What are the management strategies for electric burns in an Intensive Care Unit (ICU) setting?

Management of Electric Burns in ICU Setting

Electric burn patients in the ICU require aggressive fluid resuscitation, meticulous wound care, and vigilant monitoring for systemic complications to reduce morbidity and mortality. 1, 2

Initial Assessment and Stabilization

• Burn severity assessment:

  • Use the standardized Lund and Browder method to accurately measure total burned body surface area (TBSA) 1, 3
  • Document depth of burns (superficial, partial-thickness, full-thickness)
  • Assess for entry and exit wounds in electrical injuries 2

• Airway management:

  • Consider early intubation for patients with:
    • Deep and circular burns on the neck
    • Symptoms of airway obstruction (voice changes, stridor, laryngeal dyspnea)
    • Very extensive burns (TBSA >40%) 1
  • Do not routinely intubate patients with only face/neck burns 1

• Cardiovascular assessment:

  • Monitor for cardiac arrhythmias (particularly with high-voltage injuries)
  • Obtain ECG and cardiac enzymes
  • Consider continuous cardiac monitoring 1

Fluid Resuscitation

• Administer crystalloids according to burn formulas but be prepared to exceed calculated volumes 4

  • Fluid requirements may be higher than predicted by Parkland formula if:
    • Extent of burn is low
    • Body mass index is low
    • Deep burns are present 4

• Consider albumin administration to maintain levels >30 g/L (doses typically 1-2 g/kg/day) 1

  • May help decrease infused volumes of crystalloid and resulting morbidity
  • Particularly beneficial for patients with TBSA of 20-30% 1

• Monitor fluid status using multiple parameters:

  • Urine output (target 0.5-1.0 mL/kg/hr)
  • Vital signs
  • Consider invasive hemodynamic monitoring for severe cases, as urine output and vital signs alone may be inadequate 5

Wound Management

• Wound care protocol:

  • Cleanse and debride wounds under appropriate analgesia 3, 6
  • Apply silver sulfadiazine cream 1% to a thickness of approximately 1/16 inch once to twice daily 3, 6
  • Reapply after hydrotherapy or when removed by patient activity 6
  • Continue until satisfactory healing or until the burn site is ready for grafting 6

• Blister management:

  • Leave blisters intact unless specifically indicated 3
  • If drainage needed, pierce at base with sterile needle, leaving roof intact 3
  • Apply non-adherent dressings loosely 3

• Surgical considerations:

  • Early and serial debridement of necrotic tissue for high-tension electrical injuries 7
  • Monitor for compartment syndrome requiring fasciotomy (pain, pallor, paresthesia, pulselessness, paralysis) 3
  • Consider early surgical consultation for high-voltage injuries 2

Systemic Complications Management

• Cardiac monitoring:

  • Continuous ECG monitoring for arrhythmias
  • Treat according to standard ACLS protocols 1

• Renal protection:

  • Maintain adequate urine output to facilitate excretion of myoglobin and potassium 1
  • Monitor for acute kidney injury and electrolyte abnormalities

• Neurological assessment:

  • Regular neurological examinations
  • Monitor for spinal cord injury in high-voltage cases 2

• Infection prevention:

  • Daily washing with antibacterial products 3
  • Change dressings using aseptic technique 3
  • Obtain bacterial cultures if signs of infection appear 3
  • Consider systemic antibiotics for local or systemic signs of infection 3

• Thromboprophylaxis:

  • Routinely prescribe for severe burns patients 3

Nutritional Support

• Early nutritional intervention:
  • Start nutritional support within 12 hours after burn injury 3
  • Prefer oral or enteral routes 3
  • Insert nasogastric tube if oral intake inadequate 3
  • Monitor weight regularly (at least weekly) 3

Emergency Evacuation Considerations

• ICU evacuation protocol for fire or other emergencies:
  1. Activate manual fire call point
  2. Stop high-flow nasal oxygen or facemask oxygen to affected patients
  3. Move patients in immediate danger to safety
  4. Use appropriate fire extinguishers (CO2 for electrical fires, not water) 1
  5. Prepare patients for evacuation with portable oxygen supplies 1
  6. Establish patients in safe areas and assess for complications 1

Pain Management

• Multimodal analgesia approach:
  • First-line: Acetaminophen 1g every 4-6 hours
  • Second-line: Add NSAIDs for inflammatory pain
  • Severe pain: Consider ketamine intravenous titration
  • Breakthrough pain: Short-acting opioids at lowest effective dose 3

Rehabilitation Planning

• Begin early rehabilitation to prevent contractures
• Consider psychiatric support, particularly for patients with high-tension injuries requiring amputation 7

Electric burns require specialized care due to their unique pathophysiology and high complication rates. The management approach must address both the visible tissue damage and the often more serious internal injuries, particularly with high-voltage exposures.