Practice Guidelines for the Managementof Electrical Injuries

Brett Arnoldo, MD,* Matthew Klein, MD† Nicole S. Gibran, MD

There has been increasing emphasis on the develop-ment of practice guidelines and validated measure-ments to evaluate surgical practice. Initiatives such asthe National Surgical Quality Improvement Program(NSQIP) have demonstrated the importance of anoutcome-based approach to improving surgical care.The development of guidelines and outcome-basedbenchmarks requires established standards of practicethat should be based on level I data from well-designed prospective randomized trials.

Electrical burns are potentially devastating injurieswith both short- and long-term sequelae. In 2001, theAmerican Burn Association published a set of practiceguidelines for various aspects of burn care in the Journalof Burn Care and Rehabilitation. However, guidelinesfor the management of electrical burns were not in-cluded. Two fundamental—and controversial—issuesin the management of electrical burns are cardiac mon-itoring and evaluation and treatment of the injured up-per extremity. We have reviewed and analyzed the avail-able literature in an effort to develop practice guidelinesfor these two important issues.

SECTION I: CARDIAC MONITORINGAFTER ELECTRICAL INJURIES

RecommendationsStandards. An electrocardiogram (ECG) should

be performed on all patients who sustain electricalinjuries (high and low voltage).

Guidelines1. Children and adults who sustain low-voltage

electrical injuries, have no ECG abnormalities,

no history of loss of consciousness, and no otherindications for admission (ie, soft-tissue injury),can be discharged from the emergency room.

2. All patients with history of loss of consciousnessor documented dysrhythmia either before or af-ter admission to the emergency room should beadmitted for telemetry monitoring. Patientswith ECG evidence of ischemia should be ad-mitted and placed on cardiac monitors.

3. Creatine kinase enzyme levels, including MBfraction, are not reliable indicators of cardiacinjury after electrical burns and should not beused in decisions regarding patient disposition.Insufficient data exists on troponin levels to for-mulate a guideline.

Options. Electrical injuries can result in potentiallyfatal cardiac dysrhythmias. The need for cardiac eval-uation and subsequent cardiac monitoring are criticalcomponents in electrical burn management. Most pa-tients who sustain electrical injuries undergo ECGevaluation, and patients with documented dysrhyth-mias, cardiac ischemia, or history of loss of conscious-ness will be admitted to the hospital for further eval-uation and monitoring. However, the appropriatecardiac diagnostic tests and the indications for hospi-tal admission, necessity of cardiac monitoring, andappropriate duration of cardiac monitoring have notbeen well established.

OVERVIEW

PurposeThe purpose of this guideline review is to review the cur-rent data on practices for diagnosing cardiac injury andindications for cardiac monitoring after electrical injury.

UsersThese guidelines are designed to aid physicians in makingdecisions regarding patient disposition, diagnostic testsand management of patients following electrical injury.

From the *University of Texas Southwestern Medical Center,Parkland Memorial Hospital, Dallas; and †University ofWashington Burn Center, Harborview Medical Center, Seattle.

Address correspondence to Nicole S. Gibran, MD, University ofWashington Burn Center, Harborview Medical Center, Box359796, 325 9th Avenue, Seattle, WA 98104.

Copyright © 2006 by the American Burn Association.1559-047X/2006

DOI: 10.1097/01.BCR.0000226250.26567.4C

439

Clinical ProblemThe potential for development of cardiac dysrhyth-mia, cardiac arrest, and myocardial damage after elec-trical injury has been well documented.1–5 Cardiacdysrhythmias, cardiac standstill, and myocardial in-jury can occur after both low- (�1000 V) and high-voltage (�1000 V) injury. The potential for cardiacdysrhythmia and injury has prompted routine cardiacevaluation and low threshold for patient admissionand of all patients who sustain electrical injury.Whereas obtaining an ECG is a well-established com-ponent of the early evaluation of patients after elec-trical injury, the indications for patient admissionand appropriate duration of cardiac monitoringhave been less clear. Traditionally, patients withlow-voltage injuries who have normal ECGs and nohistory of loss of consciousness are discharged fromthe hospital. However, appropriate management ofpatients who sustain high-voltage injuries has notbeen well defined. Generally, patients who have ahistory of loss of consciousness, ECG abnormalities,or have injuries that would otherwise require admis-sion are admitted to the hospital and are placed ontelemetry monitors. There are several issues related tothe cardiac evaluation and monitoring that need to beaddressed: 1) Should all patients with high-voltageelectrical injuries be admitted to the hospital, even ifthere is no evidence of cardiac abnormality? 2) Whatis the role of cardiac enzymes in the evaluation andmanagement of electrical injuries? 3) How longshould patients be monitored on telemetry?

