96 Electrical Injuries

Published

September 15, 2025

96.1 Introduction

Electrical injuries are significant but often under-recognised causes of morbidity and mortality in children. They occur when electric current passes through the body, causing a spectrum of damage ranging from minor superficial burns to catastrophic multi-organ injury and death. Children—particularly toddlers and school-aged boys—are at higher risk due to exploratory behaviour, accidental contact with faulty wiring, and unsafe household electrical installations.

In Ghana and many parts of sub-Saharan Africa, the risk of electrical injuries is heightened by several contextual realities: exposed electrical wires in homes, non-compliant installations, poorly maintained appliances, unprotected power outlets, illegal connections, and the proliferation of artisanal repair shops. Rural electrification projects and urban slum environments also contribute to unsafe electrical exposure. As a result, paediatric emergency units in districts, regional hospitals, and tertiary facilities regularly encounter children with electrical burns, arrhythmias, tetanic muscle contractions, and associated trauma.

This chapter comprehensively reviews the mechanisms, pathophysiology, clinical patterns, management principles, complications, and prevention of electrical injuries in children, integrating Ghana-specific context for clinicians working in resource-variable environments.

96.2 Basic Electrical Concepts Relevant to Injury

Understanding electrical principles helps clinicians anticipate the pattern and severity of injury.

96.2.1 Voltage

Low voltage: <1000 volts (typical household current: 110–240V)
High voltage: ≥1000 volts (industrial lines, transformers)

Low-voltage injuries are more common in homes, while high-voltage injuries, though less frequent, cause far more severe and deep tissue damage.

96.2.2 Current Type

Alternating Current (AC): Used in households; more dangerous because it causes tetanic muscle contractions, which may “freeze” the child to the source.
Direct Current (DC): Causes a single muscular contraction that often throws the child away from the source, sometimes resulting in secondary trauma.

96.2.3 Amperage

The most important determinant of injury severity.
As little as 0.1–0.2 amperes passing through the heart can cause ventricular fibrillation.

96.2.4 Resistance

Body tissues vary in resistance:

High resistance: skin, fat, bone
Low resistance: nerves, vessels, muscle, mucous membranes

Wet skin dramatically lowers resistance, making children more vulnerable to severe injury during bathing, rainy conditions, or contact with wet surfaces.

96.3 Mechanisms of Injury

Electrical injuries involve multiple simultaneous processes:

96.3.1 Direct Electrical Damage

Electric current disrupts cell membranes and causes immediate necrosis of nerves, vessels, muscle, and organs.

96.3.2 Thermal Injury

Conversion of electrical energy into heat can cause deep burns that extend beyond what is visible on the skin.

96.3.3 Mechanical Injury

Tetanic muscle contractions may result in:

Fractures
Dislocations
Falls from heights
Blunt trauma

96.3.4 Cardiac Effects

Current passing through the thorax can cause:

Ventricular fibrillation
Asystole
Conduction abnormalities

96.3.5 Respiratory Arrest

From tetanic paralysis of respiratory muscles or central nervous system disruption.

96.3.6 Myonecrosis and Rhabdomyolysis

High-voltage injuries can cause massive muscle breakdown leading to acute kidney injury (AKI).

96.4 Epidemiology and Local Context in Ghana

Children aged 1–5 years are most vulnerable due to curiosity and hand-to-mouth interactions. School-aged boys (6–12 years) are at higher risk of outdoor incidents, such as contact with fallen power lines or tampering with electrical equipment.

Key Ghana-specific risk factors include:

Exposed sockets and non-childproof outlets.
Use of extension boards without protective covers.
Faulty electrical wiring, common in low-income households.
Overloaded sockets during power fluctuations or generator use.
Illegal connections (“tapping light”) with poorly insulated wires.
Contact with fallen power lines during heavy rains.
Burns during attempted repairs by untrained individuals.

The combination of inadequate regulation and widespread informal electrical work creates a unique risk environment for children.

