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REVIEW ARTICLE

Electricity: The Enemy Invisible

Peerzada Umar Farooq Baba, Adil Hafeez
Department of Plastic, reconstructive and microsurgery, SKIMS

ABSTRACT
Electrical injuries, as such, are less prevalent in comparison to other forms of burn injuries. However, this type of injury is considered to be one of
the most devastating injuries due to its high morbidity and mortality. It is also associated with high costs and long-term hospitalization as well as
the need for multiple surgical procedures. It is more prevalent in developing countries. Most of the pediatric population suffers injuries at home
from low voltage appliances.
The patient with electrical injury is usually a young, employed person who can potentially return to a productive working life. Successfully
achieving this goal would save society a great loss of human potential. The plastic surgeon is actively involved in all phases of the pursuit of
maximal recovery of the patient with electrical injuries. Reconstructive procedures are required both in high voltage injuries and low voltage
injuries and have improved the quality of lives of these patients by timely intervention.
Precautionary measures are necessary to reduce the incidence of high voltage injuries and their devastating effects. The incidence of high
voltage injuries would not have been so high had the electric workers been properly trained and hazards of high tension lines explained.
Moreover emphasis must be laid on the use of safety measures.
Keywords: Electrical injury, voltage, current, reconstruction
JMS: 2019; 22(e1):e004-e012 DOI: https://doi.org/10.33883/jms.v22i1.441

INTRODUCTION with high costs and longer hospitalization as well as the

Modern age is an age of electricity. It has become an
inevitable, invisible companion of modern man. Since its
inception in 1849, commercial use of electricity has been
one of the most potentially dangerous commodities in our
society. Although electrical burns occur less frequently than
thermal/scald burns, accounting for 3-9% of all patients
treated in burns centres. However, they give rise to a series
of very complex problems Electrical injuries are a common
form of trauma with a unique pathophysiology, and are
known for high morbidity and mortality. They encompass
several types, such as lightning injury, high-voltage injury,
and low-voltage injury. Clinical manifestations may range
from transient unpleasant feeling without any apparent
injury to massive tissue and /or organ system damage. Many
a times, such injuries are instantly fatal. Familiarity with the
mechanisms of injury and the principles of management
improves the patient care.1,2 These injuries are associated
Access this article online
need for multiple surgical procedures; so the need for
specific management considerations are required3, 4. The
burden of electrical burn injury is more among developing
than developed countries, with prevalence rate higher
among men5. In developing countries, people are less
acquainted to proper and safe use of electricity in contrast to
developed countries.
Electricity is unavoidable in present day life. We cannot
imagine a life without it. The uses of electricity in our daily
life are too numerous to be counted. We are becoming more
and more dependent on it, and so is the rising incidence of
electrical injuries. Demographic data reveals that more
number of electric injuries occur at work, involving the
Correspondence:
Dr. Peerzada Umar Farooq Baba, M.Ch
Associate Professor,
Department of Plastic, reconstructive and microsurgery, SKIMS
Email: drumar397@gmail.com

How to cite this article: Baba PUF, Hafeez A. Electricity: The

Website:
Enemy Invisible. jms [Internet]. 2019Mar.29 [cited
www.jmsskims.org
2019Apr.6];22(1). Available from:
http://www.jmsskims.org/index.php/jms/article/view/441
DOI:
https://doi.org/10.33883/jms.v22i1.441 Received: 27-03-2019 Accepted: 29-03-2019 Published: 30-03-2019