ProcessA Medline search was conducted of all available liter-ature from 1966 to 2004 using the key words elec-trical, burns, cardiac, monitoring. In addition, severalarticles were not identified in the Medline search butwere referenced in the articles reviewed and werefound to be relevant: a total of 27 articles were re-viewed and found to be relevant.

References were classified as Class 1 evidence (pro-spective, randomized, controlled trials); Class II evi-dence (prospective or retrospective studies based onclearly reliable data); Class III evidence (evidenceprovided by clinical series, comparative studies, casereviews or reports); or as a technology assessment (astudy that examined the utility/reliability of a partic-ular technology).

Scientific FoundationCardiac Abnormalities. All studies reviewed con-

firmed that cardiac abnormalities—including dys-rhythmias and myocardial damage—occur after both

low-voltage and high-voltage injuries, reinforcing theneed for ECG evaluation of all patients. NonspecificST-T changes were the most common ECG abnor-mality,2,6,7 and atrial fibrillation was the most com-mon dysrhythmia.

Criteria for AdmissionAdmission and cardiac monitoring for patients withhistory of loss of consciousness, ECG abnormalities,or with other indications for admission (ie, TBSAburned, need for extremity monitoring) are standardpractices in all series of electrical injuries reviewed. Inaddition, the majority of patients with low-voltageinjuries and normal ECG are discharged home fromthe emergency room without complication. Thesafety of this practice also was confirmed in two seriesof pediatric patients.1,8 The possible exceptions in-clude patients with other injuries that require hospi-talization or children with an oral burn that wouldrequire monitoring for labial artery bleeding.

Virtually all patients with high-voltage injuries areadmitted for cardiac monitoring; however, it is un-clear whether this step is necessary. With increasingemphasis on cost-effectiveness, the routine admissionof all patients with high-voltage injury must be ques-tioned. Hunt,9 Bailey et al,1 and Arrowsmith et al10

reported that all cardiac irregularities were evidenteither on admission to the emergency room or withinseveral hours of hospitalization and in 1986, Purdueand Hunt5 reported that no serious arrhythmias oc-curred in any patient who a normal ECG on admis-sion. Taken together, these studies suggest that anegative initial evaluation could obviate the need forhospital admission solely for cardiac monitoring.However, these were observations based on retro-spective data and are inadequate to form the basis ofa practice guideline. On the basis of their findings,Purdue and Hunt5 generated the following set ofadmission criteria for electrically injured patients: 1)loss of consciousness or cardiac arrest in the field; 2)documented cardiac arrhythmia in the field; 3) ab-normal ECG; or 4) a separate indication for admis-sion. They applied these criteria prospectively to 10consecutive patients and reported no complications.This study is the first to investigate not routinelymonitoring patients who sustained high-voltageinjuries. However, this series is too small to affectpractice.

One study suggested that presentation of cardiacabnormalities could be delayed. Jensen et al11 re-ported three patients with a delay in the onset ofsymptoms after low-voltage (two patients) and high-voltage (one patient) injuries. All presented to theemergency room only after they developed chest pain

Journal of Burn Care & Research440 Arnoldo et al July/August 2006

and palpitations. However, none of the patients hadECGs or any sort of evaluation at the time of injuryand, therefore, this study does not provide substan-tive evidence of truly late dysrhythmia presentation.

Duration of MonitoringNo published studies have directly studied the appro-priate duration of telemetry monitoring after injury.Several series reported monitoring for 24 hours afteradmission if there were no ECG abnormalities onadmission or monitoring for 24 hours after resolutionof dysrhythmias.1,8,12 Arrowsmith et al10 reportedthat all patients with dysrhythmias resolved within48 hours of admission either spontaneously or withpharmacologic intervention. However, there are nodata available to formulate appropriate managementguidelines for this issue.

