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260
R. Richmond and S. Dissanaike
dent on involvement of the lower airways; in these cases,
prolonged mechanical ventilation and a poor outcome are
not unusual. Fortunately, most cases are a simple flash burn
to the face, without significant consequence. While it is
impossible to conduct a randomized controlled trial on this
subject, there is evidence from surrogate markers that
patients who continue to smoke on oxygen likely do not
derive a survival benefit from long-term oxygen therapy,
although they will symptomatically feel better [24].
Pain Control, Nutrition, andSurgical
Treatment
Providing good pain control with a regimen that covers both
baseline and procedural pain is an essential part of managing
any burn patient. A misconception that there is a decrease in
pain with increasing age is challenged by literature that suggests that there is reduced pain tolerance to stimuli in the
elderly [25]. Assessment of pain may be more difficult
because of concomitant dementia and communication disorders. Despite these challenges, it is essential that care and
attention are paid to appropriately assessing and treating
pain in elderly burn patients. Lack of adequate pain control
also increases the risk of delirium in the elderly, which in turn
worsens outcomes including mortality.
Nutritional supplementation is essential to meet the
increased energy needs caused by the hypermetabolic state
that ensues after a large burn; in addition, good nutrition is
critical to healing of burn wounds, both with and without
surgery. Elderly patients are at an increased risk for preexisting nutritional deficiencies, therefore their nutritional
needs must account for their deficits in addition to the
requirements from their injury [20]. Dieticians should be consulted for all elderly burn patients, and formal assessment of
nutritional status following current guidelines, including
metabolic calorimetry for larger burns, should be undertaken.
Chapter 11. Elderly Burns
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261
It is critical that not only total caloric and fluid needs are met,
but that additionally, the correct amount of protein and
micronutrients is provided [26].
Surgical treatment of burns in the elderly is another
special consideration. While early excision and grafting of
full- thickness burns are the standard of care to reduce
hospital length of stay (LOS) and mortality [27], some debate
that a more conservative approach should be applied to the
elderly because undergoing additional physiologic stress of
early excision and grafting so soon after the burn injury does
not shorten LOS and may actually increase mortality [28, 29].
Other authors report improved outcomes with an early
excision and grafting approach with a decreased LOS and
fewer episodes of sepsis and pneumonia [30]. There is evidence of a decrease in mortality with early excision and grafting in the elderly [31, 32]. As a general principle, it is
recommended that when burn excision is needed in elderly
patients, it is performed as soon as possible after completion
of resuscitation and optimization of any medical conditions,
including correction of anticoagulation.
Non-Accidental Injury
At the extremes of age, humans are especially vulnerable to
trauma inflicted by others; therefore, a small proportion of
burns in the elderly will result from abuse and neglect. While
physicians are taught to look for signs of non-accidental
trauma in children, this aspect is often overlooked in the frail,
elderly patient. Patients who depend on others for help with
activities of daily living have impaired mobility and cognitive
decline, this possibility should be considered. Signs of general
neglect such as untreated bedsores and poor hygiene, burn
injury patterns that conflict with the account of injury given
by caregivers, and delay in seeking medical care should all be
considered red flags that may warrant reporting to adult protective services for further investigation.
262
R. Richmond and S. Dissanaike
Outcomes
The strong relationship between age and mortality in burns
has been recognized for many years, as evidenced by the classic Baux score calculation of age+percent burn=% mortality. While improvements in burn care and resuscitation have
fortunately superseded the grim expectations of this equation, it is still true that large burns, inhalation injury, and age
over 60 remain the strongest predictors of poor outcome,
with mortality in elderly increasing with age by approximately 1% per year [33].
Advances in critical care and surgical treatment of burns
have improved survival over the last several decades [7]. A
recent 20-year retrospective review showed an overall elderly
mortality rate of 22.7% with a large increase in mortality
after TBSA surpasses 20% [34]. Encouragingly, the mortality
decreased by a rate of 2.9% for every 5years of the study
with an overall decrease in mortality by 11.6% over the
20-year study period [34].
Worse prognosis in elderly patients is one reason why
transfer to an ABA verified burn center is recommended;
however, even with state-of-the-art care, a significant proportion of elderly patients, especially those with larger burns
and/or inhalation injury, will not survive. Another cohort will
survive with disability and requirements for skilled nursing or
long-term care. In order to provide optimal, individualized
care tailored to a patient’s wishes and long-term goals, it is
important that discussions on their goals of care, expectations
of treatment, and anticipated prognosis are started as early in
the course as feasible. Early involvement of palliative care
consultative services may assist in identifying cases where
standard surgical treatment, intensive care, and a prolonged
hospital course may not result in the patient’s desired
outcome, or is not compatible with patient wishes and goals
of care. Recognition of this divergence in goals may help
avoid subjecting patients to treatments that will not be beneficial in the long term; therefore, these resources should be
utilized where available.