e004 Journal of Medical Sciences 2019; 22(1):e004-e012

 Baba PUF; et al; Electricity: The Enemy Invisible
young population and work forces - the main human
resources of countries.6 In contrast, most of the paediatric
population suffer injuries at home from low voltage
appliances.7
ELECTRICITY
Electricity is generated by the flow of electrons across a
potential gradient (difference) from high to low
concentration through a conductive material. The voltage
8
(V) is the term used for this potential difference. .Amperage
represents the rate of flow of electrons. Every time 6.242 x
1015 electrons pass a given point in 1 second, 1 ampere (A) of
current is said to have passed.
Alternating current (AC) is three times more dangerous than
direct current (DC) for the same voltage exposure, leading
to more morbidity and mortality.12,14 Skin offers greater
resistance to direct current than alternating current, thus 3-4
times more direct current is required to produce the same
biologic effect elicited by alternating current. DC current
causes cardiac rhythm disturbances, and throws the patient
off, thus, limiting the exposure to the source but inflicting
traumatic injuries. With increasing alternating current,
sensations of tingling give way to contractions of muscles.
The magnitude of the muscular contractions enhances as the
current is increased. Finally, a level of alternating current is
reached for which the subject cannot release the grasp of the
conductor. The maximum current a person can tolerate
when holding a conductor in one hand and still let go of the
conductor using the muscles directly stimulated by the
current is termed the "let-go" current. A narrow range exists
between perceptible current and the "let go" current. The
"let go" current for the average child is 3-5 mA; this is well
below the 15-30 A of common household circuit breakers.
For adults, the "let go" current is 6-9 mA, slightly higher for
men than for women. Such strong muscular reactions may
cause fractures and/or dislocations. Numerous cases of
bilateral scapular fractures and shoulder dislocations and
fractures in electric accidents have been reported.
Electrical injuries are typically divided into high-voltage
and low-voltage injuries, using 1000V as the cut off. High
morbidity and mortality has been described in 600V direct
current injury associated with "third rail" contact.10,11 In
India, standard household outlets (0.5mA, 60Hz, AC,
120V) produce startle response, cutaneous burns. >10mA
alternating current produces tetany, “locked-on”
phenomenon. >100mA produces loss of consciousness,
Journal of Medical Sciences 2019; 22(1):e004-e012
asystole, and severe tissue injury.13, 14, 15, 16 Low voltage
current injuries are similar to thermal burns. High tension
injuries (>1000 volts) result in massive necrosis of deeper
structures, often necessitating fasciotomies and major limb
amputations.17
V=IR (Ohm's law) where R is Resistance, I is current.
Resistance varies depending on the electrolyte and water
content of the body tissue through which electricity is being
conducted. Blood vessels, muscles, and nerves have high
electrolyte and water content, and, thus, low resistance, and
are good conductors of electricity better than bone, fat, and
skin.18 Resistance of the human body has been likened to that
of a leather bag filled with an electrolyte fluid, with high
resistance on the outside and lower inside19. Skin resistance
is encountered primarily in the stratum corneum. Resistance
varies among different tissues and also with condition of
skin. In vivo, however, conduction of current is related to
the composite resistance of all body tissue components and
to the cross-sectional diameter of the body part. Resistance
values of hand to foot vary from 400 to 600 Ohms and ear
to ear-100 Ohms. Again resistance is inversely proportional
to cross-sectional area of joints, so small joints of body like
joints of foot and hand suffer from maximum injury.15
Skin resistance
Mucous membranes 10 ohm/cm 2
Wet skin 1,000 ohm/cm 2
Dry skin 100,000 ohm/cm 2
2
Calloused palm skin 1,000,000 ohm/cm
Pathophysiology:
The 3 major mechanisms of electricity-induced injury are as
follows:
1. Electrical energy causing direct tissue damage, altering
cell membrane resting potential, and eliciting muscle
tetany.
2. Conversion of electrical energy into thermal energy,
causing massive tissue destruction and coagulative
necrosis. (Joule effect)
3. Mechanical injury with direct trauma resulting from
falls or violent muscle contraction.
Effects of electricity on the body are determined by 7
factors: (1) type of current, (2) amount of current, (3)
pathway of current, (4) duration of contact, (5) area of
contact, (6) resistance of the body, and (7) voltage.19
e005
 Baba PUF; et al; Electricity: The Enemy Invisible
3,4,9
Effects of Electrical Current in the Human Body
Amperage Current Reaction
< 1 mA Generally not perceptible.
1 mA Faint tingle.
3–5 mA Let-go current for an average child
5 mA Slight shock felt; not painful but disturbing. Average individual can let go. Strong involuntary
reactions can lead to other injuries.
6–8 mA Let-go current for an average woman
7–9 mA Let-go current for an average man
16mA Maximum current a person can grasp and let go
16–20 mA Tetany of skeletal muscles . Individual cannot let go, but can be thrown away from the circuit if
extensor muscles are stimulated.*
20–50 mA Paralysis of respiratory muscles; respiratory arrest
50–150 mA Threshold for VF, extreme pain, respiratory arrest (breathing stops), severe muscular contrac tions.
Death is possible.
1–4 A Rhythmic pumping action of the heart ceases. Asystole (>2 A) Muscular contraction and nerve
damage occur; death likely.
10 A Cardiac arrest and severe burns occur. Death is probable.
15 A Lowest overcurrent at which a typical fuse or circuit breaker opens a circuit!
15–30 A Common household circuit breakers
*If the ext ensor muscles are excited by shock, the person may be thr own away from the power source. The lowest
overcurrent at which a typical fuse or circuit breaker will open is 15 A.