Utility of Creatine KinaseCreatine kinase levels frequently are obtained afterelectrical injury. CK has long been used as an indica-tor of muscle injury and can help in determining theextent of extremity muscle injury. The MB subunithas been reported to be more specific for myocardiumand, therefore, has been used to evaluate cardiac in-jury after electrical injury. Only one study reported areliable correlation between serum CK-MB levels andcardiac injury. Chandra et al6 reported that the timecourse of the MB fraction increase and decrease was areliable indicator of cardiac ischemia. However, thisstudy does not correlate the elevated enzyme levels withany other study of cardiac injury. Conversely, the evi-dence of poor or questionable correlation was quitestrong. Several studies demonstrated that CK-MBlevels poorly predict cardiac injury and that theelevated enzyme levels likely result from noncar-diac muscle injury.7,13–15 Housinger et al7 sug-gested that positive MB fractions in the absence of ECGfindings should be interpreted with caution becausethey may not signify cardiac injury. Given the paucity ofevidence supporting the utility of CK-MB levels, thislaboratory value should not be used as a diagnosticcriterion for cardiac injury after electrical injury.

SUMMARY

The current practices of admitting patients with his-tory of loss of consciousness, documented dysrhyth-mia in the field, or ECG abnormalities are wellsupported in the literature. Similarly, dischargingpatients from the emergency room with low-voltageinjuries and normal ECGs is well established. How-ever, few data are available to support establishmentof guidelines for the management of patients with

high-voltage injuries and normal ECGs. The twostudies that addressed this question have populationsizes that are too small to support changes in practice.Future prospective and randomized studies (as de-scribed herein) are needed to effectively establishpractice guidelines. In addition, there is inadequateevidence to formulate guidelines for the duration ofmonitoring for patients with ECG abnormalities.

Sufficient data are available to conclude thatCK-MB is an unreliable diagnostic test for cardiacinjury after electrical injury. The presence of skeletalmuscle injury in these patients confounds the resultsof this laboratory test. No studies identified in thisreview examined the specificity and utility of troponinlevels in determining cardiac injury.

Key Issues for Further Evaluation1. Utility of troponin: CK and CK-MB not specific

for cardiac muscle. Insufficient data exists eval-uating the utility of troponin in assessing cardiacinjury.

2. Duration of monitoring: insufficient data existsto determine the optimal duration of telemetrymonitoring after electrical injury for patientswho have abnormal ECGs or history of loss ofconsciousness. There have been no studies thatdirectly examined this specific question.

3. Admission for high-voltage injuries: insufficientdata exists to establish guidelines for whether toadmit patients who sustain high-voltage injuriesbut have normal ECG’s and no history of loss ofconsciousness. The available data suggest thatthese patients could be discharged but further,prospective evaluation is required.

Evidentiary TableStudies on the practices of cardiac evaluation andmonitoring are summarized in Table 1.

II. EVALUATION AND MANAGEMENTOF THE UPPER EXTREMITY

RecommendationsStandards. Insufficient data exist to support a

treatment standard for this topic.Guidelines1. Patients with high-voltage electrical injury to

the upper extremity should be referred to spe-cialized burn centers experienced with these in-juries as per American Burn Association referralcriteria.

2. Indications for surgical decompression includeprogressive neurologic dysfunction, vascular

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Table 1. Evidence table

Reference Study Description Data Class Conclusions/Comments

Ahrenholz et al,198813

Retrospective study of 125 patientsadmitted with electrical injuries

II Demonstrated that there is a poor correlation betweenelevated CK-MB levels and cardiac injury

Arrowsmith et al,199710

Retrospective study of 145 patientsadmitted with electrical injuries todetermine incidence of cardiaccomplications

II All patients with cardiac complications had them at thetime of admission. Patients with normal ECG and noloss of consciousness do not require admission forcardiac monitoring

Bailey et al,199543

Retrospective review of 141 childrenadmitted to the emergency departmentwith household electrical injuries

II Children with normal ECG and low voltage injuries donot require cardiac monitoring. Authors also suggestedthat ECG is not indicated for children with low-voltageinjuries, no loss of consciousness, no tetany, no watercontact, and no current crossing the heart region

Bailey et al,20001

Prospective evaluation of a set of admissionguidelines after electrical injury.Guidelines were applied to a total of 224patients

