Burns Open 1 (2017) 20–24

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Burns Open
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A review of electrical burns admitted in a Philippine Tertiary Hospital

Burn Center
Margarita S. Elloso ⇑, Jose Joven V. Cruz
a
Department of Surgery, Division of Plastic, Reconstructive, Aesthetic and Burn Surgery, University of the Philippines – Philippine General Hospital, Ermita, Manila, Philippines

a r t i c l e i n f o a b s t r a c t

Article history: Electrical injury is the 4th most common cause of burn which continues to be one of the most distressing
Received 7 April 2017 trauma injuries in developing countries. In the Philippines, the number of electrical injuries are typically
Received in revised form 23 April 2017 underreported.
Accepted 24 April 2017
This study is a descriptive retrospective analysis of patients suffering from electrical burns admitted at
Available online 6 May 2017
the Philippine General Hospital, Alfredo T. Ramirez Burn Center (PGH-ATR) from January 2004 to
December 2012.
Keywords:
A total of 706 (28.3%) patients with electrical burns were reviewed. Majority were males of working age
Electrical
Burn
and injuries were work related (80.45%) of which 75.5% were construction workers. The primary cause in
Voltage majority of the cases was accidental contact of overhead electrical power lines by metal poles. Most of the
Work patients admitted were high voltage electrical injuries (79.46%), 46.03% had severe electrical burns and
Surface 11.33% had associated traumatic injuries. There was a delay in time of injury to admission, 48.73% arrived
Injury at the emergency room >8 h after the injury. 40.73% of the patients underwent surgery, most of which
had moderate to severe burns. Average length of stay was 14–28 days. Overall morbidity rate and mor-
tality rate were 2.12% and 2.41% respectively.
The increase in the rate of electrical injuries may be linked to the country’s rapid pace of industrializa-
tion. Prevention must be prioritized and preventive activities should be aimed to reduce the incidence.
Ó 2017 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction electrical injuries appears to be increasing. This may be due to

Burn is commonly seen in developing countries which cause
significant morbidity and mortality [1]. Burns are also one of the
most expensive of traumatic injuries due to the extended hospital
stay and rehabilitation [2,3]. The injuries result in higher rates of
permanent disability and economic hardship for the individual as
well as their families [3]. Electrical injury, a certain type of burn,
is the most devastating and is the 4th most common cause of
admission in burn units worldwide [4]. This type of injury not only
involves the skin but deeper tissues that causes multiple acute and
chronic manifestations not seen in other burns. Individuals tend to
stay longer in hospitals, as well as morbidity and mortality rates
are much higher [4]. Burn centers across the globe have been
reporting less and less incidence of electrical injuries [5]. This is
in part due to findings and recommendations from international
studies regarding preventive programs for electrical injuries [6].
Despite this downward trend, locally the number of patients with
⇑ Corresponding author at: Zone 6, Moco Ext. Ilaya Carmen, Cagayan de Oro City
9000, Philippines.
E-mail addresses: madge.elloso@gmail.com, a9pvw@yahoo.com (M.S. Elloso).
increased exposure to potential hazards and the lack of appropriate
training and education regarding safety and proper handling of
electricity. With the rapid pace of industrialization in the Philip-
pines, the risk mostly involves front line construction workers.
The Philippines has a total of 4 burn centers and Philippine
General Hospital, Alfredo T. Ramirez Burn Center (PGH-ATR) is
the principal referral facility in the country [7]. It treats approxi-
mately 300 to 400 burn cases a year, the most in the country,
and has an extensive experience in managing patients with electri-
cal injuries. This places the study in the best setting to gather
substantive data on electrical injuries.
The goal of this study is to review and describe the profile and
characteristics of electrical burns seen at the Burn Center.
2. Methodology
This is a descriptive retrospective study of patients with electri-
cal injuries that were admitted from January 2004 to December
2012 at the Philippine General Hospital, Alfredo T. Ramirez Burn
Center (PGH-ATR).

