INTRODUCTION

Electrical burns are a distinctive and severe form of trauma, marked by deep tissue destruction and a wide spectrum of systemic complications. Unlike thermal burns, the visible extent of injury in electrical trauma often underrepresents the underlying visceral involvement, particularly in high-voltage accidents. These injuries typically cause severe lesions at contact points, most often affecting the limbs, while intrathoracic injuries remain uncommon.

Electrical injuries account for a disproportionately high number of burn unit admissions and represent a significant public health concern in Colombia. Despite their prevalence, intrathoracic complications such as pneumothorax, pneumopericardium, and direct pulmonary injury are rarely documented in the literature. When present, however, these complications may contribute to a complex clinical course and prolonged hospitalization.

We describe an unusual case of high-voltage electrical trauma that caused full-thickness chest wall injury, followed by pneumothorax, pulmonary involvement, and pleural infection. This report highlights the importance of early multidisciplinary management, close monitoring of clinical evolution, and vigilant detection of delayed complications, all of which are essential for optimizing patient outcomes.

CASE REPORT

A 65-year-old male patient sustained a 2% total body surface area (TBSA) electrical burn after accidental contact with overhead power lines. Initial evaluation at a low-complexity hospital revealed an open wound on the right chest wall (Fig. 1). Prehospital management included fluid resuscitation and coverage of the wound with a rectangular sterile occlusive dressing applied on three sides. The patient was admitted to the burn unit 90 minutes after injury. On arrival, he presented with respiratory distress and reduced chest expansion; right-sided open pneumothorax was confirmed, and an emergent tube thoracostomy was performed. Rib fractures and flail chest were ruled out (Fig. 2). Cardiac arrhythmia was excluded through noninvasive monitoring and confirmed with an electrocardiogram. Additionally, the patient developed mild rhabdomyolysis without early acute kidney injury, with creatine phosphokinase levels peaking on day 3 (on admission, 1,495 IU/L; day 1, 1,121 IU/L; day 2, 3,200 IU/L).

On hospital day 4, dyspnea persisted, and chest pain intensified. The C-reactive protein level increased from 87 to 233 mg/L. Blood cultures were collected, and empiric antimicrobial therapy was initiated. Thoracic CT revealed pneumopericardium, pneumomediastinum, residual pneumothorax, loculated pleural effusion, middle and lower lobe atelectasis, and subcutaneous emphysema (Fig. 3).

The patient subsequently developed dysfunction of the chest tube drainage. A multidisciplinary team opted to close the chest wall defect through multiple debridement procedures, the application of a negative pressure wound therapy system, and eventually a complex flap reconstruction. Drainage of the loculated pleural collections was performed by thoracoscopy, and the patient completed a course of ceftazidime-avibactam to treat Klebsiella pneumoniae carbapenemase–producing Pseudomonas aeruginosa. He was discharged after 42 days of hospitalization.

Ethics statement

This study was approved by the Institutional Review Board of Subred Integrada de Servicios de Salud Norte E.S.E. (No. CEI-58-25). Informed consent for publication of the research details and clinical images was obtained from the patient.

DISCUSSION

In Colombia, electrical injuries are a common cause of hospitalization and the leading cause of burn-related death [1]. Unlike in the United States, where electrical injuries account for only 3.6% of burn unit admissions, at Simón Bolívar Hospital, the largest national referral burn center in Colombia, they represent 24.3% of admissions, with approximately 119 hospitalizations annually [2]. This places the burn unit in fifth place worldwide for the highest annual number of hospitalizations due to electrical injuries over the past two decades, surpassed only by Safdarjung Hospital (New Delhi, India), Sawai Man Singh Hospital (Jaipur, India), Southwest Hospital TMMU (China), and Motahari Hospital (Tehran, Iran) [2].

Unlike burns of thermal origin (flame and scald injuries), electrical burns demonstrate a unique pathophysiology arising from combined electrobiological and electrothermal effects [3]. These mechanisms typically result in more severe tissue damage, numerous complications, a greater number of surgical interventions, prolonged hospitalization, and an increased risk of amputation [4]. A key feature of electrical burns is the lack of correlation between TBSA and the severity of visceral or muscular involvement, which complicates both diagnosis and the establishment of effective treatment for acute and chronic complications.

Although cardiac involvement of electrical or ischemic origin has been reported following electrical burns, there is limited information regarding thoracic or abdominal visceral involvement, with an incidence of only 1.7% or less [5,6]. In these cases, deep burns are expected due to the conversion of electrical to thermal energy through the Joule effect [3], often producing deep partial-thickness or full-thickness injuries.

Reports of full-thickness burns associated with chest wall defects and exposure of intrathoracic viscera are exceedingly rare. The first such case, described by Haberal et al. [5], involved a 15-year-old patient with exposure of the left lung, liver, spleen, and stomach. The patient developed a gastric fistula and subsequently a low-output small-bowel fistula, ultimately dying on day 44 after injury. Xu et al. [7] reported a second case, a patient with a 6-cm thoracoabdominal wall defect, partial diaphragmatic necrosis, and necrosis of the right middle and lower lung lobes requiring lobectomy. This patient also had carbonized necrosis of the left lower limb and intestinal obstruction, among other severe complications. A third case, presented by Chandra and Kumar [8], described a precordial chest wall defect through which the beating heart was visible; closure by secondary intention occurred prior to surgical coverage. In the most recent report, Sun and Wang [9] described a child with intrathoracic exposure requiring extensive debridement, partial resection of costal arches, and left lower lobectomy. A shared feature of the last two cases was the need for high transhumeral amputation of the left arm.