II Guidelines for admission were used in the majority ofcases. According to the guidelines, all patients withhigh-voltage injuries were admitted, as were patientswith low-voltage injuries with ECG abnormalities, pastcardiac history, water contact, and tetany

Chandra et al,19906

Prospective evaluation of 34 patientsadmitted with high-voltage electricalinjuries to determine predictors ofmyocardial damage

II Time course of CK-MB elevation in patients withelectrical injuries suggests that it is cardiac in etiology.ECG may not be reliable for diagnosing myocardialdamage

Cunningham,199144

Retrospective study of 70 patients admittedwith electrical injury

II Discharged all patients with low-voltage injuries who areasymptomatic and had normal ECG withoutcomplication

Guinard et al,198715

Prospective evaluation of 10 patientsadmitted with electrical injuries

III Demonstrated poor reliability of CK-MB to identifycardiac injuries

Housinger et al,19857

Prospective study of 16 patients to determineincidence of possible myocardial damagefollowing electrical burn

III Demonstrated poor correlation between elevation ofCK-MB levels and ECG abnormalities. Pyrophosphatescans were used as diagnostic standard for cardiacinjury

Hunt et al,19809

Retrospective review of 102 patients withhigh-voltage injuries

II All cardiac abnormalities were evident either onadmission of within several hours of hospitalization

Jensen et al,198711

Three case reports of late presentation ofcardiac abnormalities after electrical injury

III Three patients with late presentation of cardiacabnormalities. However, none of the patients wereevaluated immediately after injury

Lewin et al,19834

Case report of 19-year old patient withmyocardial injury after electrical injury

III Demonstrated correlation of CK-MB levels with ECGabnormalities and myocardial injury

Purdue and Hunt,19865

Retrospective study of 48 patients admittedwith high-voltage injuries. On the basis ofthese findings, a prospective study of 10patients applying guidelines for admission

II Designed a protocol for determining which patientsshould be admitted following high voltage injury. Nocomplications following discharge of patients with highvoltage injuries and no other indications foradmission.Comment: First study to demonstrate safety ofdischarging patients with high-voltage injuries andnormal ECGs. However, small group of patients studied

Wallace et al,19958

Retrospective study of 35 pediatric patientswith both low and high voltage injuries

II Children with low-voltage injuries and normal ECGs canbe discharged. However, all patients with high-voltageinjuries were admitted and monitored

Zubair et al,199712

Retrospective study of 127 pediatric patientswith low- and high-voltage injuries

II Recommend 4 hours of monitoring for all patients beforedischarge and admission of all patients with high-voltage injuries, loss of consciousness, or ECGabnormalities

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compromise, increased compartment pressure,and systemic clinical deterioration from sus-pected ongoing myonecrosis. Decompressionincludes forearm fasciotomy and assessment ofmuscle compartments. The decision to includea carpal tunnel release should be made on acase-by-case basis.

Options. There are several methods to evaluate theinjured extremity. Compartment pressures may bemeasured as an adjunct to clinical examination. Pres-sures greater than 30 mm Hg, or tissue pressurereaching within 10 to 20 mm Hg of diastolic pres-sure, may be used as evidence of increased compart-ment pressure and potential deep-tissue injury, indi-cating the need for surgical decompression in theappropriate clinical setting. Technetium-99m pyro-phosphate scan may be used as an adjunct to clinicalexamination at centers experienced with this technol-ogy. Doppler flow meter can be used as an adjunct toassess extremity perfusion. It should not be relied onas the sole indicator of deep-tissue viability and ade-quate perfusion.

OVERVIEW

PurposeThe purpose of this guideline is to review the princi-ples of monitoring and treatment of high-voltageelectrical burn injury to the upper extremity. The up-per extremity is commonly injured after high-voltageelectrical and carries with it a high rate of morbidity.

