What is the management for a patient who was electrocuted three days ago and now presents with chest pain on the right side?

Management of Chest Pain Following Electrical Injury

A patient presenting with chest pain three days after electrocution should be immediately evaluated for potential cardiac injury with a 12-lead ECG, cardiac biomarkers, and placed on continuous cardiac monitoring, as electrical injuries can cause delayed cardiac complications including myocardial infarction.

Initial Assessment

• Immediate Triage Priority: All patients presenting with chest pain should be considered high-priority triage cases 1
• Cardiac Monitoring: Place patient on continuous cardiac monitoring immediately with emergency resuscitation equipment including a defibrillator nearby 1
• ECG: Perform 12-lead ECG within 10 minutes of arrival to evaluate for:
  • ST-segment elevation or depression
  • T-wave changes
  • New conduction abnormalities
  • Compare with previous ECGs if available 2
• Laboratory Tests: Draw blood for:
  • Cardiac troponin (preferably high-sensitivity)
  • Complete blood count
  • Basic metabolic panel 2

Specific Considerations for Electrical Injury

Electrical injuries can cause cardiac damage through several mechanisms:

• Delayed Myocardial Injury: Myocardial infarction can occur following electrical injury, even in previously healthy individuals with no cardiac risk factors 3
• Atypical Presentation: Cardiac complications from electrical injuries can be delayed in onset or atypical in presentation 4
• Right-Sided Chest Pain: May indicate pulmonary injury which can occur with electrical trauma 5

Management Algorithm

1. Initial Stabilization:

   • Administer oxygen if O₂ saturation <90%
   • Provide pain relief with appropriate analgesia
   • Administer aspirin 160-325 mg unless contraindicated
   • Consider sublingual nitroglycerin if systolic BP >90 mmHg and heart rate between 50-100 bpm 2

2. Risk Stratification:

   • High Risk Features:
     • Dynamic ECG changes
     • Elevated troponin levels
     • Hemodynamic instability
     • Arrhythmias 2

3. Diagnostic Evaluation:

   • Serial ECGs (at presentation and if symptoms change)
   • Serial cardiac biomarkers (at presentation and 6-12 hours later)
   • Consider echocardiography to assess for structural damage 2
   • Consider chest imaging to evaluate for pulmonary injury 5

4. Disposition Decision:

   • Abnormal Findings: Admit for observation and further cardiac evaluation
   • Normal Initial Workup: Consider observation for at least 6-12 hours with repeat ECG and troponin before discharge decision 4

Important Caveats

• Extended Monitoring: Even with initially normal findings, patients with electrical injury should be monitored for at least 12-24 hours as cardiac complications can be delayed 4
• Standard Treatment Protocols: When cardiac complications are identified, standard therapeutic regimens for ACS are generally appropriate 4
• Reperfusion Therapy: Should only be considered when occlusive coronary thrombosis is strongly suspected or confirmed 4
• Follow-up: Patients with confirmed cardiac injury should be followed for at least 12 months 4

Pitfalls to Avoid

• Premature Discharge: Do not discharge patients with electrical injury and chest pain without adequate cardiac evaluation, even if initial ECG and troponin are normal
• Assuming Non-cardiac Etiology: Chest pain after electrical injury should be presumed cardiac until proven otherwise
• Delayed Evaluation: Patients with electrical injury and chest pain should be evaluated immediately, as delayed presentation of cardiac complications is well-documented