eMedicine Specialties > Emergency Medicine > Environmental

Electrical Injuries: Differential Diagnoses & Workup

Author: Tracy A Cushing, MD, MPH, Instructor in Medicine, Department of Emergency Medicine, Harvard Medical School; Attending Physician, Department of Emergency Medicine, Mount Auburn Hospital
Coauthor(s): Ronald K Wright, MD, JD, Associate Professor (Retired), Department of Pathology, University of Miami School of Medicine; Private Practice, Forensic Pathology
Contributor Information and Disclosures

Updated: Oct 7, 2009

Differential Diagnoses

Burns, Chemical
Seizures
Burns, Ocular
Status Epilepticus
Burns, Thermal
Syncope
Intracranial hemorrhage
Ventricular Fibrillation
Lightning Injuries
Respiratory arrest
Rhabdomyolysis

Workup

Laboratory Studies

In all patients in whom history or physical examination indicates more than a trivial electrical injury and/or exposure, the following tests should be considered:

  • CBC – Hemoglobin, hematocrit, white blood cell count 
  • Electrolytes – Sodium, potassium, chloride, carbon dioxide, blood urea nitrogen, glucose 
  • Creatinine – High risk of rhabdomyolysis/myoglobinuria in electrical injuries (Mortality in one study was 59% for patients with acute renal failure.17 )
  • Urinalysis – Specific gravity, pH, hematuria, and urine myoglobin if urinalysis is positive for hemoglobin 
  • Serum myoglobin – If urine is positive for myoglobin, a serum level should be obtained.
  • Arterial blood gas – To be obtained for patients needing ventilatory support, or those with severe rhabdomyolysis who require urine alkalinization therapy
  • Creatine kinase (CK) levels
    • This level may be extremely elevated in patients with massive muscle damage from high-voltage injuries. Normal CK values published by the laboratory may be low for typical construction and electrical workers whose vocation involves heavy exercise. Some evidence suggests that initial CK levels may help predict which patients could benefit from early fasciotomy to prevent subsequent amputations.11
    • CK-MB subfractions are also often elevated in electrical injuries, but their significance in the setting of electrical injuries is not known.3 CK-MB fractions and troponin should be checked if the current pathway involved the chest/thorax, if the patient has any signs of ischemia or arrhythmia on ECG, or if the patient has specific complaints of chest pain.
    • One retrospective review created a decision rule for clinical identification of patients likely to have rhabdomyolysis.18 Multivariate modeling revealed that high-voltage exposure, prehospital cardiac arrest, full-thickness burns, and compartment syndrome were associated with myoglobinuria. Defining "positive" as ³ 2 of these findings has a sensitivity of 96% and negative predictive value of 99%.

Imaging Studies

Choice of imaging studies is dictated by the presence of blunt trauma, altered mental status, cardiac or respiratory arrest, and type of electrical exposure. Studies to be considered are as follows:      

  • Chest radiography - Any patient with cardiac or respiratory arrest, shortness of breath, chest pain, hypoxia, CPR at the scene, or fall/blunt trauma  
  • Head computed tomography - Any patient with altered mental status, significant traumatic mechanism, seizure, loss of consciousness, or focal neurologic deficits 
  • Cervical/spine imaging - Patients with loss of consciousness or significant trauma should be cervical spine immobilized and imaging performed accordingly. Normal mental status without significant injuries may be clinically cleared, whereas others may require plain radiography. Patients with focal neurologic deficits or evidence of spinal cord injury should undergo full spinal imaging.  
  • CT/ultrasonography - Depending on the amount of trauma sustained and the pathway of the current exposure, patients may require further imaging to evaluate for internal injuries. Imaging modality varies depending on suspected injury and availability.

Other Tests

  • ECG/cardiac monitoring
    • All adult patients should have an initial ECG and cardiac monitoring in the ED. The duration of monitoring depends on the circumstances of the exposure; any patients with chest pain, arrhythmia, abnormal initial ECG, cardiac arrest, loss of consciousness, transthoracic conduction, or history of cardiac disease should undergo monitoring. No definitive guideline is available on duration of monitoring for adults, but patients are unlikely to develop significant arrhythmias after 24-48 hours if they have no other significant injuries. Several large reviews have not identified risk of delayed arrhythmia among patients with low-voltage exposure and no arrhythmia upon initial presentation. One such review of 196 exposures concludes that admission for cardiac monitoring is not indicated among such patients.19
    • Several studies have shown that low-voltage (household) exposures in patients with no cardiac complaints and a normal initial ECG can be safely discharged.20 It is unclear how this applies to patients with preexisting heart disease. In the pediatric population, healthy children with household current exposures (120 to 140V, no water contact) can be safely discharged if they are asymptomatic, without a VF or cardiac arrest in the field, and have no other injuries requiring admission.21

Procedures

  • Obtain intravenous access in all adult patients with electrical injuries. Consider central access in any patient with significant trauma, large burns, cardiac or respiratory arrest, or loss of consciousness. 
  • Fasciotomy of a burned extremity may be required in high-voltage injuries or prolonged low-voltage injuries. Obtain early surgical consultation, preferably with experience in electrical burn injury, early in the treatment of any patient with a high-voltage burn, since appropriate early fasciotomies may prevent subsequent amputations. If emergently indicated, fasciotomy should not be delayed.

