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Electrical Injuries in Emergency Medicine Treatment & Management

  • Author: Tracy A Cushing, MD, MPH, FACEP, FAWM; Chief Editor: Joe Alcock, MD, MS  more...
 
Updated: Mar 08, 2016
 

Prehospital Care

First, rescuers should practice awareness of scene safety and be sure there is no imminent threat to bystanders or responders in attempting to remove the victim from the electrical source. For high-voltage incidents, the source voltage should be turned off before rescue workers enter the scene.

After ensuring scene safety, rescuers should approach victims of electrical injuries as both trauma and cardiac patients. Patients may need basic or advanced cardiac life support and should undergo spinal immobilization as indicated by the mechanism of injury.

Given that injuries may be limited to a ventricular arrhythmia or respiratory muscle paralysis, aggressive and prolonged CPR should be initiated in the field for all electrical injury victims, as they are likely to be younger with fewer comorbid conditions and have better chances of survival after prolonged CPR.

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Emergency Department Care

Stabilize patients and provide airway and circulatory support as indicated by ACLS/ATLS protocols. Obtain airway protection and provide oxygen for any patient with severe hypoxia, facial/oral burns, loss of consciousness/inability to protect airway, or respiratory distress. Cervical spine immobilization with or without spinal immobilization is needed based on the mechanism of injury/neurologic examination. Primary survey should assess for traumatic injuries such as pneumothorax, peritonitis, or pelvic fractures.

After primary assessment, begin fluid resuscitation and titrate to urine output of 0.5-1 mL/kg/h in any patient with significant burns or myoglobinuria. Consider furosemide or mannitol for further diuresis of myoglobin. Urine alkalinization increases the rate of myoglobin clearance and can be achieved using sodium bicarbonate titrated to a serum pH of 7.5. Obtain adequate intravenous access for fluid resuscitation, whether peripheral or central. Initiate cardiac monitoring for all patients with anything more than trivial low-voltage exposures.

Burn care should include tetanus immunization as indicated, wound care, measurement of compartment pressures as indicated, and it may include early fasciotomy. Extremities with severe burns should be splinted in a functional position after careful documentation of full neurovascular examination.

The risks of electrical injury to the fetus in a pregnant patient are unknown. Pregnant women who are involved in electrical injuries should have a careful examination for traumatic injuries and obstetrical consultation. Women in the second half of pregnancy should be admitted for fetal monitoring in any cases of severe electrical injuries, high-voltage exposures, or minor electrical injuries with significant trauma.

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Further Inpatient Care and Transfer

Further inpatient care

Inpatient care is required for patients with anything other than minor low-voltage injuries. Burn and trauma care, preferably at a specialized center, should be instituted early. Any patients with cardiac arrest, loss of consciousness, abnormal ECG, hypoxia, chest pain, dysrhythmias, and significant burns or traumatic injuries must be admitted.

Transfer

All patients with a history of exposure to high-voltage electricity and patients with significant burns should be transferred to a specialized burn center for further inpatient treatment and rehabilitation.

Pediatric patients with significant oral burns should be transferred to a pediatric burn center. Patients with minor oral burns who have close follow-up can be discharged.

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Consultations

Patients with high-voltage electrical injuries require the ongoing care of a burn specialist, which should be instituted as early as possible, as aggressive early intervention via fasciotomy can prevent subsequent limb amputation.

Consider additional consultations with a trauma/critical care specialist, orthopedist, plastic surgeon, and general surgeon, depending on the type and severity of traumatic injuries.

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Complications

Low-voltage

If no significant burns are present and if consciousness returns before arriving to or in the ED, full recovery is expected. Rare persistent arrhythmias have been reported.

Persistence of unconsciousness carries a worse prognosis, and full recovery is not expected after 24 hours of unconsciousness.

With proper treatment, the disfigurement of low-voltage mouth injuries can be minimized. Scarring is almost always present.

High-voltage

Survival with massive burns is now the rule rather than the exception. However, rates of amputation and significant morbidity from traumatic injuries and burns remain high.