96.5 Classification of Electrical Injuries

Electrical injuries in children can be categorised as:

Low-voltage household injuries
- Most common in toddlers.
- Often involve oral commissure burns from chewing charger cables or cords.
High-voltage industrial or outdoor injuries
- Cause deep tissue damage, rhabdomyolysis, limb ischemia.
- Common in children playing near transformers or climbing trees near power lines.
Lightning strikes
- Rare but deadly.
- Often associated with mass casualties in rural communities.
Flash burns (arc injuries)
- Occur without direct contact.
- Caused by electrical arcs generating intense heat.

96.6 Pathophysiology

The pattern of injury depends on voltage, resistance, current pathway, and duration of contact.

96.6.1 Current Pathway

Determines the organs affected:

Hand-to-hand or hand-to-foot pathways may cross the thorax → risk of arrhythmia.
Mouth-to-hand injuries in toddlers → severe facial burns and feeding difficulties.
Head-to-foot pathways → highest risk of brain and spinal cord injury.

96.6.2 Skin Burns Do Not Predict Severity

Electrical burns often appear deceptively small. Deep muscle necrosis may exist beneath a tiny entry wound. For this reason, the clinical evaluation must not be guided solely by external findings.

96.6.3 Rhabdomyolysis

High-voltage electrical injury leads to: - Muscle breakdown
- Release of myoglobin
- Renal tubular obstruction
- Acute kidney injury

96.7 Clinical Presentation

Children present with a wide range of symptoms depending on the severity of injury.

96.7.1 General Symptoms

Burns at entry and exit sites
Pain or numbness
Weakness
Arrhythmias
Loss of consciousness
Respiratory distress
Seizures
Myoglobinuria (dark urine)

96.7.2 Cardiac Manifestations

Ventricular fibrillation
Tachyarrhythmias
AV block
Asystole

Cardiac arrest at the scene is the most common cause of death.

96.7.3 Neurological Manifestations

Confusion
Seizures
Peripheral neuropathy
Spinal cord injury
Some children develop delayed neurological deficits days to weeks later.

96.7.4 Skin and Soft Tissue Injury

Entry and exit wounds
Deep tissue necrosis
Compartment syndrome
Limb ischaemia

96.7.5 Oral Commissure Burns (Common in Toddlers)

Caused by chewing electrical cords.
Complications: - Bleeding when eschar separates
- Microstomia
- Feeding difficulty
- Cosmetic deformity

96.7.6 Secondary Trauma

Including fractures, head injury, and soft tissue damage due to falls.

96.8 Investigations

Investigations are tailored to the severity of the injury.

96.8.1 Essential Tests

ECG for all patients
Urinalysis for myoglobin
Serum electrolytes and renal function
CK and myoglobin

96.8.2 Additional Tests (as indicated)

Full Blood Count
Chest X-ray (if inhalation injury or arrhythmia suspected)
Echocardiography (if chest pain or arrhythmia)
CT/MRI if neurological deficit
Doppler ultrasound for limb vascular compromise

96.8.3 Monitoring

Children with moderate-to-severe injuries should be observed for: - Arrhythmias (continuous ECG monitoring)
- AKI (urine output, creatinine)
- Compartment syndrome

96.9 Management

Management begins with immediate stabilisation, followed by detailed evaluation and treatment of burns, cardiac complications, and systemic injury.

96.10 Initial Stabilisation

96.10.1 Ensure Scene Safety

Do not touch the child until the electrical source is deactivated.
High-voltage injuries require safety clearance from the electricity company.

96.10.2 Airway, Breathing, Circulation (ABCs)

Give high-flow oxygen.
Secure airway if the child has inhalation injury, altered mental status, or respiratory distress.
Provide fluid resuscitation according to burn protocols or rhabdomyolysis risk.

96.11 Control Active Arrhythmias

Follow paediatric advanced life support protocols.
Defibrillate ventricular fibrillation promptly.

96.12 Specific Management

96.12.1 1. Burn Care

Clean wounds with saline.
Apply non-adherent dressings.
Elevate limbs to reduce swelling.
Provide analgesia (paracetamol, opioids if needed).
Avoid topical agents that interfere with wound assessment.