Clinical ProblemBurns resulting from high-voltage electric current(�1000 V) often are associated with a greater degreeof deep-tissue injury than is initially appreciated. As aresult these rather infrequent injuries, which make uponly 3% to 12% of burn center admissions,16 are as-sociated with high amputation rates and greater useof resources than comparable %TBSA cutaneousburns.6,10,17 Unnecessary exploration can increasemorbidity, length of stay, and the use of scarce re-sources. Delayed exploration and decompression inthe compromised extremity, however, may result inincreased amputation rates along with increased or-gan failure and mortality.31

ProcessA Medline search from 1966 to the present was usedto evaluate monitoring and the need for early explo-ration and fasciotomy in electrical injury to the ex-tremity. A search for the key words, “electrical in-jury,” “fasciotomy,” “compartment syndrome,”

“compartment pressure,” “Doppler flow meter,”“technetium 99m pyrophosphate,” “infrared pho-toplethysmography,” and “burn injury” was per-formed, and relevant articles were reviewed. Stud-ies of patients with lower-extremity injuries wereincluded because of the scarcity of data involving ex-clusively the upper extremity. An attempt was madehowever to analyze the data involving the upper ex-tremity exclusively where possible.

Scientific FoundationElectrical injuries, including lightning strikes, shouldbe referred to a specialized burn center as per Amer-ican Burn Association criteria.18 Many surgeons ad-vocate immediate surgical exploration (usually withinthe first 24 hours), and decompression of patientswith high-voltage electrical injuries.19,20–32 Early ex-ploration, fasciotomy, and debridment are followedby serial debridment of necrotic tissue and subse-quent closure. These studies are somewhat difficult tointerpret; however, because of the differences in thedegree of injury no prospective, randomized, con-trolled trials evaluating immediate exploration havebeen performed. The rational for this aggressive ap-proach relates to thermal mechanics. Joule’s law de-fining the amount of power (heat) delivered to anobject:

Power (J-Joule) � I2 (Current) times R (Resistance).Accordingly, deep muscle necrosis can occur in the

muscle adjacent to bone, which has a high resis-tance.33–35 Failure to perform adequate fasciotomyand to evaluate all muscle compartments may lead tomisdiagnosis of deep thermal injury.20 This approachhowever, commits the patient to several operationsand may prolong hospital stay and morbidity.

In the d’Amato20 series, six patients underwentemergency exploratory surgery and amputation forobvious necrotic extremities, followed by serial de-bridment. No patient required an amputation formisdiagnosed deep muscle necrosis. However,missed injury was present in two patients, who re-quired further surgical intervention, although neitherrequired amputation because of the missed injury.Parshley’s series evaluated 41 patients with 27 ex-tremities explored. Amputation rate was 40% with 10extremities salvaged, which the authors attribute toearly aggressive operative intervention. Haberal’s se-ries of 94 patients had an amputation rate of 43%. Theauthors attributed this high amputation rate in partbecause of a delay in surgical exploration as a result ofpatients being transferred from nonspecialized facili-ties. Achauer et al21 reported a series of 22 patientswith an amputation rate of 40%. They recommend“extensive debridement of all damaged tissue and ex-

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Table 2. Evidentiary table: high-voltage electric injury to upper extremity

Reference Description Data Class Comments

Quinby et al,197825

Retrospective review of 44 patientsdivided into 22 with electric arc and22 with flow of current

II In conductive burns with entrance site in hand, incision wascarried from hand to interconnect the arc burns at wrist,elbow, and shoulder. Fasciotomies done if musclediscolored, or tense, transverse carpal ligament release done.Amputation rate 68%

Luce et al,198426

Retrospective review of 31 patients II Fasciotomy and wound exploration and debridement within24 hours of admission Amputation rate 35.5%

Parshley et al,198522

Retrospective review 41 patients withpassage of current

II Early fasciotomy in patients with passage of currentAmputation rate 40%

Achauer et al,199421

Retrospective analysis of electric injuryof the hand in 22 patients

II Extensive debridement and compartment release almost alwaysdone on day of injury. Amputation rate 40%

Mann et al,199631

Retrospective review 62 patients withhigh voltage upper extremity injury

II Fasciotomy indications: severe pain and loss of arterialDoppler signal, neurologic deterioration, systemic clinicaldeterioration from suspected ongoing myonecrosis. Carpaltunnel release performed along with fasciotomy. 16 of 62patients (25.8%) required emergent decompression withinfirst 24 hours. Amputation rate in these patients 45%.Overall amputation rate 10%

Yowler et al,199832

Retrospective chart review 51 patientswith high voltage injuries to theupper and lower extremity

III Indications for fasciotomy: Elevated muscle compartmentpressure greater than 30 mmHg. Neurologic dysfunction,vascular compromise, extensive deep burn. 11 patientsunder went 18 major amputations

