Open access Research BMJ Open: first published as 10.1136/bmjopen-2018-025990 on 14 May 2019. Downloaded from Acute and long-term clinical, neuropsychological and return-to-work sequelae following electrical injury: a retrospective cohort study Nada Radulovic,1 Stephanie A Mason,2 Sarah Rehou,2,3 Matthew Godleski,2,4 Marc G Jeschke 2,3 To cite: Radulovic N, ABSTRACT Strengths and limitations of this study Mason SA, Rehou S, et al. Objective To determine acute and long-term clinical, Acute and long-term clinical, neuropsychological, and return-to-work (RTW) effects of ► Our study evaluated broad sequelae, including clin- neuropsychological and return- electrical injuries (EIs). This study aims to further contrast to-work sequelae following ical, neuropsychological and return-to-work param- sequelae between low-voltage and high-voltage injuries electrical injury: a retrospective eters during acute and long-term intervals, which (LVIs and HVIs). We hypothesise that all EIs will result cohort study. BMJ Open have not been collectively investigated for electrical in substantial adverse effects during both phases of 2019;9:e025990. doi:10.1136/ injuries in prior studies. bmjopen-2018-025990 management, with HVIs contributing to greater rates of ► Outcome measures included a comprehensive list of sequelae. Prepublication history and neuropsychological symptoms and diagnoses that ► Design Retrospective cohort study evaluating EI additional material for this have not been contrasted between voltage groups paper are available online. To admissions between 1998 and 2015. in existing literature. Setting Provincial burn centre and rehabilitation hospital view these files, please visit ► Due to the longitudinal nature of our outcomes of the journal online (http:// dx. doi. specialising in EI management. interest, and the associated loss to follow-up, our org/ 10. 1136/ bmjopen- 2018- Participants All EI admissions were reviewed for acute findings may underrepresent the long-term neuro- 025990). clinical outcomes (n=207). For long-term outcomes, psychosocial sequelae within our study cohorts. rehabilitation patients, who were referred from the burn Received 12 August 2018 centre (n=63) or other burn units across the province Revised 1 December 2018 (n=65), were screened for inclusion. Six patients were Accepted 11 February 2019 excluded due to pre-existing psychiatric conditions. This INTRODUCTIOn http://bmjopen.bmj.com/ cohort (n=122) was assessed for long-term outcomes. Electrical injuries (EIs) account for approx- Median time to first and last follow-up were 201 (68–766) imately 5% of all annual burn admissions and 980 (391–1409) days, respectively. in North America, yet are a leading cause Outcome measures Acute and long-term clinical, of occupational burns worldwide.1 These neuropsychological and RTW sequelae. injuries result in substantial limitations that Results Acute clinical complications included infections impede return-to-work (RTW) and decrease (14%) and amputations (13%). HVIs resulted in greater © Author(s) (or their quality of life.2–5 Several studies globally employer(s)) 2019. Re-use rates of these complications, including compartment permitted under CC BY-NC. No syndrome (16% vs 4%, p=0.007) and rhabdomyolysis have proposed that EIs are implicated in on October 1, 2021 by guest. Protected copyright. commercial re-use. See rights (12% vs 0%, p<0.001). Rates of acute neuropsychological persistent functional, cognitive and neuro- and permissions. Published by sequelae were similar between voltage groups. Long-term psychological sequelae, including flashbacks, BMJ. outcomes were dominated by insomnia (68%), anxiety depression, anxiety and post-traumatic stress 1 School of Medicine, Queen's (62%), post-traumatic stress disorder (33%) and major disorder (PTSD).3 5–16 However, clinical University, Kingston, Ontario, depressive disorder (25%). Sleep difficulties (67%) were Canada evidence regarding such effects is limited, as 2Ross Tilley Burn Centre, common following HVIs, while the LVI group most frequently the majority of reported findings are based 17 Sunnybrook Health Sciences experienced sleep difficulties (70%) and anxiety (70%). on case reports or small clinical studies. Centre, Toronto, Ontario, Canada Ninety work-related EIs were available for RTW analysis. Additionally, uncertainty with EI classifica- 3 Sunnybrook Research Institute, Sixty-one per cent returned to their preinjury employment tion remains. EIs can be classified in various Sunnybrook Health Sciences and 19% were unable to return to any form of work. RTW ways and defined as either high or low voltage. Centre, Toronto, Ontario, Canada rates were similar when compared between voltage groups. 