.74 (15.52) 32.76 (15.19) 42.85 (14.21) < 0.001 Male; n (%) 153 (94.4) 77 (93.9) 76 (95.0) 0.760 Clinical presentation % TBSA burned; mean (SD) 16.0 (18.77) 25.93 (21.34) 5.85 (6.67) < 0.001 ABSI; mean (SD) 5.21 (2.29) 6.32 (2.44) 4.08 (1.40) < 0.001 Inhalation injury; n (%) 13 (8.0) 10 (12.2) 3 (3.8) 0.048 Admission temperature, °C; mean (SD) 35.67 (1.32) 35.17 (1.59) 36.18 (.67) < 0.001 Cardiac arrhythmia 0.209 On scene; n (%) 18 (11.1) 11 (13.4) 7 (8.8) EMS transport; n (%) 1 (.6) 0 (0.0) 1 (1.3) BICU < 24 h; n (%) 3 (1.9) 0 (0.0) 3 (3.8) BICU > 24 h; n (%) 1 (.6) 1 (1.2) 0 (0.0) 0.124 Extrasystole/ST/AF; n (%) 9 (5.6) 2 (2.4) 7 (8.8) VT/VF; n (%) 3 (1.9) 2 (2.4) 1 (1.3) Asystole/PEA; n (%) 4 (2.5) 4 (4.9) 0 (0.0) Trauma context; n (%) 0.002 Work 105 (64.8) 43 (52.4) 62 (77.5) Non-work 48 (29.6) 31 (24.3) 17 (23.7) Suicide attempt 9 (5.6) 8 (9.8) 1 (1.3) SD standard deviation, TBSA total body surface area, ABSI abbreviated burn severity index, EMS emergency medical service, BICU burn intensive care unit, ST/AF sinus tachycardia/atrial fibrillation, VT/VF ventricular tachycardia/ventricular fibrillation, PEA pulseless electric activity italicized p values indicate statistical significance (p < 0.05) Gille et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2018) 26:43 Page 4 of 9 Table 2 Emergency tracheal intubation, surgery, burn intensive care, and outcomes of patients with electric injury Total (n = 162) > = 1000 V (n = 82) < 1000 V (n = 80) p value Emergency tracheal Intubation < 0.001 On scene EMS; n (%) 60 (37.0) 53 (64.6) 7 (8.8) Resuscitation room; n (%) 14 (8.6) 8 (9.8) 6 (7.5) Surgery Interventions; mean (SD) 2.77 (3.28) 4.07 (3.70) 1.44 (2.10) < 0.001 Fasciotomy; n (%) 29 (17.9) 27 (32.9) 2 (2.5) < 0.001 Split thickness skin graft; n (%) 116 (71.6) 71 (86.6) 45 (56.3) < 0.001 Flap surgery; n (%) 24 (14.8) 18 (22.0) 6 (7.5) 0.010 Minor limb amputation; n (%) 23 (14.2) 21 (25.6) 2 (2.5) < 0.001 Major limb amputation; n (%) 2 (1.2) 2 (2.4) 0 (0.0) Decompression laparotomy; n (%) 5 (3.1) 5 (6.1) 0 (0.0) 0.025 Burn intensive care Mechanical ventilation; n (%) 71 (43.8) 59 (72.0) 12 (15.0) < 0.001 Ventilator days; mean (SD) 3.89 (8.98) 6.83 (10.96) 0.88 (4.79) < 0.001 Prone positioning/Rotorest®; n (%) 13 (8.0) 12 (14.6) 1 (1.3) 0.002 Renal replacement therapy; n (%) 18 (11.1) 17 (20.7) 1 (1.3) < 0.001 Sepsis; n (%) 31 (19.1) 26 (31.7) 5 (6.3) < 0.001 Outcome LOS BICU, days; mean (SD) 20.98 (20.54) 29.49 (22.62) 12.25 (13.52) < 0.001 30-day mortality; n (%) 11 (6.8) 11 (13.4) 0 (0.0) < 0.001 Hospital mortality; n (%) 17 (10.5) 15 (18.3) 2 (2.5) < 0.001 SD standard deviation, EMS emergency medical service, LOS length of stay, BICU burn intensive care unit italicized p values indicate statistical significance (p < 0.05) Table 3 Admission characteristics of patients with electrical injury Total (n = 162) > = 1000 V (n = 82) < 1000 V (n = 80) p value BICU admission; n (%) 0.950 From scene 111 (68.5) 56 (68.3) 55 (68.8) Interfacility 51 (31.5) 26 (31.7) 25 (31.3) EMS vehicle; n (%) < 0.001 Ground ambulance 92 (56.8) 34 (41.5) 58 (72.5) Helicopter rescue 70 (43.2) 48 (58.5) 22 (27.5) BICU admission time after injury; n (%) 0.774 < 1 h 29 (17.9) 16 (19.5) 13 (16.3) 1-4 h 107 (66.0) 53 (64.6) 54 (67.5) 4-8 h 18 (11.1) 10 (12.2) 8 (10.0) 8-24 h 4 (2.5) 2 (2.4) 2 (2.5) 24-48 h 2 (1.2) 1 (1.2) 1 (1.3) > 48 h 2 (1.2) 0 (0.0) 2 (2.5) BICU distance to scene, km; mean (SD) 78.08 (62.29) 83.67 (62.29) 72.36 (71.02) < 0.001 BICU burn intensive care unit, EMS Emergency medical service italicized p values indicate statistical significance (p < 0.05) Gille et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2018) 26:43 Page 5 of 9 (LOS), ventilator days, number of interventions, mortality, burn intensive care, which confirms the findings of amputation, flap surgery, RRT, and sepsis (p <0.001). In previous studies [1–3, 7, 9]. Independent predictors of HVI, the highest serum levels were measured at PID 1 mortality of electrical injury (both HVI and LVI) were (myoglobin) and PID 2 and 3 (CK) (Figs. 2 and 3). Tropo- respirator days, number of surgical interventions, and nin values were associated with