What are the immediate steps and lab tests for suspected electrocution?

Immediate Management of Electrocution

For suspected electrocution, ensure scene safety first, then immediately assess for cardiopulmonary arrest and initiate standard CPR/ACLS protocols, obtain a 12-lead ECG within 10 minutes, establish continuous cardiac monitoring, secure IV access for rapid fluid resuscitation, and obtain basic laboratory tests including complete blood count, electrolytes, renal function, coagulation studies, and capillary glucose. 1, 2

Scene Safety and Initial Assessment

Critical first step: Never approach the victim while power is still on—turn off the power at its source before approaching 1. If power cannot be immediately turned off, use a non-conducting object to separate the victim from the electrical source 2.

Once the scene is safe:

• Assess for cardiopulmonary arrest immediately, as this is the primary cause of immediate death from electrocution 1, 3
• Begin standard CPR with C-A-B sequence if the victim is unresponsive and not breathing 1, 2
• Attach an AED as soon as possible, as ventricular fibrillation is a common consequence of electrical injury 2
• For victims with respiratory arrest but maintained cardiac function, provide rescue breathing immediately 1, 2

Special consideration for multiple victims: When multiple victims are struck simultaneously (as in lightning strikes), prioritize patients in respiratory or cardiac arrest—this reverses normal triage principles 1, 2.

Immediate Cardiac Evaluation

ECG and Monitoring

• Obtain a 12-lead ECG within 10 minutes of first medical contact to assess for arrhythmias and evidence of cardiac injury 4
• Establish continuous cardiac monitoring immediately, as cardiac arrhythmias (ventricular fibrillation, ventricular asystole, ventricular tachycardia) may result from both low and high-voltage current 1, 3
• Continue monitoring for at least 24 hours or until alternative diagnosis is made 4

Arrhythmia Management

• Follow standard ACLS protocols without modification for electrical injury victims 1
• Use synchronized cardioversion starting at 100 J for unstable monomorphic ventricular tachycardia with pulses 1
• Use unsynchronized high-energy shocks for pulseless ventricular tachycardia or ventricular fibrillation 1

Important caveat: Lightning strike victims may experience spontaneous return of cardiac activity but continued respiratory arrest, requiring ventilatory support to prevent secondary hypoxic cardiac arrest 1, 2.

Laboratory Investigations

Essential Initial Labs

The following laboratory tests should be obtained routinely as part of the initial evaluation 4:

• Hematology: Complete blood count 4
• Electrolytes: Sodium, potassium, chloride, bicarbonate 4
• Renal function: Creatinine, estimated glomerular filtration rate (e-GFR) 4
• Coagulation: Activated partial thromboplastin time (aPTT), international normalized ratio (INR) 4
• Capillary glucose level 4

Rationale: These tests identify metabolic derangements, assess renal function (critical for myoglobin clearance), and establish baseline values for ongoing management 4.

Fluid Resuscitation

Immediate IV Access and Fluid Administration

• Initiate therapy with crystalloid isotonic fluids (0.9% saline solution) as first-line treatment for patients showing signs of shock 2, 3
• Administer fluids using a fluid challenge technique with boluses of 250-1000 ml and reevaluate after each bolus 2, 3
• Rapid IV fluid administration is particularly critical for victims with significant tissue destruction to counteract shock and facilitate excretion of myoglobin, potassium, and other byproducts of tissue destruction 1, 2

Monitoring Fluid Response

• Evaluate response by measuring lactate levels (aim for 20% reduction in first hour) and clinical signs of tissue perfusion 3
• Monitor for signs of fluid overload such as pulmonary edema, especially in patients with limited access to mechanical ventilation 2, 3
• Consider vasopressors (such as norepinephrine) if hypotension persists despite adequate fluid resuscitation 3

Airway Management

• Consider early intubation for patients with extensive burns, particularly those involving the face, mouth, or anterior neck 1, 2, 3
• Use caution with airway control measures due to potential soft-tissue swelling 1, 2
• If vomiting occurs during resuscitation, turn the victim to the side and remove vomitus; if spinal cord injury is suspected, logroll the victim 1, 2

Pitfall to avoid: Standard ACLS protocols apply, but maintain attention to possible cervical spine injury 1.

Burn Assessment

• Document the total body surface area (TBSA) affected using the Lund-Browder method, which is more accurate than other assessment methods 2, 3

Critical caveat: Underestimating injury severity based on visible skin damage can lead to delayed recognition of serious complications, as electrical burns often cause extensive internal tissue damage not apparent on the skin surface 2, 3.

Common Pitfalls to Avoid

• Never delay resuscitation to obtain blood samples or perform non-essential assessments 1
• Do not underestimate injury severity based on visible skin damage—electrical injuries vary widely in severity and extent of injury often does not correlate with visible skin damage 2, 3
• Failure to monitor cardiac function can result in missed arrhythmias, which are a significant cause of mortality 2, 3
• Neglecting fluid resuscitation in patients with significant tissue destruction can lead to acute kidney injury from myoglobin precipitation 1, 2