More on Electrical Injuries

Overview: Electrical Injuries
Differential Diagnoses & Workup: Electrical Injuries
Treatment & Medication: Electrical Injuries
Follow-up: Electrical Injuries
Multimedia: Electrical Injuries
References
[ CLOSE WINDOW ]

References

  1. Lee RC. Injury by electrical forces: pathophysiology, manifestations, and therapy. Curr Probl Surg. Sep 1997;34(9):677-764. [Medline].

  2. Rabban J, Adler J, Rosen C, Blair J, Sheridan R. Electrical injury from subway third rails: serious injury associated with intermediate voltage contact. Burns. Sep 1997;23(6):515-8. [Medline].

  3. Spies C, Trohman RG. Narrative review: Electrocution and life-threatening electrical injuries. Ann Intern Med. Oct 3 2006;145(7):531-7. [Medline].

  4. Koumbourlis AC. Electrical injuries. Crit Care Med. Nov 2002;30(11 Suppl):S424-30. [Medline].

  5. Price T, Cooper MA. Electrical and Lighting Injuries. In: Marx J, Hockberger R, Walls R. Rosen's Emergency Medicine. 3. 5th. Mosby; 2002:2010-2020.

  6. Rai J, Jeschke MG, Barrow RE, Herndon DN. Electrical injuries: a 30-year review. J Trauma. May 1999;46(5):933-6. [Medline].

  7. Casini V. Worker Deaths by Electrocution: A summary of NIOSH Surveillance and Investigative Findings. Washington DC: Department of Health and Human Services (NIOSH); May 1998. 5-8.

  8. Luz DP, Millan LS, Alessi MS, et al. Electrical burns: A retrospective analysis across a 5-year period. Burns. Jun 5 2009;[Medline].

  9. Thomas SS. Electrical burns of the mouth: still searching for an answer. Burns. Mar 1996;22(2):137-40. [Medline].

  10. Ferreiro I, Melendez J, Regalado J, Bejar FJ, Gabilondo FJ. Factors influencing the sequelae of high tension electrical injuries. Burns. Nov 1998;24(7):649-53. [Medline].

  11. Kopp J, Loos B, Spilker G, Horch RE. Correlation between serum creatinine kinase levels and extent of muscle damage in electrical burns. Burns. Nov 2004;30(7):680-3. [Medline].

  12. Hussmann J, Kucan JO, Russell RC, Bradley T, Zamboni WA. Electrical injuries--morbidity, outcome and treatment rationale. Burns. Nov 1995;21(7):530-5. [Medline].

  13. Baker MD, Chiaviello C. Household electrical injuries in children. Epidemiology and identification of avoidable hazards. Am J Dis Child. Jan 1989;143(1):59-62. [Medline].

  14. Rabban JT, Blair JA, Rosen CL, Adler JN, Sheridan RL. Mechanisms of pediatric electrical injury. New implications for product safety and injury prevention. Arch Pediatr Adolesc Med. Jul 1997;151(7):696-700. [Medline].

  15. Jensen PJ, Thomsen PE, Bagger JP, Nørgaard A, Baandrup U. Electrical injury causing ventricular arrhythmias. Br Heart J. Mar 1987;57(3):279-83. [Medline].

  16. Saffle JR, Crandall A, Warden GD. Cataracts: a long-term complication of electrical injury. J Trauma. Jan 1985;25(1):17-21. [Medline].

  17. Haberal MA. An eleven-year survey of electrical burn injuries. J Burn Care Rehabil. Jan-Feb 1995;16(1):43-8. [Medline].

  18. Rosen CL, Adler JN, Rabban JT, Sethi RK, Arkoff L, Blair JA, et al. Early predictors of myoglobinuria and acute renal failure following electrical injury. J Emerg Med. Sep-Oct 1999;17(5):783-9. [Medline].

  19. Bailey B, Gaudreault P, Thivierge RL. Cardiac monitoring of high-risk patients after an electrical injury: a prospective multicentre study. Emerg Med J. May 2007;24(5):348-52. [Medline].

  20. Dollery W. Towards evidence based emergency medicine: best BETs from the Manchester Royal infirmary. Management of household electrical injury. J Accid Emerg Med. Jul 1998;15(4):228. [Medline].

  21. Chen EH, Sareen A. Do children require ECG evaluation and inpatient telemetry after household electrical exposures?. Ann Emerg Med. Jan 2007;49(1):64-7. [Medline].

