What are the key steps in managing electrical burns?

Management of Electrical Burns

The first and most critical step in managing electrical burns is ensuring rescuer safety by turning off the power source before approaching the victim, followed by immediate assessment and treatment of life-threatening conditions including cardiac arrhythmias and respiratory arrest. 1

Initial Safety and Assessment

1. Ensure scene safety first:

   • Turn off power at the source (e.g., circuit breaker, fuse box)
   • For high-voltage electrocutions (e.g., fallen power lines), immediately notify authorities (911/fire department)
   • Do not touch the victim until power is confirmed off
   • Do not attempt to move wires with any object, even wooden ones 1

2. Once power is off, perform immediate assessment:

   • Check for cardiac arrest (may require CPR)
   • Assess for respiratory arrest
   • Look for entry and exit points of electrical current
   • Evaluate for associated trauma from falls or being thrown 2

Medical Management Algorithm

Step 1: Resuscitation (if needed)

• Begin CPR if cardiac arrest is present
• Provide ventilatory support if respiratory arrest has occurred
• Establish IV access for fluid resuscitation
• Monitor cardiac rhythm continuously 1, 2

Step 2: Fluid Management

• Initiate aggressive fluid resuscitation, especially with high-voltage injuries
• Standard burn formulas may underestimate fluid needs due to hidden muscle damage
• For adults with ≥20% TBSA and children with ≥10% TBSA, administer 20 ml/kg balanced crystalloid solution in the first hour 3
• Monitor urine output closely for myoglobinuria (dark, tea-colored urine)
• If myoglobinuria is present:
  • Increase fluid rate to maintain urine output of 1-2 ml/kg/hour
  • Consider urine alkalinization or mannitol to prevent renal tubular damage 2

Step 3: Wound Assessment and Management

• Identify entry and exit wounds
• Look for thermal burns from ignited clothing
• Assess for compartment syndrome in extremities (pain, pallor, paresthesia, pulselessness)
• Perform escharotomy if deep burns cause compartment syndrome affecting limbs, trunk, or compromise airways/circulation 1
• Clean wounds by gently irrigating with warmed sterile water or saline 3
• Apply silver sulfadiazine cream (1/16 inch thickness) to second and third-degree burns once to twice daily 4

Step 4: Specialized Care

• All electrical burn victims require medical assessment as extent of injury may not be apparent 1
• Perform serial neurological examinations to detect delayed neurological deficits 2, 5
• Monitor for cardiac arrhythmias for at least 24 hours with high-voltage injuries 2
• Consider CT imaging to rule out internal injuries
• Evaluate for occult fractures from tetanic muscle contractions 2
• Maintain cervical spine stabilization if trauma is suspected 1

Special Considerations

High vs. Low Voltage Injuries

• High-voltage injuries (>1000V) are associated with:
  • Higher rates of loss of consciousness (69.1%)
  • Greater risk of cardiac arrest (20%)
  • Increased likelihood of requiring amputation (23.6%)
  • More extensive deep tissue damage 5

Complications to Monitor

1. Cardiac complications:

   • Arrhythmias (most common)
   • Myocardial damage

2. Renal complications:

   • Acute renal failure (occurs in ~18% of cases) 6
   • Myoglobinuria from muscle breakdown

3. Musculoskeletal complications:

   • Compartment syndrome requiring fasciotomy
   • Tissue necrosis potentially requiring amputation
   • Fractures from tetanic contractions 2

4. Neurological complications:

   • Can present early or late (up to 2 years post-injury)
   • May include peripheral nerve damage, spinal cord injury, or cognitive deficits 2, 5

Common Pitfalls to Avoid

1. Underestimating injury extent - Electrical burns often have minimal external signs but severe internal damage

2. Inadequate fluid resuscitation - Standard burn formulas may be insufficient due to hidden muscle damage

3. Delayed fasciotomy - Early surgical decompression is crucial to prevent compartment syndrome complications 6

4. Missing associated trauma - Approximately 15% of electrical burn victims also sustain traumatic injuries from falls or being thrown 2

5. Failure to monitor for delayed complications - Neurological deficits may appear months after the initial injury 2

By following this structured approach to electrical burn management, focusing first on safety and life-threatening conditions, then addressing wound care and monitoring for complications, providers can significantly improve patient outcomes and reduce mortality and morbidity associated with these complex injuries.