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.
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.
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.
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.
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.
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.
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.
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.  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.
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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