http://dx.doi.org/10.1016/j.burnso.2017.04.002
2468-9122/Ó 2017 The Authors. Published by Elsevier Ltd.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
 M.S. Elloso, J.J.V. Cruz / Burns Open 1 (2017) 20–24
The study population consists of 706 patients who sustained
electrical injuries, with or without cutaneous burns, admitted at
the ATR Burn Center. Patients were identified using the Integrated
Surgical Information System (ISIS) of the Department of Surgery.
Patient charts were retrieved with all the names omitted to protect
patient privacy. This study was conducted with the ethics approval
from EHRO (Expanded Hospital Research Office of PGH).
The study population was divided into two age groups, adult
(age  18) and pediatric (age < 18). The percentage of total body
surface involvement was classified as minor (10% TBSA [total
body surface area]), moderate (11–19% TBSA) and severe (20%
TBSA) based on the American Burn Association classification of
burn severity. Type of electrical burn refers to voltage intensity,
high voltage (>1000 v) or low voltage (<1000 v). Injury was classi-
fied as work related if the injury was caused or contributed by
events or exposures in the work environment or non-work related.
The time it takes from the injury to referral or admission to the
burn center was categorized as either immediate < (1 h), early
(<8 h post-injury), intermediate (>8 h), or late (>24 h post-injury).
Patients were also grouped in relation to the length of hospital
stay, those who stayed for less than or equal to 7 days, those
who stayed between 7 days to 14 days, those who stayed between
15 and 28 days, and those who stayed for more than a month.
Subjects were also grouped based on the number of operations,
those who had none, those who had 1 operation, and those who
had more than 2. Patients were also categorized as having morbid-
ity, such as pneumonia, burn infection and graft loss, as well as
mortality, either the patient survived or not.
Descriptive statistics were done based on age, gender, TBSA,
type of electrical burn, mode of injury, types of trauma, length of
time from injury to admission/referral, types of operations, total
length of hospital stay and number of operations.
2.1. Patient management
Patients were managed according to our burn guidelines at the
PGH-ATR Burn Center which is based on the American Burn Asso-
ciation Practice Guidelines for Burn Care. All of the patients
received standard intensive care and trauma survey at the emer-
gency room prior to admission at the burn center. Electrocardio-
Fig. 1. Annual distribution of patients with electrical injury 2004–2012.
21
gram monitoring was done and initial labs/diagnostics were
taken. Patients with moderate to major burns were resuscitated
using the Parkland formula, regulated to maintain an adequate
urine output which was monitored hourly. All patients received
immunization for tetanus prophylaxis, prophylactic antibiotics
were not used. When there were clinical signs of compartment
syndrome, escharotomy/fasciotomy was done.
Daily wound care was done with silver sulfadiazine sandwich
dressing which is the most available dressing our burn center.
Wound status was assessed daily during dressing changes.
Debridement of necrotic tissues, excision and grafting was done
usually within 4–5 days. Limb amputations were performed after
the formation of the demarcation line which was mostly after
7 days.
Management of the patients included the cooperation of the
anesthesiologists, pediatricians and rehabilitation medicine. Reha-
bilitation began immediately after the injury to ensure a speedy
return of a functional patient to society. Rehabilitation included
splinting and positioning, active and passive exercises.
3. Results
A total of 2596 burn patients were admitted at the PGH-ATR
burn Center from January 2004 to December 2012. 706 were
patients with electrical injuries. Fig. 1 shows the number of
patients with electrical injuries from 2004 to 2012 which displays
an increase in the number of electrical injuries.
This study reveals that most of the electrical burn patients
admitted were adult, employed males particularly construction
workers injured at work as shown in Table 1, which is consistent
with other studies [8]. It is significant to note that there are more
injured construction workers than electricians, 533 compared to
47. In about 64.59% of the cases, accidental contact of overhead
electrical power lines by metal poles in the hands of construction
workers was the primary cause of injury.
Table 2 shows that high voltage electrical injury is a common
cause of admission and is directly proportional to the severity,
and increased length of hospital stay. Almost all of individuals with
severe TBSA burns came from high voltage (99.69%); 87.97% of
individuals with moderate TBSA burns came from high voltage;
22 M.S. Elloso, J.J.V. Cruz / Burns Open 1 (2017) 20–24

Table 1 Table 3
Demographic profile of patients with electrical Number of operations, operations done, hospitaliza-
injury. tion duration, morbidly, mortality.

Independent Variable N (%) Variable N (%)

Sex Patients
Male 685 (97) 1 surgery 138 (20)
Female 21 (3) 2 or more surgeries 147 (21)
Age Type of Surgeries
<18 71 (10) Tangential excision, STSG 129 (24)
>18 635 (97) Debridement 147 (27)
Place of burn STSG 76 (14)
Home 138 (20) Amputations 59 (11)
Work 586 (80) Fasciotomy/escharotomy 67 (12)
Occupation Others 64 (12)
Electrician 47 (7) Hospital stay
Construction worker 533 (76) <7 days 172 (24)
Non occupational 126 (18) 7–14 days 137 (19)
Mode of injury 14–28 days 230 (33)
Direct 250 (35) >1 month 167 (24)
Secondary contact 456 (65) Morbidity
Pneumonia 10 (1)
Graft loss 5 (0.7)
Mortality
Pulmonary 9 (1.2)
Table 2 Burn wound sepsis 8 (1.1)
Type of electrical injury, total body surface area involve-
ment, time of consult, associated trauma. STSG – split thickness skin grafting.