Chapter 11. Elderly Burns
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263
References
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2010%20Census,this%20population%20numbered%20
35.0%20million.&text=In%202010%2C%20the%20older%20
population,from%2012.4%20percent%20in%202000.
2. Petro JA, Belger D, Salzberg CA, Salisbury RE.Burn accidents
and the elderly: what is happening and how to prevent it.
Geriatrics. 1989;44(3):26–7.
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4. Barillo DJ, Goode R. Fire fatality study: demographics of fire
victims. Burns. 1996;22:85–8.
5. Anous MM, Heimbach DM.Causes of death and predictors in
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7. Lionelli GT, Pickus EJ, Beckum OK, DeCoursey RL, Korentager
RA.A three decade analysis of factors affecting burn mortality
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8. Advanced burn life support course provider manual 2018
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9. Milzman DJ, Rothenhaus TC. Resuscitation of the geriatric
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DT, Haut ER, et al. Redefining hypotension in the elderly:
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14. Lewis MC, Abouelenin K, Paniagua M.Geriatric trauma: special
considerations in the anesthetic management of the injured
elderly patient. Anesthesiol Clin. 2007;25(1):75–90.
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Dermatol. 1994;130:87–95.
16. Hunt JL, Purdue GF. The elderly burn patient. Am J Surg.
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1 7. Kurban RS, Bhawan J.Histologic changes in skin associated with
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18. Grossman MD, Miller D, Scaff DW, Arcona S.When is an elder
old? Effect of preexisting conditions on mortality in geriatric
trauma. J Trauma. 2002;52(2):242–6.
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20. Keck M, Lumenta DB, Andel H, Kamolz LP, Frey M. Burn
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K, editors. Trauma. 7th ed. NewYork: McGraw Hill; 2012.
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R, Torke AM. Smoking-related home oxygen burn injuries:
continued cause for alarm. Respiration. 2016;91(2):151–5.
23. Assimacopoulos EM, Liao J, Heard JP, Kluesner KM, Wilson
J, Wibbenmeyer LA. The national incidence and resource
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oxygen therapy. J Burn Care Res. 2016;37(1):25–31.
24. Lacasse Y, LaForge J, Maltais F. Got a match? Home oxygen
therapy in current smokers. Thorax. 2006;61(5):374–5.
25. Gibson S, Helme R. Age-related differences in pain perception
and report. Clin Geriatr Med. 2001;17:433–56.
26. Rollins C, Huettner F, Neumeister MW. Clinician’s guide to
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2 7. Janzekovic Z.A new concept in the early excision and immediate
grafting of burns. J Trauma. 1970;10:1103–9.
28. Herd BM, Herd AN, Tanner NSB. Burns to the elderly: a
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31. Burdge JJ, Katz B, Edwards R, Ruberg R.Surgical treatment of
burns in elderly patients. J Trauma. 1988;28:214–7.
32. Deitch EA. A policy of early excision and grafting in elderly
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Chapter 12
Electrical Injuries
ManriqueGuerrero, CaseyKohler, andBrettArnoldo
Introduction
Electricity gives us the chance to run our technology from
lights and personal computers to cars, space shuttles, and
power plants, but it also comes with the chance of injury or
death. The American Burn Association (ABA) Burn Incidence
Fact Sheet from 2016 demonstrated that 4% of 30,000 burn
admissions to burn centers were electrical in origin [1].
Electrical injuries are the most common causes of amputations related to burns [2]. There is a bimodal distribution of
injury with most adults undergoing high- voltage injuries at
work and children under six experiencing low-voltage injuries
from electrical outlets and power cords [3–7].
M. Guerrero (*)
Department of Surgery, University of South Florida Morsani
School of Medicine, Tampa, FL, USA
e-mail: guerrerom@usf.edu
C. Kohler · B. Arnoldo
Department of Surgery, Case Western Reserve University School of
Medicine, Cleveland, OH, USA
e-mail: Ckohler@metrohealth.org;
Brett.arnoldo@utsouthwestern.edu
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
J. O. Lee (ed.), Essential Burn Care for Non-Burn Specialists,
https://doi.org/10.1007/978-3-031-28898-2_12
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M. Guerrero et al.
Electrical injuries are unique and require early, aggressive
management. Quick decisions regarding diagnosis and treatment of cardiac injuries or compartment syndrome must be
made while appropriately resuscitating a patient to protect
their kidneys from the devastating effects of myoglobinuria.