4 Currently, an EI below 1000 V is considered Physical Medicine and Conclusions This is the first investigation to determine Rehabilitation, St. John's Rehab acute and long-term patient outcomes post-EI as a a low-voltage injury (LVI), whereas one of Hospital, Toronto, Ontario, continuum. Findings highlight substantial rates of 1000 V or greater is considered a high-voltage Canada neuropsychological and social sequelae, regardless of injury (HVI). These voltage categories have 18 Correspondence to voltage. Specialised and individualised early interventions, been defined based on arcing risk. Clear Dr Marc G Jeschke; including screening for mental health concerns, are classification is necessary as LVIs and HVIs marc. jeschke@ sunnybrook. ca imperative to improvingoutcomes of EI patients. have been suggested to result in different Radulovic N, et al. BMJ Open 2019;9:e025990. doi:10.1136/bmjopen-2018-025990 1 Open access clinical courses. For example, two recent reviews found and EI type (flash, contact, both contact and flash, light- BMJ Open: first published as 10.1136/bmjopen-2018-025990 on 14 May 2019. Downloaded from that HVIs experience longer hospital stays and greater ning or unspecified). rates of complications relative to LVIs.19–21 Differences Clinical outcomes during the acute period that were between these EI subgroups during the acute and long- collected included length of stay (LOS) at RTBC, LOS term phases of treatment are currently unknown. adjusted for %TBSA (LOS/%TBSA), number of ampu- Within our provincial healthcare system, a large tations, amputation levels and number of operations. proportion of EI survivors are treated at a single acute Incidences of mortality, rhabdomyolysis, compartment care surgical site, the Ross Tilley Burn Centre (RTBC) at syndrome, one or more infections, sepsis, multiple organ Sunnybrook Health Sciences Centre (SHSC). Typically, patients failure and rehabilitation requirements (inpatient or requiring ongoing inpatient or outpatient rehabilitation outpatient) were additionally analysed. services are managed at St. John’s Rehabilitation Hospital Patients transferred to SJRH for rehabilitation under- (SJRH), which additionally serves as a referral site for went neuropsychological screening by the care team other acute care centres and the workplace injury insur- prior to discharge, as part of the required referral docu- ance system. Fewer sites allow for the centralisation of mentation. This screen was observational and included services and collection of information for an uncommon the following symptoms: depressed mood, anxiety, diagnosis across multiple phases of care. flashbacks, avoidance, hypervigilance, hyperarousal, There are two primary objectives to this study. First, we nightmares, sleep difficulties, social withdrawal, suicidal aim to determine the effects of EIs on the clinical course ideations, memory and concentration difficulties, dizzi- of acute hospitalisation and long-term outcomes during ness, headaches and phantom limb pain. rehabilitation. Second, we aim to examine and contrast individual short-term and long-term outcomes by voltage Long-term period outcomes (HVI vs LVI). We hypothesise that EIs result in substan- Injury, demographic and neuropsychological outcomes tial morbidity during acute hospitalisation and are associ- data for patients in the long-term cohort were obtained ated with significant impairments in rehabilitation, RTW through chart review of SJRH documentation. Variables and neuropsychology. Additionally, we expect HVIs to be collected included voltage (HVI vs LVI), work-related implicated in more adverse clinical sequelae, longer reha- nature of the EI and occupation. Neuropsychological bilitation phases and poorer long-term outcomes. symptoms identified from rehabilitation records were depressed mood, anxiety, flashbacks, avoidance, hypervig- ilance, hyperarousal, nightmares, sleep difficulties, social withdrawal, suicidal ideations, memory and concentra- MATERIALS AND METHODS tion difficulties, dizziness, headaches, phantom limb Study design pain and chronic pain. Additionally, we recorded formal We conducted a cohort study of all EI patients admitted diagnoses of PTSD, major depressive disorder (MDD), http://bmjopen.bmj.com/ to RTBC and SJRH between November 1998, the date generalised anxiety disorder (GAD), adjustment disorder of RTBC establishment at SHSC, and December 2015. and panic disorder, as well as the time to diagnosis post- Patients were defined as HVI (≥1000 V) or LVI (<1000 injury. Treatment by a psychologist or psychiatrist and the V), based on the voltage documented at the time of acute need for medications to address these sequelae were also admission at RTBC or from existing records at the time of recorded, with rates defined as the proportion of patients entering