  22. Achauer BM, Martinez SE. Burn wound pathophysiology and care. Crit Care Clin. Mar 1985;1(1):47-58. [Medline].

  23. Bailey B, Gaudreault P, Thivierge RL. Cardiac monitoring of high-risk patients after an electrical injury: a prospective multicentre study. Emerg Med J. May 2007;24(5):348-52. [Medline].

  24. Bailey B, Gaudreault P, Thivierge RL. Neurologic and neuropsychological symptoms during the first year after an electric shock: results of a prospective multicenter study. Am J Emerg Med. May 2008;26(4):413-8. [Medline].

  25. Baxter CR, Waeckerle JF. Emergency treatment of burn injury. Ann Emerg Med. Dec 1988;17(12):1305-15. [Medline].

  26. Canady JW, Thompson SA, Bardach J. Oral commissure burns in children. Plast Reconstr Surg. Apr 1996;97(4):738-44; discussion 745; 746-55. [Medline].

  27. Colic M, Ristic L, Jovanovic M. Emergency treatment and early fluid resuscitation following electrical injuries. Acta Chir Plast. 1996;38(4):137-41. [Medline].

  28. Cooper MA. Electrical and lightning injuries. Emerg Med Clin North Am. Aug 1984;2(3):489-501. [Medline].

  29. El-Badawy A, Mabrouk AR. Epidemiology of childhood burns in the burn unit of Ain Shams University in Cairo, Egypt. Burns. Dec 1998;24(8):728-32. [Medline].

  30. Fish RM. Electric injury, part I: treatment priorities, subtle diagnostic factors, and burns. J Emerg Med. Nov-Dec 1999;17(6):977-83. [Medline].

  31. Fish RM. Electric injury, part III: cardiac monitoring indications, the pregnant patient, and lightning. J Emerg Med. Feb 2000;18(2):181-7. [Medline].

  32. Gomez R, Cancio LC. Management of burn wounds in the emergency department. Emerg Med Clin North Am. Feb 2007;25(1):135-46. [Medline].

  33. Hammond JS, Ward CG. High-voltage electrical injuries: management and outcome of 60 cases. South Med J. Nov 1988;81(11):1351-2. [Medline].

  34. Leibovici D, Shemer J, Shapira SC. Electrical injuries: current concepts. Injury. Nov 1995;26(9):623-7. [Medline].

  35. Milano M. Oral electrical and thermal burns in children: review and report of case. ASDC J Dent Child. Mar-Apr 1999;66(2):116-9, 85. [Medline].

  36. Singerman J, Gomez M, Fish JS. Long-term sequelae of low-voltage electrical injury. J Burn Care Res. Sep-Oct 2008;29(5):773-7. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

electrical injury, electrical shock, electrical burns, lightning injury, electrocution, low-voltage injury, high-voltage injury, nerve depolarization, muscle depolarization, alternating current injury, AC injury, thermal burns, electrical flashes, direct current electrical injuries, DC electrical injuries, flash burns, arc burns, contact burns, internal electrical injury, external electrical energy, burn treatment, electrical injury treatment, myoglobinuria, myoglobinemia, lightning strike

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Tracy A Cushing, MD, MPH, Instructor in Medicine, Department of Emergency Medicine, Harvard Medical School; Attending Physician, Department of Emergency Medicine, Mount Auburn Hospital
Tracy A Cushing, MD, MPH is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine, and Wilderness Medical Society
Disclosure: Nothing to disclose.

Coauthor(s)

Ronald K Wright, MD, JD, Associate Professor (Retired), Department of Pathology, University of Miami School of Medicine; Private Practice, Forensic Pathology
Ronald K Wright, MD, JD is a member of the following medical societies: American Academy of Forensic Sciences, American College of Legal Medicine, American Medical Association, American Society for Clinical Pathology, College of American Pathologists, and National Association of Medical Examiners
Disclosure: Nothing to disclose.

Medical Editor

Jerry Balentine, DO, Professor of Emergency Medicine, New York College of Osteopathic Medicine; Executive Vice President, Chief Medical Officer, Attending Physician in Department of Emergency Medicine, St. Barnabas Hospital
Jerry Balentine, DO is a member of the following medical societies: American College of Emergency Physicians, American College of Osteopathic Emergency Physicians, American College of Physician Executives, American Osteopathic Association, and New York Academy of Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Eric L Legome, MD, Chair, Department of Emergency Medicine, St Vincent's Hospital Manhattan; Associate Professor, Department of Emergency Medicine, New York Medical College
Eric L Legome, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, Council of Emergency Medicine Residency Directors, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Jonathan Adler, MD, Attending Physician, Department of Emergency Medicine, Massachusetts General Hospital; Division of Emergency Medicine, Harvard Medical School
Jonathan Adler, MD is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.