These patients often need to be transferred to a specialized
burn center to receive advanced wound care and reconstruction, as well as extensive physical and occupational therapy.
However, important steps in care and survival start as soon as
they land on your doorstep and whether you are a specialized
center or not, early actions in the correct direction can make
a big difference in survival.
Pathophysiology
Clinically electrical injuries can be classified into four types
of injury: (1) True electrical injury by current flow; (2) arc
injury from the electrical arc as it passes from the source to
an object; (3) flame injury from ignition of clothing or surroundings, and (4) lighting strikes [8]. The mechanism by
which these types of electrical injuries cause tissue damage is
multifactorial with both thermal and nonthermal causes. The
direct electrical forces can damage cell proteins, membranes,
and other cellular structures. Just as devastating is the damage caused by heat generated from the electrical injuries [9].
How severe the injury depends on voltage, current, type of
current, path of current flow, duration of contact, and the
resistance at the point of contact.
Voltage can be categorized arbitrarily into low voltage
(<1000V) and high voltage (>1000V). Low-voltage injuries
will localize to the area of the contact point. Conversely, highvoltage injuries are characterized by extension into deep tissues and by spreading out to the surrounding structures.
High-voltage insults tend to demonstrate a “tip of the iceberg” phenomenon affecting deep tissues at the contact point
and tissues distally [10]. Thus, high-voltage injuries are often
higher acuity and require urgent medical intervention.
Chapter 12. Electrical Injuries
269
It is important to note that domestic wiring in the United
States operates on alternating current (AC) at 120 V. This
allows the clinician to characterize indoor electrical injuries
into a low-voltage type. However, at the industrial level, highvoltage injuries are more commonly seen. Industrial settings,
computers, light emitting diodes (LED), solar cells, and electrical vehicles utilize direct current (DC) [11]. Furthermore,
while the voltage during the electrical injury can be identified, the current cannot and is dependent on voltage and
resistance as demonstrated by Ohm’s law (Current=Voltage/
Resistance). The resistance during an electrical injury varies
with time. Initially it decreases slowly and then more rapidly
until arcing occurs. The resistance will then rapidly rise to
infinity and the current flow will cease. Interestingly, temperature at the contact site is directly proportional with the
current flow. However, it will not increase distally and cause
most of its thermal damage at the contact point. This phenomenon can commonly be seen in wrist and ankle injuries
where distal digits can remain unharmed [10].
The path the current takes during the electrical injury can
alter the clinical management of the patient. Heart conduction abnormalities and central nervous system deficits are
seen when current traverses through these vital structures.
Tetanic muscle contractions also commonly occur. The contractions are exhibited by either throwing the individual back
or “pulling them into” continuous contact [12].
At 4000 °C, electricity arcs causing flash like injuries
without actual current flow through the tissue. This is
commonly seen in electricians and industrial workers as they
labor near metallic objects within short distances of electrical
power sources [8]. The same arcing of electricity may also
throw the patient, causing additional trauma.
Finally, a thermal burn due to an electrical injury is the
result of high temperatures caused by the power (heat) of a
current [13]. The human body serves as a volume conductor;
thus, the severity of the injury is inversely proportional to the
cross-sectional area of the body part [11]. The most severe
injuries with the highest heat are seen in the wrist and ankle.
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More proximal regions such as the thighs and torso experience less heat. Deeper tissues and regions between 2 bones
(tibia and fibula; ulna and radius) also retain heat to a greater
degree. Furthermore, excessive heat production is associated
with immediate and non-reversible macroscopic and microscopic vascular injury [14]. The injury pattern can progress for
more than a week, thus outlining the importance of serial
surgical debridements.
Types ofInjuries
Low-Voltage Injuries
The most common type of electrical injury is low-voltage
(<1000V) alternating current. These are usually the injuries
that occur around the house and are often localized to the
points of contact. However, tissue damage can be deeper and
more extensive if prolonged contact has occurred. Arrhythmias
directly following the electrical injury are possible in lowvoltage injuries but not as common as high voltage and do
not require 24-h monitoring if initial EKG is normal [15]. The
oral cavity is one the most common places for young children
to experience an electrical burn, usually from chewing on an
electrical cord [16]. It is important to note that the most serious complication of this injury is bleeding from the labial
artery which usually happens 10–14 days after the original
injury. The labial artery should be compressed digitally until
it can be definitively controlled. If this complication occurs,
there is a high chance that the child will require further treatment in the future including reconstructive surgery [17, 18].
High-Voltage Injuries
Injuries are considered high voltage if it is >1000 V and
oftentimes are occupational exposures. Patients or witnesses
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