HIGH VOLTAGE ACCIDENTS
Burns are often ultimately much worse than they appear
initially. The national electric code defines high-voltage
exposure as greater than 600 volts. In the medical literature,
high-voltage exposure is judged as greater than 1,000
volts20. In high-voltage accidents, the victim is often thrown
away from the electric circuit, which leads to traumatic
injuries (e g, fracture, brain haemorrhage). Burns due to
contact with high-voltage electric circuits conform to 4
general types:
1. Burns from an electric arc
An electric arc is formed between two bodies of sufficiently
different potential that are not in direct contact of each other.
The arc(intense, pale-violet light) consists of ionized
particles that are driven by the voltage pressure between the
two bodies. Temperature of the ionized particles and
immediately surrounding gases of the arc can reach as high
as 2500-5000o C, resulting in deep thermal burns where it
contacts the skin.
2. Burns from an electric current
When electric current passes through body of a person
between the entry and exit site the electric energy is
converted into thermal energy which causes hidden deep
tissue damage. High-voltage electric entry wounds are
charred, centrally depressed, and leathery in appearance,
while exit wounds are more likely to "explode" as the charge
exits.
3. Burn from a flame
Ignition of clothing causes direct burns from flames. Both
electro-thermal and arcing currents can ignite clothing.
4. Burn from flash
When heat from a nearby electrical arc causes thermal burns
but current does not actually enter the body, the result is a
flash burn. Flash burns may cover a large surface area of the
body but are usually only partial thickness.
MORTALITY/MORBIDITY
Electrical injuries are the fourth most common cause of
traumatic work related deaths. It is estimated that 0.8-1% of
accidental deaths are due electrical injury, with
approximately one quarter caused by natural lightning.
Overall, mortality rate is 3-15%.Morbidity and mortality
are largely affected by the particular type of electrical