96.12.1.1 Surgical referral is required for:

Deep partial or full-thickness burns
Compartment syndrome
Limb ischemia requiring fasciotomy
Debridement of necrotic tissue

96.12.2 Fluid Management

Children with high-voltage injuries or rhabdomyolysis need aggressive hydration: - Aim for urine output of 1–2 mL/kg/hour.
- Use IV crystalloids.
- Consider sodium bicarbonate infusion if myoglobinuria is significant.

96.12.3 Management of Oral Commissure Burns

Maintain oral hygiene.
Apply soft dressings.
Monitor for bleeding when eschar separates.
Speech and feeding support as needed.

96.12.4 Pain Management

IV analgesics for severe burns.
Avoid NSAIDs in AKI or rhabdomyolysis.

96.12.5 Antibiotics

Not routinely recommended unless: - Infection is present
- Open wounds with contamination
- Surgical debridement

96.12.6 Tetanus Prophylaxis

Administer according to immunisation status.

96.12.7 Management of Compartment Syndrome

High-voltage injuries may cause large amounts of muscle swelling.
Signs include:

Pain out of proportion to injury
Palpable tenseness
Distal neurovascular compromise

Immediate fasciotomy is required.

96.12.8 Renal Protection

Maintain adequate hydration.
Monitor creatinine closely.
Treat rhabdomyolysis aggressively to prevent AKI.

96.13 Complications

Electrical injuries can lead to severe, long-term complications.

96.13.1 Acute Complications

Cardiac arrest
Respiratory arrest
Arrhythmias
Shock
Seizures
Rhabdomyolysis
AKI
Compartment syndrome
Limb ischaemia and need for amputation

96.13.2 Chronic Complications

Peripheral neuropathy
Cognitive impairment
Chronic pain
Cataracts (weeks to years later, especially after high-voltage injury)
Scarring and contractures
Oral commissure deformities
Growth disturbances in injured limbs

Children require long-term follow-up by a multidisciplinary team.

96.14 Prevention

Preventive strategies are crucial to reducing the burden of electrical injuries.

96.14.1 Household Interventions

Childproof outlets.
Keep cords out of reach.
Replace frayed wires.
Avoid using exposed extension boards.
Supervise toddlers, especially during rainy seasons.

96.14.2 Community and Policy Strategies

Strengthen electrical installation regulations.
Public education via CHPS compounds and community durbars.
Enforcement against illegal connections.
Safe playground design.
School curricula incorporating electrical safety education.

96.14.3 Industry and Utility-Level Measures

Regular maintenance of transformers and power lines.
Prompt removal of fallen electrical cables.
Rapid response during storms or power surges.

96.15 Prognosis

Prognosis depends on voltage exposure, current pathway, duration of exposure, and timeliness of resuscitation.
Key prognostic indicators include:

Presence of cardiac arrest at the scene
Deep tissue necrosis
Rhabdomyolysis and AKI
Neurological impairment
Extent of burns

Children who survive the acute phase may still experience lifelong disability, psychosocial difficulties, cosmetic deformities, and chronic pain.

96.16 Key Points

Electrical injuries in children range from minor burns to multi-organ failure.
Voltage, current pathway, and duration of contact determine severity.
Cardiac arrhythmias and respiratory arrest are leading causes of mortality.
High-voltage injuries require aggressive fluid management and assessment for compartment syndrome.
Oral commissure burns are characteristic of toddlers chewing electrical cords.
Prevention is essential and must be community-driven, regulatory, and household-based.

96.17 Further Reading

Koumbourlis AC. Electrical injuries. Crit Care Med.
Arnoldo BD, Purdue GF, Kowalske K. Electrical injuries in children. J Craniofac Surg.
World Health Organization. Child Injury Prevention Guidelines.
Paediatric Society of Ghana. Paediatric Emergency Management Protocols.
American Burn Association. Guidelines for managing electrical burns.