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Prevention

Prevention of high-voltage electrical injuries requires ongoing public education about potential hazards, and targeted education to individuals in construction trades, those using cranes and lifts, or those exposed to the extreme danger of overhead power lines. One study found particularly high rates of electrical injuries in cable splicers, electricians, line workers, and substation operators.[33] Prevention strategies and occupational safety changes should be targeted to these high-risk occupations.

Prevention of household exposures requires public education about child protection, outlet covers, and appliance safety. Appliances that produce a shock should not be used until professionally repaired. Encourage use of GFCIs on all outlets but especially bathrooms, kitchens, and exterior outlets.

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Long-Term Monitoring

Patients exposed to low-voltage electrical sources who are otherwise completely asymptomatic with a normal physical examination can often be discharged from the emergency department.

Patients with minor burns or mild symptoms can be observed for several hours and discharged if their symptoms resolve and they do not have elevated CPK/myoglobinuria. Patients should be made aware of possible long-term neurologic or ocular effects of electrical injuries, and have follow-up available as needed. Significant hand burns should be referred to a hand specialist for close follow-up.

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Contributor Information and Disclosures
Author

Tracy A Cushing, MD, MPH, FACEP, FAWM Assistant Professor and Attending Physician, Department of Emergency Medicine, University of Colorado School of Medicine

Tracy A Cushing, MD, MPH, FACEP, FAWM is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine, 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: College of American Pathologists, American Academy of Forensic Sciences, American Medical Association, American Society for Clinical Pathology, National Association of Medical Examiners

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Eric L Legome, MD Chief, Department of Emergency Medicine, Kings County Hospital Center; Professor Clinical, Department of Emergency Medicine, State University of New York Downstate College of Medicine

Eric L Legome, MD is a member of the following medical societies: Alpha Omega Alpha, Council of Emergency Medicine Residency Directors, American Academy of Emergency Medicine, American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Joe Alcock, MD, MS Associate Professor, Department of Emergency Medicine, University of New Mexico Health Sciences Center

Joe Alcock, MD, MS is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

Additional Contributors

Jerry R Balentine, DO, FACEP, FACOEP Vice President, Medical Affairs and Global Health, New York Institute of Technology; Professor of Emergency Medicine, New York Institute of Technology College of Osteopathic Medicine

Jerry R Balentine, DO, FACEP, FACOEP is a member of the following medical societies: American College of Emergency Physicians, New York Academy of Medicine, American College of Osteopathic Emergency Physicians, American Association for Physician Leadership, American Osteopathic Association

Disclosure: Nothing to disclose.

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Arcing electrical burns through the shoe around the rubber sole. High-voltage (7600 V) alternating current nominal. Note cratering.
Contact electrical burn. This was the ground of a 120-V alternating current nominal circuit. Note vesicle with surrounding erythema. Note thermal and contact electrical burns cannot be distinguished easily.
Contact electrical burns, 120-V alternating current nominal. The right knee was the energized side, and the left was ground. These are contact burns and are difficult to distinguish from thermal burns. Note entrance and exit are not viable concepts in alternating current.
Electrical burns to the hand.
Electrical burns to the foot.
High-voltage electrical burns to the chest.
Superficial electrical burns to the knees (flash/ferning).
Energized site of low-voltage electrical burn in a 50-year-old electrician.
Grounded sites of high-voltage injury on the chest of a 16-year-old boy who climbed up an electric pole.
Energized site of the high-voltage injury depicted in Media File 9 (16-year-old boy who climbed up an electric pole).
Entrance site of a low-voltage injury.
Grounded sites of a low-voltage injury in a 33-year-old male suicide patient.
Grounded site of a low-voltage injury in the same 33-year-old male patient depicted in Media File 12.
Grounded sites of low-voltage injury on the feet.
A histologic picture of an electrical burn showing elongated pyknotic keratinocyte nuclei with vertical streaming and homogenization of the dermal collagen (40X). Courtesy of Elizabeth Satter, MD.
Table. Physiologic Effects of Different Electrical Currents
Effect Current (milliamps)
Tingling sensation/perception 1-4
Let-go current – Children 3-4
Let-go current - Women 6-8
Let-go current – Men 7-9
Skeletal muscle tetany 16-20
Respiratory muscle paralysis 20-50
Ventricular fibrillation 50-120
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