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We read with interest the Cover Features article on Electrical Injury by Waldmann et al in this month's BMJ. As Plastic and Reconstructive surgeons that have dealt with spectrum of electrical burns in adult and paediatric patients, we feel the article, although wide in scope, under emphasises the potential serious surgical consequences of these injuries.
Firstly, it makes no reference to standardised emergency management of these patients as per Advanced Trauma Life Support (ATLS) and Emergency Management of Severe Burns (EMSB) precepts, crucial for the correct management of these potentially critically ill patients. This is widely practised by Emergency Department physicians, Trauma Surgeons as well as Burns and Plastic Surgeons around the world, daily. Also, quiet simply electrical injuries are burn injuries.
Secondly, only a token image (Fig 2) and part of a cartoon (Fig 3) is dedicated to the actual burn injury itself, which although small in terms of total body surface area, can be limb threatening due to the circulatory compromise in the upper and lower limbs requiring emergent escharotomies and fasciotomies under general anaesthetic. Furthermore, early tangential excision, debridement and skin grafting under general anaesthetic along with multiple dressing changes in theatre and on the ward, may be required to ensure correct healing of the burn. Importantly, modern Burns Units provide total patient care with HDU/ICU beds and staff and have identical means of invasive cardio-respiratory and circulatory support as most Level 3 Critical Care Units. They are not merely a debridement and grafting service.
Thirdly, there is no comment on fluid resuscitation and the need to maintain a high urine output of more than 1.5ml/kg/hr to abrogate the effects of rhabdomyolysis and acute kidney injury due to release of myoglobin from muscle damaged by the electrical injury. Rhabdomyolysis also affects cardiac as well as skeletal muscle and there is the potential for continuous damage to deeper tissues and bone due to the dynamic nature of the electrical burn injury.
We feel the above points add further important information that was missing from the original article,
Competing interests: No competing interests
This article, featured on the front cover of the BMJ as 'Managing Electrical Injury', hardly does what it says on the tin. Whilst the authors provide a hint of the potential complexity of the problems associated with the passage of electrical injury injury through the human body, they virtually dismiss the management as "mainly symptomatic". That is to ignore a whole host of problems which should be dealt with not by awaiting symptoms, but by the experienced clinician anticipating problems.
For example, a problem not often appreciated in the case of the "finger skin burns" illustrated at fig. 2A, is that such burns may be far more than skin only, with a deep underlying column of injured tissue which if not addressed will persist and often become infected over many weeks. Or that the 'severe foot burn' seen in fig 2B may represent the exit/entry burn of a high tension current which has also caused un-appreciated bone and muscle heating leading to very severe secondary effects such as haemolysis, rhabdomyolysis, and compartment syndrome with secondary circulatory occlusion to the extremity. These must all be dealt with ahead of symptoms by protecting renal circulation, fasciotomies and possibly massive tissue debridement.
Setting aside the fact that it is quite simply unfair on readers to suggest that the management of electrical injuries can be usefully covered in three pages, the generalist will rightly ask questions such as "when can I allow a patient to be unsupervised after suffering an electric shock?", "when might there be complications ahead?", "what is the difference between low and high tension electrical injury", and "when should I involve a specialist?". These questions are neither asked nor answered in the article and to perfectly fair to the authors, perhaps the BMJ should instead have entitled the piece as "A brief review of the possible effects of electric shock" to avoid encouraging readers into thinking they might pick up practical management points in this field.
Competing interests: No competing interests