The triad of cutaneous injury, occult soft tissue destruction and multiple organ damage secondary to high-voltage electrical injury may lead to a potentially devastating scenario. The management of the injured soft tissue can be particularly challenging because treatment decisions directly affect both the acute resuscitation of the patient and the long-term functional result. Opinions regarding the timing and extent of the initial debridement and subsequent wound closure in patients that have sustained significant soft tissue injury secondary to electrical trauma are far from uniform. These differences of opinion and consequent varied therapeutic approaches evolve from different understandings of the pathophysiologic mechanism of this injury.

Several mechanisms have been postulated to explain the particular form of tissue destruction caused by high-voltage electrical injury. Artz and Rouse and Dimick equate electrical trauma with the injury associated with a crush syndrome. Lee believes that nonthermal electrical damage at the cellular level is an important component. Many others, however, ascribe the damage caused by electrical trauma to heat generated by the passage of current through the tissues, the joule effect.

Although any one of the above theories may account for acute cell death, none of them adequately addresses the concept of progressive tissue necrosis. This concept has a major influence on soft tissue management. Key questions about soft tissue management include:

1. Does all lethal tissue injury occur immediately? or

2. Does progressive tissue damage occur after electrical trauma?

3. If tissue damage is progressive, is it preventable?

4. Can nonviable tissue be reliably identified?

5. Is there an optimal time sequence for debridement and coverage?

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