HVI, mortality, flap sur- incidence of amputation. In contrast to our results, other gery, RRT and sepsis but not with limb amputation or studies observed even higher mortality rates in LVI cardiac arrhythmia. patients than in patients with high voltage trauma. This HVI patients required significantly longer BICU LOS, discrepancy may be explained by the fact that these more ventilator days and had a higher incidence of studies included patients with fatal outcomes at the sepsis and RRT and significantly increased 30-day and accident site, which may be related to initial cardiac hospital mortality (p < 0.001) than LVI (Table 2). Logistic arrhythmia and subsequent arrest. Consequently, LVI regression analysis identified ventilator days (OR 1.27, should not be under-estimated . 95% CI 1.06–1.51, p = 0.009), number of surgical inter- In the literature, most electrical injuries were observed ventions (OR 0.47, 95% CI 0.27–0.834, p = 0.010) and in work-related accidents [1, 2, 4, 7]. This finding was also limb amputations (OR 14.26, 95% CI 1.26–162.1, p = observed in our study, where two-thirds of the patients 0.032) as independent predictors of mortality of HVI had work-related injuries. Interestingly, non-work-related and LVI (Table 4). injuries had a significantly higher proportion of HVI (Table 1). This subgroup of patients included mainly younger patients who had accidents at railway areas Discussion (“train surfing” and other illegal activities). Studies of acute In our dual center study, electrical injuries accounted for prehospital emergency approaches to patients with a relatively low 3.9% proportion of BICU admissions, electrical injuries are scarce. We observed that patients which is in line with the results of a recent literature suffering from HVI were more frequently admitted via review that estimated an incidence of below 5% . The helicopter rescue (Table 3), which was probably due to results of our study show that patients suffering from longer distances to the burn centers and more complex HVI show significantly higher morbidity and mortality injury patterns (higher rates of tracheal intubation at the rates than low voltage victims. Patients with HVI re- scene); however, the incidence of prehospital cardiac quired more extensive burn surgery and more complex arrhythmia in HVI patients was comparable to that of LVI Fig. 2 Boxplots of serum myoglobin values of high voltage injury patients. In the boxes, the dark horizontal line represents the median, with the box representing the 25th and 75th percentiles, the whiskers the 5th and 95th percentiles, the circles the outliers, and extreme outliers (three times the height of the boxes) represented by asterisks Gille et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2018) 26:43 Page 6 of 9 Fig. 3 Boxplots of serum creatine kinase values of high voltage injury patients. In the boxes, the dark horizontal line represents the median, with the box representing the 25th and 75th percentiles, the whiskers the 5th and 95th percentiles, the circles the outliers, and extreme outliers (three times the height of the boxes) represented by asterisks patients. Cardiac arrhythmia after BICU admission was regarding the diagnostic accuracy and independence of observed in only 2.5% of our patients, all of which were confounding factors are currently not available . self-limiting and did not require intervention. This result Particularly in HVI, rhabdomyolysis markers, such as may support previous studies, which suggested that pro- serum myoglobin and CK, were associated with injury longed cardiac monitoring after electrical injuries, particu- severity, RRT rate, amputation rate and mortality, as larly LVI, is not required [8, 10, 11]. Moreover, other published previously [1–3, 15–19]. The highest myoglo- studies found that left ventricular dysfunction and cardiac bin level was observed at BICU admission with a linear injury were uncommon and not associated with serum decrease in contrast to the course of CK, which in- troponin and CK in patients after HVI [12, 13]. A new creased until day 2 and 3 after BICU admission until its marker of cardiac injury after electrical injury