e006 Journal of Medical Sciences 2019; 22(1):e004-e012

 Baba PUF; et al; Electricity: The Enemy Invisible
contact involved in each exposure. There are reports which
record deaths after exposure to 46 volts or after therapeutic
application of currents with tension as low as 30-50 volts. In
the United States, about 1000 deaths are due to electric
injuries each year.1,2
Flash burns have a better prognosis than arc or conductive
burns6. Persons, who experience low-voltage injuries
without immediate cardiac or respiratory arrest, have low
mortality, but they may have significant morbidity from oral
trauma in children who bite electrical cords22or adults who
suffer burns to the hand. High-voltage injuries often
produce severe burns and blunt trauma with high risk of
myoglobinuria and renal failure. (Photo1)
Photo 1: High tension electric injury patient with gross myoglobinuria
Age and Gender
Incidence of electrical injury is higher among boys than
girls; rates of injury in adults are significantly higher in men
than in women, likely because of occupational
predisposition. Most series show more than 80% of
electrical injuries occurring in men21,23,24,25.A bimodal
distribution of electrical injuries exists among the very
young (children <6 y) and again among young
adults/working age25.Patterns of electrical injury vary by
age (for example, low voltage household exposures among
toddlers and high-voltage exposures among risk-taking
25,26
adolescents and via occupational exposure) .
COMPLICATIONS OF ELECTRICAL INJURIES:
1. Traumatic injuries due to fall or throw away force.
Journal of Medical Sciences 2019; 22(1):e004-e012
2. Neurologic complications are the most common
complications of electric injury.In high-voltage electric
injuries, nearly 70% of patients are rendered
unconscious. Delayed spinal cord injuries causing
paraplegia or quadriplegia. Peripheral nerve injury may
be involved by direct injury at the site of entrance or exit
or in polyneuritic syndrome involving nerves far
removed from the points of contact.
3. High-voltage electric current can produce a wide variety
of different cardiac rhythm and conduction
disturbances27. Cardiac arrest either from asystole or
ventricular fibrillation often presents in electrical
injuries. Hand to hand pathway (across heart) produces
more mortality.
4. Acute pulmonary complications in the form of pleural
damage resulting in effusions and lobular pneumonitis
directly adjacent to the entrance and exit wounds .
5. A wide spectrum of abdominal visceral complications
has been reported following high-voltage electrical
injury 28 .Nonspecific adynamic ileus occurs in
approximately 25% of patients. Stress ulceration
(Curling ulcer) is probably one of the most serious
complications (3%)29.
6. In high-voltage accidents in which the current enters
near bony tissue, lesions of the bone are common30. High
resistance of bone to the passage of electric current
results in periosteal necrosis and melting of the calcium
phosphate matrix.
7. Electric injuries to the eye occur chiefly when current
enters the body through the patient's head.( Photo2)
Cataract can occur in 6% of cases22,31
Prehospital Care
First, rescuers should practise awareness of scene safety and
be sure there is no imminent threat to bystanders or
responders in attempting to remove the victim from the
electrical source. A witness of the accident must turn off the
power source as soon as possible. Wearing insulated gloves,
the victim should be separated from the circuit by a specially
insulated pole. Looping a polydacron rope around the
injured patient is another method of pulling him or her from
the electric power source. Patients may need basic or
advanced cardiac life support. Spine should be immobilized
prior to movement, indicated by the mechanism of injury.
e007
 Baba PUF; et al; Electricity: The Enemy Invisible
Given that injuries may be limited to a ventricular
arrhythmia or respiratory muscle paralysis, aggressive and
prolonged cardiopulmonary resuscitation (CPR) should be
initiated in the field for all electrical injury victims, as they
are likely to be younger with fewer comorbid conditions and
have better chances of survival after prolonged CPR.
Photo 2: Post electric burn exposed nasal bones
EMERGENCY DEPARTMENT CARE
Stabilize patients and provide/secure airway and circulatory
support as indicated by ACLS/ATLS protocols. Full spinal
immobilization as needed based on mechanism of injury.
Primary survey should assess for traumatic injuries such as
pneumothorax, peritonitis, or pelvic fractures. Initiate
cardiac monitoring for all patients with anything more than
trivial low-voltage exposures.
Hydration is the key to reducing the morbidity of severe
burns. There is no formula, however, to assist in
management due to the unpredictable nature of the
underlying tissue damage. In general, the fluid requirements
per percent of burn are 1.5 to 2 times that of a skin burn alone
given the nature of the added soft tissue injury. The rate of
fluid administration is based on the amount necessary to
maintain adequate perfusion using the same guidelines as
for burn shock management. High voltage injuries have a
e008
greater incidence of muscle necrosis, myoglobinuria, raised
creatine phosphokinase levels and renal failure. A urine
flow of 1 cc/kg/hr or more is needed until pigment load has
decreased. Mannitol (25g bolus followed by 12.5 g every 2
to 4 hours) is often required to maintain this level of output.
In addition, sodium bicarbonate is often needed to maintain
urine pH equal to or greater than 7 in order to minimize
pigment precipitation. In refractory cases, dialysis should
be considered.
Patients with high-voltage electrical injuries require the
ongoing care of a burn specialist, which should be instituted
as early as possible, as aggressive early intervention via
fasciotomy can prevent subsequent limb amputation.
Consider additional consultations with trauma/critical care,
orthopaedics, plastic surgery, and general surgery,
depending on the type and severity of traumatic injuries.
Cutaneous burn size may be of lesser magnitude compared
to the non-electric burn population. Increased rate of
orthopedic injuries, head injuries and other organ injuries
due to fall associated with high voltage injuries are
observed.46 The threshold for suspicion of associated
injuries in high voltage injuries should be kept low for
prompt diagnosis and management.
A greater number of fasciotomies, escharotomies and
amputations are seen in high voltage injuries in comparison