Variable N (%)
Type of electrical injury
>1000 v 561 (79) 4. Discussion
<1000 v 145 (21)
TBSA In the 2012 WHO data, burn deaths every year amounted to
Minor < 10% 223 (32)
195,000 and majority occur in low and middle-income countries
Moderate > 10% 158 (22)
Severe > 20% 325 (46) and almost half occur in the WHO South-East Asia Region [11].
Time Of the different types of burns, electrical burns are one of the
<1 h 35 (5) most distressing [3]. There are no studies on the global epidemiol-
1–8 h 327 (46) ogy of electrical injuries but a number of regional studies provide
>8 h 187 (26)
>24 h 157 (22)
some data.
Trauma 80 (11) From January 2004 to December 2012, 706 (28.3%) patients
Spinal cord injury 14 (18) admitted at the PGH-ATR Burn Center constituted of electrical
Cranial Injury 13 (16) burns. The most recent published study on electrical injury in the
Abdominal Injury 4 (5)
Philippine General Hospital was in 1995 [9]. The study had a total
Fractures 27 (34)
Multiple injuries 22 (28) of 211 admitted burn patients and 68 (32.2%) were associated with
electrical injuries. In a study done by Nable et al. in 1997, a total of
149 patients were admitted at the Center and electrical burns
accounted for 41.6% of the cases [10]. The incidence of electrical
and only 43.95 of individuals with minor TBSA burns came from injury is quite higher than in developed countries. International
high voltage. data shows that electrical injuries account for 5.8% of all burn
46.32% consulted at the ER between 1–8 h post burn and the cases. For example, the USA (3.7%), Italy (4%), Singapore (2.8%), Tai-
48.73% more than 8 h after injury. The delay in admission at the wan (5.6%) and China (6.9%) [5,12–15]. However, developing coun-
hospital can be due to the distance from the place of burn to the tries have electrical burn admission rate between 21–27% [16].
hospital, or the patients were initially managed at a nearer hospital The high incidence of electrical burns may be the consequence
prior to transfer to the PGH-ATR Burn Center. of the low social and economic level of the population, improperly
Concomitant trauma was seen in 11.33% of patients with elec- insulated wires, poorly placed and managed electrical switches,
trical injuries, which were usually due to falls from scaffolding. illegal electrical connections, and repair work on the electricity
As shown in Table 3, 56.23% of patients stayed in the hospital grid done by non-professionals [17].
longer than 14 days (duration of 14–28 days and >1 month). The demographic profile of electrical burn patients admitted in
A total of 542 operations were performed on 285 (40.37%) the study is consistent with other studies ? adult, male construc-
patients, most of which had moderate to severe burns. tion workers. This can be attributed to the lack of appropriate
While admitted at the PGH-ATR burn center, 10 patients sus- training and education with regards to safety and proper handling
tained pneumonia while 5 patients had partial and/or complete of electricity plus the increased exposure to potential hazards due
graft loss. Overall morbidity rate is 2.12%. 17 patients expired at to the country’s industrialization [18]. A 10-year retrospective
the burn center, giving an overall mortality rate of 2.41%. Mortality study in China, which reviewed 383 patients, also revealed similar
rate is relatively low, which is a marked improvement from the findings. Their patients were predominantly male (90.3%), and
1995 and 1997 studies wherein mortality was 22.7% and 20.8% were composed by those injured in work-related incidents
respectively. Patients who died, succumbed to pneumonia and (78.3%) [19]. In India, 84 patients with electrical injuries were ana-
burn wound sepsis, similar to the study in 1995 wherein the lyzed from 2004 to 2009 to identify the causative and demographic
patients died from sepsis rather than a direct result of electrical risk factors. The age of patients ranged from 3 to 61 years and
injury [9,10]. males accounted for 84.5% [20]. Work-related activity was
 M.S. Elloso, J.J.V. Cruz / Burns Open 1 (2017) 20–24
responsible for the majority of these high-voltage injuries, with the
most common occupations being linemen and electricians. These
patients tended to be younger men in the prime of their working
lives who are more at risk due to the fact that their occupation
involves more exposure to electric current, high voltages, heavy
machinery and equipment. This may also be due to improper
equipment, education and/or training. Human error can also be a
factor but proper training and education can negate this, as was
indicated in other studies [8,21].
Electrical wirings in the Philippines are often installed low
enough that they can easily be reached and some are very close
to homes. A number of patients reported that they sustained their
injuries from secondary contact from these low lying live wires
with such objects as metal poles, wrench, umbrellas, metal ladders
