What is the treatment for electrical injury?

Treatment for Electrical Injury

The management of electrical injuries requires immediate assessment of cardiopulmonary status, ensuring scene safety, and administering appropriate fluid resuscitation, with specific interventions tailored to the severity and type of electrical exposure. 1, 2

Initial Management

• Scene safety is paramount - Turn off the power source before approaching the victim; if power cannot be immediately turned off, use a non-conducting object to separate the victim from the electrical source 1
• Immediate cardiopulmonary assessment - Assess for cardiac arrest and begin standard CPR with C-A-B sequence if the victim is unresponsive and not breathing 1
• Attach an AED as soon as possible for victims in cardiac arrest, as ventricular fibrillation is a common consequence of electrical injury 1
• For victims with respiratory arrest but maintained cardiac function, provide rescue breathing immediately 1
• When multiple victims are affected simultaneously (as in lightning strikes), prioritize patients in respiratory or cardiac arrest 1, 2

Cardiac Management

• Continuous cardiac monitoring is essential due to the risk of arrhythmias, which are a primary cause of immediate death from electrocution 1, 2
• Follow standard ACLS protocols for managing arrhythmias, with synchronized cardioversion starting at 100 J for unstable monomorphic ventricular tachycardia with pulses, and unsynchronized high-energy shocks for pulseless ventricular tachycardia or ventricular fibrillation 1
• Cardiac monitoring beyond 24 hours post-injury is generally unnecessary if no arrhythmias are detected in the first day, as most cardiac complications occur immediately or shortly after the injury 3

Fluid Management

• Initiate therapy with crystalloid isotonic fluids (0.9% saline solution) as first-line treatment for patients showing signs of shock 2
• Administer fluids using a fluid challenge technique with boluses of 250-1000 ml and reevaluation after each bolus 2
• Rapid IV fluid administration is particularly important for victims with significant tissue destruction to counteract shock and facilitate excretion of myoglobin, potassium, and other byproducts of tissue destruction 1, 2
• Monitor for signs of fluid overload such as pulmonary edema, especially in patients with limited access to mechanical ventilation 2

Airway Management

• Consider early intubation for patients with extensive burns, particularly those involving the face, mouth, or anterior neck 1, 2
• Use caution with airway control measures due to potential soft-tissue swelling 1
• If vomiting occurs during resuscitation, turn the victim to the side and remove vomitus; if spinal cord injury is suspected, logroll the victim 1

Burn and Wound Management

• Document the total body surface area (TBSA) affected using the Lund-Browder method, which is more accurate than other assessment methods 2
• Be aware that cutaneous burns often underestimate the true extent of injury because most current travels through deep tissues 4
• Initial debridement can be delayed for 24-48 hours to allow tissue demarcation, with emergent surgical exploration reserved only for patients with compartment syndrome 4
• High-voltage injuries (HVI) require more extensive burn surgery and more complex burn intensive care than low-voltage injuries (LVI) 3

Laboratory Monitoring and Specific Treatments

• Monitor serum creatinine kinase (CK) and myoglobin levels over the first 4 post-injury days, with peak levels typically observed at post-injury day 1 (myoglobin) and day 2 (CK) 3
• These markers correlate significantly with injury severity and can predict complications including need for amputation, renal replacement therapy, sepsis, and mortality 3
• Consider multimodal analgesia combining non-opioid analgesics, antihyperalgesic drugs (ketamine), and opioids during surgical management to prevent the occurrence of prolonged pain 5

Special Considerations

• Lightning strike victims may experience spontaneous return of cardiac activity but continued respiratory arrest, requiring ventilatory support to prevent secondary hypoxic cardiac arrest 1
• Patients with high-voltage injuries are at greater risk for severe complications and should be treated in specialized burn units due to the need for highly specialized surgery and intensive care 3
• Early rehabilitation, wound coverage, and delayed deformity reconstruction are important concepts in treating electrical injuries, particularly for upper extremity injuries which are most common 4

Common Pitfalls to Avoid

• Underestimating injury severity based on visible skin damage can lead to delayed recognition of serious complications 2
• Failure to monitor cardiac function can result in missed arrhythmias, which are a significant cause of mortality 2
• Neglecting to implement pressure ulcer prevention measures in patients with spinal cord injuries from electrical trauma, including early mobilization (once spine is stabilized), regular repositioning, and use of appropriate support surfaces 5