to low voltage injuries where amputations, if any, are
limited to digits only, most of the times.47 High tension
injury produces gradual ischemia due to thrombus
formation in the small arterioles, thus, constricting blood
flow in vessels, subsequently resulting in amputation.
Most of the injuries are afflicted to the upper limbs.33Hands
are mostly first part of body to come in contact with electric
circuit. So hand & forearm are most commonly & most
severely affected.16Small circumference also contributes to
greater tissue injury. All of this illustrates the vulnerability
of the extremities, particularly the upper limb to the injuries.
(Photo3) Injury may appear to be superficial at the first
instance; however, deeper structures like bone, tendon &
neurovascular bundles are affected requiring flap cover for
future reconstruction of these structures to get functional
and sensate hand. Involvement of the plastic surgeon in
early management helps prevent the progression of nerve
injury and preservation of muscle and tendon function.32In
the early phase, plastic surgeons are involved in
Journal of Medical Sciences 2019; 22(1):e004-e012
 Baba PUF; et al; Electricity: The Enemy Invisible
fasciotomies, nerve tunnel release, and possible options for
immediate resurfacing. Many authors like Kamar et al, 34
Zhu et al,35Yunchuanet al,36 and Chai37 all reported
reconstruction during this period with excellent results.
They utilized multiple local and pedicled flaps for
reconstruction. However, more study is needed to
determine the best timing of major reconstruction and to
evaluate whether progression of injury is prevented by
doing so.38 Patients lacking sufficient tissue to perform
successful reconstruction, dermal matrix or tissue
transplant may be considered as future options for coverage
of massive electrical wounds.39Despite all these efforts
complete return of function & sensation in hand and
forearm is very difficult to achieve.40,41 Out of various
options available for resurfacing of defects, we have to
choose one option taking into consideration, the defect size,
local tissue availability, availability of regional tissue,
condition of neurovascular bundle at recipient site. Groin
flap is a time tested, easily available work horse option with
proper positioning of hand without much discomfort to
patient. Next easily available option is random pattern
abdominal flap or its various modifications. Reverse radial
forearm flap can be used in cases with availability of local
tissue in radial forearm territory. Cross finger flap and First
dorsal metacarpal artery flap are used for covering small
defects over fingers. For larger defects which cannot be
covered by other options, free tissue transfer is to be
considered.42
Photo 3: High tension electric injury with charred
right hand and forearm
Scalp injuries are also challenging to definitively cover.
Many types of flaps(local, regional and distant) have been
reported and dermal matrix or substitute maybe a viable
option, if all other options are exhausted.42
Journal of Medical Sciences 2019; 22(1):e004-e012
Reconstructive procedures improve the quality of lives of
these patients by timely intervention.7Amputations, major
or minor (as per the indication) are performed at this stage.
The advocates of early surgery need further studies to reach
some final protocol designing.43Authors like Al-Qattan et
al44 and Barone et al45 have described satisfactory results
with splinting after primary healing. Physical and
occupational therapy is started to minimize complications
such as contracture, decreased range of motion and eventual
joint fusion, pressure sores, and generalized
deconditioning. The plastic surgeon revisits the patient after
the primary healing period is over; trying to fully restore
function. Particularly, tendon and nerve procedures may
restore some lost function during the late reconstructive
phase. Ultimately, all these interventions may decrease final
impairment and facilitate them return to work and society as
a useful member.9
The operative procedures required and length of hospital
stay are more in high voltage injuries.48The patient is usually
a young, employed person who can potentially return to a
productive working life. Successfully achieving this goal
would save society a great loss of human potential and
benefit the patient greatly. The impact of amputation is
grievous in the life of electric burn survivor both physically
and economically. The psychosocial impact of such events
leaves a stigma in the patient's life forever. Most of the
patients are linemen or workers and are not able to resume
their occupation. Rehabilitation of such patients is another
issue.49
Electric department workers (Photo4) are at a greater risk of
exposure to high voltage injuries. To reduce the incidence of
high voltage injuries and their devastating effects,
precautionary measures are indispensable. (One of the most
effective precautions was expressed by Kennely in 1927
who recommended keeping one hand in the pocket while
visiting an electric plant!) Main culprit is lack of proper
knowledge and training of electrical workers.
Standardization of electrical devices, continuous
supervision of workers, proper use the devices, security
precautions, using “danger” labels on highly dangerous
electrical devices, restriction of access of unskilled
individuals to dangerous electrical instruments, setting
proper shifts, settlement of continuous educational
programs for workers and electrician, informing them about
e009
 Baba PUF; et al; Electricity: The Enemy Invisible
the dangers of improper use of electrical devices and
explaining preventive methods to them would be beneficial
in reducing this type of injury. New rules and regulations
should be designed and implemented for prevention of
electrical burn injuries. Use of insulated devices, ground
fault circuit interrupters (GFCI) may prove a boon.
Departments should have a safety wing, laying emphasis on
safety measures like helmets, electrician's gloves, safety
belts, insulated ladders and other insulated equipments. Up-
gradation of transmission system especially in rural areas
can decrease such accidents. For general population mass
media awareness programs on electrical safety are
necessary. Proper and quick referral after initial
resuscitation at peripheral centres can save many lives.
Photo 4: Electric workers without any precautionary measures
or safety gadgets
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