What is the management of electrical injuries?

Management of Electrical Injuries

Ensure scene safety by turning off the power source before approaching the victim, then immediately assess for cardiac arrest and begin standard CPR with the C-A-B sequence if unresponsive and not breathing, attaching an AED as soon as possible. 1, 2

Immediate Scene Safety and Assessment

Scene Safety First:

• Never approach a victim while power is still on 1
• Turn off power at its source (typically near the fuse box in homes) 1
• If power cannot be immediately shut off, use a non-conducting object to separate the victim from the electrical source 2

Initial Assessment:

• Check responsiveness by talking to the victim and gently shaking their shoulders 1
• Assess for cardiopulmonary arrest immediately, as this is the primary cause of death from electrocution 1, 3
• Attach an AED as soon as possible since ventricular fibrillation is a common consequence 2

Resuscitation Priorities

Cardiac Arrest Management:

• Begin standard CPR with C-A-B sequence if victim is unresponsive and not breathing 1, 2
• Follow standard ACLS protocols without modification, except for attention to possible cervical spine injury 1
• Use synchronized cardioversion starting at 100 J for unstable monomorphic ventricular tachycardia with pulses 1, 2
• Use unsynchronized high-energy shocks for pulseless ventricular tachycardia or ventricular fibrillation 1, 2

Respiratory Arrest Without Cardiac Arrest:

• Provide rescue breathing immediately for victims with respiratory arrest but maintained cardiac function 1, 2
• 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

Multiple Casualty Situations:

• When multiple victims are struck simultaneously by lightning, prioritize patients in respiratory or cardiac arrest (reverse normal triage) 1, 2

Airway Management

• Consider early intubation for patients with extensive burns, particularly 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 1, 2
• If spinal cord injury is suspected, logroll the victim 1, 2

Cardiac Monitoring and Evaluation

Immediate Cardiac Assessment:

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

Why Cardiac Monitoring is Critical:

• Alternating current (AC) is more dangerous than direct current (DC) because it causes tetanic muscle contractions and increased likelihood of ventricular fibrillation 1
• AC causes tetanic skeletal muscle contractions that "lock" victims to the electrical source, leading to prolonged exposure 1
• The frequency of AC increases the likelihood of current flowing through the heart during the relative refractory period, precipitating ventricular fibrillation 1, 3

Fluid Resuscitation

Aggressive Fluid Management:

• 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 important for victims with significant tissue destruction to counteract shock and facilitate excretion of myoglobin, potassium, and other byproducts of tissue destruction 1, 2, 3

Monitoring Fluid Response:

• Evaluate response by measuring lactate levels (aim for 20% reduction in the first hour) and clinical signs of tissue perfusion 3
• Consider vasopressors (such as norepinephrine) if hypotension persists despite adequate fluid resuscitation 3
• Monitor for signs of fluid overload such as pulmonary edema, especially in patients with limited access to mechanical ventilation 2, 3
• Interrupt fluid resuscitation when no improvement in tissue perfusion is observed in response to volume loading 3

Laboratory Investigations

• Obtain routine laboratory tests including complete blood count, electrolytes, renal function, coagulation studies, and capillary glucose level as part of initial evaluation 1
• Never delay resuscitation to obtain blood samples or perform non-essential assessments 1

Burn Assessment and Documentation

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

Pain Management

• Consider multimodal analgesia combining non-opioid analgesics, antihyperalgesic drugs (ketamine), and opioids during surgical management to prevent prolonged pain 2

Critical Pitfalls to Avoid

Underestimating Injury Severity:

• Do not underestimate injury severity based on visible skin damage, as electrical injuries vary widely and extent of injury often does not correlate with visible skin damage 2, 3
• Injuries may be thermal, electrical, and/or mechanical, potentially causing burns, thrombosis, tetany, falls, and blast injury 4, 5

Monitoring Failures:

• Failure to monitor cardiac function can result in missed arrhythmias, which are a significant cause of mortality 2, 3
• Long-term consequences may include pain, vascular symptoms, cognitive and neurological symptoms even when initial symptoms were relatively modest 6

Spinal Cord Injury Considerations:

• Do not neglect 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 2

Prognosis Considerations

• Victims of electrical shock and lightning strike may have a greater chance for successful resuscitation than those with other causes of cardiac arrest, even with initial rhythms traditionally unresponsive to therapy, because the majority are relatively young and seldom have significant underlying cardiac disease 7