might be decrease. Thus, in contrast to myoglobin, CK on admis- brain natriuretic peptide (BNP), whereas prospective studies sion may not adequately reflect the severity of injury. Table 4 Multivariate analysis for mortality/independent predictors Parameter OR Lower 95% CI Upper 95% CI p value Cardiac arrhythmia 2.25 0.24 21.20 0.479 Voltage (kV) 0.33 0.02 6.92 0.477 Intubation on scene 3.56 0.22 57.16 0.370 Ventilator days 1.27 1.06 1.51 0.009 Age (years) 1.05 0.95 1.15 0.330 Admission temperature (°C) 0.99 0.51 1.95 0.990 ABSI score (points) 1.13 0.42 3.00 0.812 TBSA burned (%) 1.11 0.98 1.27 0.111 Interventions 0.47 0.27 0.83 0.010 Limb amputation 14.26 1.26 162.1 0.032 ABSI abbreviated burn severity index, TBSA total body surface area, OR odds ratio, CI confidence interval italicized p values indicate statistical significance (p < 0.05) Gille et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2018) 26:43 Page 7 of 9 One study on 37 HVI patients found that the CK serum using microvascular tissue transplantation. The reliabil- concentration peaked on the second and third day fol- ity of prognostic parameters after electrical injury should lowing injury, whereas the highest CK measurements be interpreted with caution and in regard to the individ- were obtained in patients with burn sizes of 21 to 40% ual course and context of the case. TBSA. In contrast, patients with more extensive TBSA The current study has some strengths. Due to the long showed the highest CK levels on the day of admission, study period and the dual center design, we were able to which subsequently decreased over the following days. include a relevant number of patients with reduced In all patients with TBSA > 41%, serum levels decreased center-specific aspects. Our analysis allows us to form no later than the third day following injury and reached statements on the epidemiology and treatment of elec- almost physiologic values within 1 week . Other trical injuries in a mid-European country. Many studies studies found a linear decrease of CK levels in all pa- on electrical injuries have been conducted in consider- tients after HVI [19, 20]. To what extent the delay in CK ably different health care systems, where the incidence, increase is related to burn size or other factors is still de- management and outcomes of electrical injuries may not batable. However, the delay might be based on an be comparable . The long study period and retro- enzyme-dependent activation characteristic, which is spective study design also represent a limitation of the probably associated with latency in response to muscle current study. We cannot disclose whether therapy strat- tissue degeneration due to burns and cellular hydrops. egies were influenced by the implementation of new Future studies should address this phenomenon to clar- guidelines (e.g., introduction of low tidal volume ventila- ify underlying pathomechanisms. Moreover, it would be tion in acute respiratory distress syndrome management, interesting to investigate first, whether rhabdomyolysis is avoidance of fluid creep and secondary abdominal com- influenced by early therapeutic measures (e.g., fasciot- partment syndrome in large burns, and improved sed- omy and/or burn wound excision) and second, whether ation management) and/or changes in the departments’ different strategies of rhabdomyolysis therapy influence administrative positions during the 18-year study period outcomes. The common treatment includes aggressive [31–34]. Furthermore, simultaneous concomitant injur- fluid resuscitation and adjuvant application of mannitol ies (e.g., falls from railway pylons) were not analyzed in and bicarbonate for AKI prevention [21, 22]. However, this study, which could have influenced outcomes. How- randomized controlled trials regarding the benefit of ever, although well-powered prospective randomized both fluids and adjuvant pharmacological therapies are controlled studies in patients with electrical injuries not available and clinical studies provided inconsistent would be desirable, there are many confounders that results . The role of continuous RRT remains un- may not be addressed