etc. Even fixing the TV antenna or flying a kite can be dangerous.
High voltage electrical injury was noted to be a common cause
of admission at the PGH-ATR Burn Center which was also directly
related to severity of injury and length of hospital stay. Similar to a
study in Brazil, where high voltage was directly correlated to
severity, clinical complications, and amputation. A higher propor-
tion of amputations and compartment syndrome were noted along
with lengthier hospital stays, higher number of patients subjected
to flaps as well as a higher incidence of cardiac arrhythmias [22].
In the study, electrical injury had a low morbidity and mortality
rate (2.12% and 2.41% respectively). A marked improvement from
the 1995 and 1997 studies [9,10]. This can be attributed to
improved initial monitoring and resuscitation, better wound man-
agement, and early excision and grafting. In other countries, mor-
bidity and mortality rate from electrical injury are as follows:
Czech Republic 17.07%, Turkey 9.1%, Taiwan, 6%, United States 3–
15% [23–26]. In a study in China, one hospital had no mortalities.
They attributed this to the early excision of necrotic tissue, result-
ing in a decreased risk of late invasive infection. The avoidance of
invasive infection, often leading to sepsis, limits this most common
cause of death in the bum unit [27]. The variation of morbidity and
mortality may simply arise from severity of injury, characteristics
of electrical injury, and lever of specialized care that each patient
receives. The decrease in electrical injury related mortality over
time is probably as a result of advance in modern burn care and
trauma [28]. However, it would be rational to assume that some
patients died before proper medical assistance could be rendered
at an institutional level as here are three variants in electric inju-
ries: Death of the victim on the scene of incident, transportation
to hospital and treatment, and death in the hospital in spite of
the treatment, which may underestimate the mortality from elec-
trical injuries [26]. In the United States, the most common cause of
death after electrical injury remains to be cardiac arrest following
acute arrhythmias at the site of the accident [29].
Post injury, the quality of life and work of patient with electrical
burns suffer. Most patients have significant difficulty in returning
to work. Only 23% of patients are able to return to their previous
employment and perform the same duties, with a mean time off
work of 17 weeks, and 32% of patients did not return to work at
all. Other patients either took on modified duties with the same
employer or worked in an entirely new setting altogether. The
return to work characteristics are known to be much worse than
reported in general burn literature [30].
5. Limitations
Due to the retrospective design of the study, early or late out-
comes including return to work, disability, long term complica-
tions, quality of life were not investigated.
Also, since the authors practice in a resource-restricted country,
it is unusual for us to perform early tissue transfers in patients with
23
electrical injury. We advise following the standard protocols for
free tissue transfer only if it is applicable to their facility of practice.
6. Conclusion
The increase in electrical burns may be linked to the country’s
rapid pace of industrialization especially when proper education
and training with regards to safety and proper handling of electric-
ity is overlooked. With this, the workforce may be severely affected
since majority of the victims are males of working age. Not only
that, care for burns is a long and costly journey and most of these
patients are the sole provider for their family.
Prevention must be prioritized and preventive activities should
be aimed to reduce the incidence of burns to address the burden of
burn management in developing countries. Prevention is not easy.
There are different risk factors and epidemiological patterns in dif-
ferent communities, thus government programs must be utilized
to educate people on safety and proper handling of electricity. Edu-
cation, enforcement and training should be stressed as the primary
weapons to combat this problem. The enforcement of existing
safety regulations should be reiterated, and the employers should
do stricter adherence to these regulations. Workers exposed to
electric current and electrical equipment should be fully trained/
certified and properly dressed. The education/certification will les-
sen the burden of having electrical burns, which affects the person,
the family as well as the workplace. It decreases productivity and
also adds cost of having to train another work to replace their jobs.
Conflict of interest statement
The author confirms that there are no known conflicts of inter-
est associated with this publication and there has been no signifi-
cant financial support for this work that could have influenced its
outcome.
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