The lung parenchyma may undergo coagulation necrosis similar to that observed in skeletal muscle [10]. In a recent review, Chang et al. [11] identified eight cases of electrical burn–associated lung injury, six of which involved direct pulmonary damage. Closed pneumothorax is also a rare complication, with Dash et al. [6] reporting it in only 1 of 550 cases. Pulmonary injury and pneumothorax may appear immediately, within days, or even in the absence of chest wall burns, as described by Handa et al. [12] in a low-voltage exposure case, or with late onset, as reported by Gümüş [13] 5 days after injury.

The management of such burns is challenging not only because of cutaneous destruction but also due to impairment of respiratory mechanics from rib fractures, open or closed pneumothorax, and associated pulmonary complications. These include atelectasis, pleural effusion, empyema [12], pneumonia, and parenchymal damage unrelated to trauma or infection, ranging from mild injury [14] to pulmonary hemorrhage [15], infarction, or necrosis requiring lobectomy [9,10].

Due to their high complexity, electrical burns are associated with prolonged hospitalization [4]. Our patient required 42 days of inpatient care. Other reports describe even longer stays: 50 days [10], 56 days [9], 60 days [7], and 77 days [11].

Rare complications of high-voltage electrical trauma may involve direct damage to lung tissue caused by current flow, explained in part by Kouwenhoven factors. The complexity and variability of these complications highlight the necessity of an interdisciplinary treatment approach. Secondary pleural infection following open pneumothorax should be anticipated and managed using strategies such as surgical drainage and thoracostomy.

ARTICLE INFORMATION

Author contributions

Conceptualization: NN; Investigation: all authors; Methodology: NN, FF; Project administration: NN, FF; Visualization: FF; Writing–original draft: NN, SJB, LSN; Writing–review & editing: all authors. All authors read and approved the final manuscript.

Conflicts of interest

The authors have no conflicts of interest to declare.

Funding

The authors received no financial support for this study.

Data availability

Data sharing is not applicable as no new data were created or analyzed in this study.

Fig. 1.

Full-thickness electrical burn involving the anterior chest wall, resulting in open pneumothorax.

Fig. 2.

Chest x-ray revealed pneumothorax on the right side, but without any evidence of subcutaneous emphysema.

Fig. 3.

A cross-sectional computed tomographic image of the chest showed areas of consolidation in the right lung parenchyma with subcutaneous emphysema, pneumomediastinum, and pleural effusion. (A) Obtained at the level of the pulmonary veins. (B) Obtained at the level of the right diaphragmatic dome.

REFERENCES

• 1. Navarrete N, Rodriguez N. Epidemiologic characteristics of death by burn injury from 2000 to 2009 in Colombia, South America: a population-based study. Burns Trauma 2016;4:8.ArticlePubMedPMCPDF
• 2. Navarrete N, Schulz JT. Electrical burn injuries in Colombia, South America: a major source of morbidity and mortality. Ann Burns Fire Disasters 2025;38:108–18.PubMedPMC
• 3. Fish RM, Geddes LA. Conduction of electrical current to and through the human body: a review. Eplasty 2009;9:e44PubMedPMC
• 4. Handschin AE, Vetter S, Jung FJ, Guggenheim M, Künzi W, Giovanoli P. A case-matched controlled study on high-voltage electrical injuries vs thermal burns. J Burn Care Res 2009;30:400–7.ArticlePubMed
• 5. Haberal M, Uçar N, Bayraktar U, Oner Z, Bilgin N. Visceral injuries, wound infection and sepsis following electrical injuries. Burns 1996;22:158–61.ArticlePubMed
• 6. Dash S, Arumugam PK, Muthukumar V, Kumath M, Sharma S. Study of clinical pattern of limb loss in electrical burn injuries. Injury 2021;52:1925–33.ArticlePubMed
• 7. Xu X, Zhu W, Wu Y. Experience of the treatment of severe electric burns on special parts of the body. Ann N Y Acad Sci 1999;888:121–30.ArticlePubMed
• 8. Chandra R, Kumar P. Electric burn of the precordial region. Indian J Plast Surg 1986;19:106–9.Article
• 9. Sun Y, Wang X. Full thickness chest wall defection and lung injury by electrical burn: a 5-years-old child reconstruction case. Asian J Surg 2019;42:474–6.ArticlePubMed
• 10. Masanès MJ, Gourbière E, Prudent J, et al. A high voltage electrical burn of lung parenchyma. Burns 2000;26:659–63.ArticlePubMed
• 11. Chang LR, Chen CC, Lin IC, Tsai IT, Feng GM, Jeng SF. Acute lung parenchymal injury caused by high-voltage electrical injury: a case report and literature review. E-Da Med J 2023;10:52–8.Article
• 12. Handa A, Tendolkar MS, Singh S, Gupta PN. Electrical injury: an unusual cause of pneumothorax and a review of literature. BMJ Case Rep 2019;12:e230590.ArticlePubMedPMC
• 13. Gümüş N. Pneumothorax followed by atelectasis after severe electrical burn. J Burn Care Res 2009;30:1050.ArticlePubMed
• 14. Alpaslan M, Oktay M, Kiliç E. Lung parenchymal damage due to high voltage electric shock. J Emerg Med Case Rep 2023;14:91–2.Article
• 15. Chen CW, Lin YK, Yeh YS, Chen CW, Lin TY, Chang SH. Low-voltage electricity-associated burn damage of lung parenchyma: case report and literature review. J Emerg Med 2021;60:e33–7.ArticlePubMed

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