What are the initial admitting orders for a patient with electrocution injuries?

Admitting Orders for Electrocution

All electrocution patients require immediate cardiac monitoring, 12-lead ECG within 10 minutes, continuous telemetry for at least 24 hours, IV access with aggressive crystalloid resuscitation, and comprehensive assessment for occult internal injuries regardless of external appearance. 1, 2

Immediate Safety and Resuscitation

• Ensure scene safety is confirmed - verify power source is disconnected before patient transport 1, 2
• Initiate ACLS protocols immediately if cardiopulmonary arrest is present, with standard C-A-B sequence and early AED/defibrillator application 1, 2
• Provide rescue breathing for patients with isolated respiratory arrest, as lightning victims may have spontaneous cardiac recovery but persistent respiratory failure requiring ventilatory support to prevent secondary hypoxic arrest 1, 2

Cardiac Monitoring and Assessment

Continuous cardiac monitoring for minimum 24 hours is mandatory for all electrocution patients, as ventricular fibrillation, asystole, and ventricular tachycardia are primary causes of immediate death 1, 3, 4

• Obtain 12-lead ECG within 10 minutes of first medical contact to assess for arrhythmias and cardiac injury 1
• Continue telemetry monitoring for at least 24 hours or until alternative diagnosis is made 1
• Monitor for delayed arrhythmias, though recent evidence suggests malignant arrhythmias occur immediately post-injury rather than in delayed fashion 5, 6

Important caveat: While older practice recommended routine 24-hour monitoring for all patients, recent data suggests asymptomatic patients with normal initial ECG and no loss of consciousness may not require prolonged monitoring 5, 7. However, given the catastrophic consequences of missed arrhythmias and medicolegal considerations, err on the side of admission with monitoring 8, 4.

Fluid Resuscitation

Initiate aggressive IV crystalloid resuscitation immediately with 0.9% normal saline as first-line therapy 2, 3

• Administer fluid boluses of 250-1000 mL with reassessment after each bolus 2, 3
• Rapid fluid administration is critical for victims with significant tissue destruction to counteract shock and facilitate excretion of myoglobin, potassium, and other tissue breakdown products 1, 2
• Monitor for fluid overload including pulmonary edema, especially in patients requiring mechanical ventilation 2, 3
• Target lactate reduction of 20% in first hour as marker of adequate tissue perfusion 3
• Consider vasopressors (norepinephrine) if hypotension persists despite adequate fluid resuscitation 3

Airway Management

Consider early intubation for patients with extensive burns, particularly involving face, mouth, or anterior neck due to risk of rapid soft-tissue swelling 1, 2, 3

• Use caution with airway manipulation due to potential cervical spine injury and progressive edema 1, 2
• Maintain spinal precautions if mechanism suggests trauma or loss of consciousness occurred 9

Laboratory Assessment

Obtain comprehensive laboratory panel immediately including: 1

• Complete blood count
• Comprehensive metabolic panel with electrolytes (specifically potassium and calcium, as hypokalemia occurs in 18% and hypocalcemia in 3.3% of cases) 5
• Renal function tests (creatinine, BUN)
• Coagulation studies
• Creatine kinase (CK) and myoglobin levels - these correlate with injury severity, burn size, need for amputation, renal replacement therapy, sepsis, and mortality 6
• Cardiac troponin (cTnI or hs-cTnT) - though elevated in only 5.7% of cases and not clearly helpful for risk stratification 5
• Capillary glucose 1

Monitor CK and myoglobin serially - peak myoglobin occurs at post-injury day 1, peak CK at post-injury day 2 6

Imaging

Obtain CT imaging based on mechanism and clinical findings - while not specifically addressed in electrocution guidelines, high-energy mechanisms warrant evaluation for occult trauma 9

Burn Assessment and Wound Care

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

Critical pitfall: External skin appearance grossly underestimates internal tissue damage in electrical injuries - extensive deep tissue necrosis may exist beneath minimal skin changes 2, 3

Monitoring Parameters

Continuous monitoring should include: 1, 2

• Cardiac rhythm (telemetry)
• Urine output (target >30 mL/hour, watch for myoglobinuria)
• Vital signs including blood pressure and respiratory rate
• Neurological status
• Peripheral perfusion and compartment assessment

Surgical Consultation

Obtain immediate surgical consultation for: 2

• Significant burns requiring escharotomy or debridement
• Suspected compartment syndrome
• Deep tissue injury requiring exploration
• Potential need for amputation

Special Considerations for High-Voltage Injuries

High-voltage injuries (>1000V) require more intensive management with higher morbidity, mortality, more extensive surgery, and complex intensive care needs compared to low-voltage injuries 6

• These patients are younger on average but have considerably worse outcomes 6
• Transfer to specialized burn center should be considered for high-voltage injuries with significant tissue destruction 6

Admission Criteria

Admit all patients with: 8, 4, 5

• High-voltage exposure (>1000V)
• Abnormal initial ECG
• Loss of consciousness or syncope
• Cardiac arrest requiring resuscitation
• Burns >10% TBSA
• Deep tissue injury
• Arrhythmias documented in field or emergency department
• Electrolyte abnormalities (particularly hypokalemia or hypocalcemia, which correlate with increased arrhythmia risk) 5
• Myoglobinuria or elevated CK/myoglobin
• Concomitant traumatic injuries

Discharge may be considered only for: 5

• Asymptomatic patients
• Low-voltage injury (<1000V)
• Normal initial ECG
• No loss of consciousness
• No burns or minimal superficial burns
• Normal laboratory values

However, the threshold for admission should be low given unpredictable injury patterns and potential for delayed complications 4.