DiVincenti et al,196924

Retrospective review of 65 electricalinjuries over 17 years, upper andlower extremities included, high andlow voltage injuries included

III Early fasciotomy indicated for cyanosis of distal uninjured skin,impaired capillary refill, progressive neurologic change,brawny edema and muscle compartment tightness.Amputation rate 32.5%

Butler et al,197723

Retrospective review of 182 cases overtwenty years. Includes high voltageand low voltage injuries

III 40 patients underwent an average of 5 operations. Markedswelling of the wrist and hand, the volar carpal ligament isdivided at time of extremity fasciotomy. Amputation rate65%

Mann et al,197527

Series of 8 patients with high voltageinjury. Includes upper and lowerextremities

III Early decompression fasciotomy and debridement.Amputations done on at least one extremity in all patients

D’Amato et al,199420

Series of 6 patients with high voltageupper extremity injury

III Mandatory exploration of forearm and hand compartmentsfollowing initial resuscitation. All patients requiredamputation

Hussmann et al,199545

Retrospective evaluation of 38 highvoltage injuries. Included upper andlower extremity

III Early serial debridement of obviously necrotic tissue,fasciotomy including carpal tunnel release for “compartmentsyndrome” 39 amputations performed in 38 patients

Saffle et al,198035

Evaluation of wick catheter to measureintramuscular compartmentpressures (IMP) in 31 extremities in18 patients, compared with clinicaland Doppler findings

II Recommended routine measurement of IMP as a moresensitive than Doppler pulses, and use of a threshold valueof 30 mmHg for performance of escharotomy

Moylan et al,197136

Prospective evaluation of ultrasonicflowmeter to assess circulatorychanges in 60 limbs in 24 patientswith circumferential burns

II Escharotomy is indicated when Doppler flow is absent in distalarteries or arches. Note: This paper documents that Dopplerpulses can be present in the face of clinical evidence of tissuecompression and ischemia

Salisbury et al,197437

Evaluated post-mortem intrinsicmuscle biopsies following extremityburns. Presence of necrosis wassimilar in patients with (72.2%) andwithout (66%) escharotomies

II/III Muscle ischemia or necrosis can occur with intact pulses and evenfollowing escharotomy. Note: since this was a post-mortemstudy, tissue necrosis may have been a non specific finding

(Continued)

Journal of Burn Care & Research444 Arnoldo et al July/August 2006

tensive compartment release done as an emergency(almost always on the day of injury).” Luce reporteda series of 31 patients with an extremity amputationrate of 35.5% who “were taken to the operating roomwithin 24 hours of admission.” In the DiVincenti etal24 series of 65 patients, there was an amputation rateof 32.5%. There are no studies that specifically eval-uated the impact of timing on treatment outcome.

Some recent literature has supported a more selec-tive approach to management may reduce the num-ber of operative interventions and subsequently themorbidity of high voltage electrical injury.31,32 Mannet al31 followed a selective management algorithm forupper-extremity high-voltage electrical injury. Indi-cations for surgical decompression included extrem-ities that exhibited progressive peripheral nerve dys-function, clinical manifestations of compartmentsyndrome, or injury sufficient to cause difficulty inresuscitating the patient. Sixty-two patients had a to-tal of 100 upper-extremity injuries. Early (within 24hours of admission), surgical decompression was re-quired in 22% of injured upper extremities. An am-

putation was ultimately required in 10% of the ex-tremities. Extremities that were not decompressedimmediately did not require amputation. The ampu-tation rate for those patients requiring immediate sur-gical decompression was 45%. This amputation rate issimilar to previous studies, which appear to includepatients with lesser degree of injury. In the series fromthe Army Institute of Surgical research,32 51 patientswith high-voltage injury were managed selectively.Indications for operative intervention were evidenceof neurologic dysfunction, vascular compromise, ex-tensive deep burn, or increased muscle compartmentpressures (repeated measurements �30 mm Hg). Atotal of 11 patients (21.6%) underwent 18 major ex-tremity amputations.

