Electrical Injuries in Emergency Medicine Workup

  • Author: Tracy A Cushing, MD, MPH, FACEP, FAWM; Chief Editor: Rick Kulkarni, MD   more...
 
Updated: Apr 12, 2010
 

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.[25] )
  • 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.[26] Multivariate modeling revealed that high-voltage exposure, prehospital cardiac arrest, full-thickness burns, and compartment syndrome were associated with myoglobinuria. Defining "positive" as ≥ 2 of these findings has a sensitivity of 96% and negative predictive value of 99%.
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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.
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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.[27]
    • Several studies have shown that low-voltage (household) exposures in patients with no cardiac complaints and a normal initial ECG can be safely discharged.[28] 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.[29, 23]
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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.
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Contributor Information and Disclosures
Author

Tracy A Cushing, MD, MPH, FACEP, FAWM  Assistant Professor, Department of Emergency Medicine, University of Colorado School of Medicine; Attending Physician, Denver Health Medical Center

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, 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 Medical Association, American Society for Clinical Pathology, College of American Pathologists, and National Association of Medical Examiners

Disclosure: Nothing to disclose.

Specialty Editor Board

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.

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

Disclosure: Medscape Salary Employment

Eric L Legome, MD  Chief, Department of Emergency Medicine, Kings County Hospital Center; 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.

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

Rick Kulkarni, MD  Attending Physician, Department of Emergency Medicine, Cambridge Health Alliance, Division of Emergency Medicine, Harvard Medical School

Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: WebMD Salary Employment

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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 1. Physiologic Effects of Different Electrical Currents
Effect Current (milliamps)
Tingling sensation/perception1-4
Let-go current – Children3-4
Let-go current - Women6-8
Let-go current – Men7-9
Skeletal muscle tetany16-20
Respiratory muscle paralysis20-50
Ventricular fibrillation50-120
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