appropriately in these settings be- clear. In our patients, RRT was not used in an attempt cause of low incidence, incalculably high variability of to avoid AKI but only in cases of manifest AKI. A current exposure, extension of burned TBSA, and pre- meta-analysis revealed insufficient evidence to discern disposing morbidity. any benefits of RRT over conventional therapy in the prevention of rhabdomyolysis-induced AKI . In a Conclusions small study on burn patients, myoglobin elimination Our data consistently confirm the results of previous myoglobin by RRT using a standard filter was not studies supporting the need for specialized burn inten- greater than that by fluid resuscitation alone . How- sive care after electrical injury. Particularly in HVI, ever, some studies suggest the early use of newer mem- life-threating complications may occur. A high propor- branes, such as AN69 ST150, to eliminate myoglobin tion of these patients need complex surgical interven- [25, 26]. Recently, the application of novel cytokine ad- tions (e.g., microvascular tissue transplantation). Serum sorbers for myoglobin removal was proposed . A myoglobin and CK levels reflect the severity of injury prospective, randomized, non-blinded, controlled study and may predict a more complex clinical course. The de- on this topic is currently underway . layed onset of CK peak levels after HVI needs to be in- Although our data revealed that rhabdomyolysis was vestigated in further studies. Routine cardiac monitoring associated with the need for amputation and that ampu- > 24 h post injury does not seem to be necessary. tation independently predicted mortality, other studies found that the need for amputation was not associated Abbreviations ABSI: Abbreviated burn severity index; AKI: Acute kidney injury; ARDS: Acute with increased mortality [29, 30]. Furthermore, one respiratory distress syndrome; BICU: Burn intensive care unit; BNP: Brain study found that the need for amputation was not asso- natriuretic peptide; CI: Confidence interval; CK: Creatine kinase; ciated with increasing burn size . The reasons for CPR: Cardiopulmonary resuscitation; CT: Computed tomography; CVVHD: Continuous veno-venous hemodialysis; CVVHDF: Continuous veno- these contradictory findings may be different patterns of venous hemodiafiltration; ED: Emergency department; EMS: Emergency injury, different thresholds and timings of amputation, medical service; HVI: High voltage injury; LOS: Length of stay; LVI: Low and different infrastructures to perform limb salvage voltage injury; OR: Odds ratio; PEA: Pulseless electric activity; PID: Post injury Gille et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2018) 26:43 Page 8 of 9 day; RRT: Renal replacement therapy; SD: Standard deviation; TBSA: Total 5. Hussmann J, Kucan JO, Russell RC, Bradley T, Zamboni WA. Electrical body surface area injuries–morbidity, outcome and treatment rationale. Burns. 1995;21:530–5. 6. Chudasama S, Goverman J, Donaldson JH, van Aalst J, Cairns BA, Hultman CS. 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Correlation between serum creatinine Publisher’sNote kinase levels and extent of muscle damage in electrical burns. Burns. 2004; Springer Nature remains neutral with regard to jurisdictional claims in 30:680–3. published maps and institutional affiliations. 19. Hsueh YY, Chen CL, Pan SC. Analysis of factors influencing limb amputation in high-voltage electrically injured patients. Burns. 2011;37:673–7. Author details 20. Vierhapper MF, Lumenta DB, Beck H, Keck M, Kamolz LP, Frey M. Electrical Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, injury: a long-term analysis with review of regional differences. Ann Plast St. Georg Hospital, Delitzscher Str. 141, 04129 Leipzig, Germany. Department Surg. 2011;66:43–6. of Medical Psychology, Bergmannstrost Hospital, Merseburger Str. 165, 06112 21. Chavez LO, Leon M, Einav S, Varon J. Beyond muscle destruction: a Halle, Germany. 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Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine – Springer Journals
Published: May 31, 2018
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