No precedent exists in the literature for measuringcompartment pressures in the setting of high-voltageupper-extremity electrical injury. Some surgeons ad-vocate their use, however, on the basis of the ortho-pedic and vascular literature.33,34 Measurement ofcompartment pressures in circumferential extremityburn wounds has been recommended by Saffle et al.35

Table 2. (Continued)

Reference Description Data Class Comments

Smith et al,198438

Prospective evaluation of infraredphotoplethysmography (PPG) toevaluate vascular status in burnedextremities and compared with IMP,Doppler, and muscle blood flow(MBF). PPG correlated well withIMP and MBF, but poorly withDoppler with changes noted withIMP �30 mm Hg

III Advocated use of PPG as a noninvasive method of assessingvascular compromise. This study supports an IMP �30 mmHg as an appropriate threshold for escharotomy in burnedextremities

Chen et al,200339

High resolution color and pulseDoppler ultrasonography used todetermine burn wound area in 12patients with deep electrical injury

III Different tissue found to have differing degree of injury.Concluded that ultrasound could demonstrate morphologicchanges in subcutaneous tissue, muscle, and blood vesselsafter deep electric injury

Hunt et al,197940

Technetium-99 m pyrophosphate scansperformed in 14 patients with highvoltage electrical injury. Scans wereperformed between first and fifth daypost injury

II Location and extent of muscle injury was correctly ascertainedpreoperatively in all patients

Affleck et al,200141

Retrospective review of computerizedregistry identified 11 patients whounderwent Pyrophosphate (PyP)scan. Eight patients had high voltageelectrical injury, one had frostbite,and two had soft-tissue infection

III Revealed a sensitivity of 94% and specificity of 100% showingdemarcation between viable and nonviable tissue, confirmedat operation

Hammond et al,199442

Early scanning (within 3 days of injury)with PyP in 19 limbs in 15 patientswith electrical injury. Sensitivity of75% and specificity of 100%

II Compared to control group of 17 patients treated withoutPyP scan, the scan was not associated with reduced lengthof stay, or with decreased number of surgical procedures

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A wick-catheter technique was used to measure intra-muscular pressures. A threshold of 30 mm Hg was anindication for escharotomy (based on vascular com-partment syndrome literature). Whether or not thiscan be extrapolated to include electric injury is un-clear. In addition, Moylan et al36 showed that ultra-sonic (Doppler flow meter) signal from the distal ar-teries and palmar arch was a more sensitive indicatorof perfusion than clinical palpation. Salisbury37 dem-onstrated, however, that this objective measure ofperfusion could not be relied on as the sole indicatorof deep tissue viability and need for escharotomy incircumferential burns. Therefore, more sensitive in-dicators of perfusion have been investigated.

Small studies have evaluated the use of infraredphotoplethysmography (PPG) to assess vascularcompromise in injured extremities, including directvascular injury, crushing forces, and severe burns.38

PPG correlated well with muscle blood flow, and in-tramuscular pressure, but not with Doppler measure-ments.

Recently, high-resolution color and pulse Dopplerultrasound has been used to evaluate wound area inelectrical injuries.39 In this study, 12 patients withdeep electric injury were evaluated. It was found thatdegree of injury differed between tissue types.Changes in course, and blood flow speed also werenoted in injured tissue. Findings were all confirmed atsubsequent operation.

Some authors recommend the use of nuclear med-icine scans in an attempt to identify areas of musclenecrosis.40,41 Other studies have questioned the util-ity of nuclear scans in this setting. They have fallenout of favor in routine cases,42 although some centersreported use of this modality selectively.

SUMMARY

No definitive data exist to show that immediate sur-gical decompression reduces the need for amputationin any series. The management of these patients hastraditionally included immediate (within the first 24hours), surgical exploration and decompression. Amore selective approach based on clinical findingsmay be used at specialized centers.

Key Issues for Further EvaluationEvaluation of the Upper Extremity. Studies to

evaluate the utility of measuring compartment pres-sures in the presence of electrical injury need to beperformed. It is unclear whether data from the ortho-pedic and vascular literature can be extrapolated toburn care. In addition, studies evaluating more non-invasive technologies, such as infrared PPG and high-

resolution ultrasound, may add much-needed clarityto this clinical problem.

Surgical Management. Prospective randomizedstudies that evaluate immediate vs expectant debrid-ment using well-defined criteria would be useful indefining guidelines for surgical management of theinjured extremity.

Evidentiary Table. Table 2 summarizes researchon the monitoring and treatment of high-voltage up-per-extremity injury.

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