What to do in case of a high voltage electrical burn?

High Voltage Electrical Burn Management

Immediately ensure scene safety by confirming the power source is disconnected before approaching the victim, then initiate ACLS protocols if cardiac arrest is present, establish aggressive IV fluid resuscitation with 0.9% normal saline, and arrange for continuous cardiac monitoring with transfer to a burn center. 1, 2

Immediate Scene Safety and Initial Assessment

• Verify the power source is completely turned off before approaching the victim to prevent injury to rescuers and further harm to the patient 1, 2
• If the victim is in cardiopulmonary arrest, immediately begin CPR following standard ACLS protocols with early defibrillator application, as cardiac arrest from ventricular fibrillation or asystole is the primary cause of immediate death 1, 2
• For victims with isolated respiratory arrest but spontaneous cardiac activity, provide rescue breathing immediately, as respiratory failure can lead to secondary hypoxic cardiac arrest 2

Critical Cardiac Monitoring

• Obtain a 12-lead ECG within 10 minutes of first medical contact to assess for arrhythmias including ventricular fibrillation, asystole, and ventricular tachycardia 1, 2
• Continue telemetry monitoring for at least 24 hours, as cardiac arrhythmias are a primary cause of mortality and may occur with delayed presentation 1, 2
• The frequency of alternating current increases the likelihood of current flow through the heart during vulnerable periods of the cardiac cycle, potentially precipitating fatal arrhythmias 1

Aggressive Fluid Resuscitation Protocol

• Initiate immediate IV crystalloid resuscitation with 0.9% normal saline as first-line therapy, not lactated Ringer's solution, as hypotonic solutions increase tissue edema in electrical injuries 1, 3, 2
• Administer fluid boluses of 250-1000 mL with reassessment after each bolus to ensure adequate resuscitation without fluid overload 1, 2
• Target urine output of 100 mL/hour (not the typical 0.5-1 mL/kg/hour used in thermal burns) due to myoglobin and tissue breakdown product excretion requirements 1, 2
• Aim for lactate reduction of 20% in the first hour as a marker of adequate tissue perfusion 1, 2
• Standard burn resuscitation formulas based on body surface area are inadequate for electrical injuries because extensive deep tissue damage exists beneath minimal visible skin changes 2, 4

Airway Management

• Consider early intubation for patients with extensive burns involving the face, mouth, or anterior neck due to risk of rapid soft-tissue swelling that can compromise the airway 1, 2
• Maintain spinal precautions during airway manipulation if the mechanism suggests trauma or loss of consciousness occurred, as electrical injuries can cause falls from height or tetanic muscle contractions leading to cervical spine injury 2, 5

Wound Assessment and Cooling

• Do NOT rely on external skin appearance to estimate injury severity, as high-voltage electrical burns cause extensive deep tissue necrosis (muscle, fat, bone) beneath minimal skin changes 2, 4, 5
• For thermal burn components, cool with tap water at 15-25°C for at least until pain is relieved, ideally within 30 minutes of injury, but only for burns with total body surface area <20% in adults and <10% in children without shock 3
• Monitor for hypothermia when cooling large burns, as this is a significant risk 6, 3
• Document total body surface area using the Lund-Browder method, which is more accurate than other assessment methods 1, 2

Essential Laboratory and Imaging

• Obtain comprehensive laboratory panel immediately including complete blood count, comprehensive metabolic panel with electrolytes, coagulation studies, capillary glucose, and urinalysis to detect myoglobin 2, 5
• If myoglobin is detected in urine, continue aggressive volume resuscitation and consider alkalinization of urine or IV mannitol to minimize pigment precipitation in renal tubules and prevent acute renal failure 5, 7
• Obtain CT imaging based on mechanism and clinical findings to evaluate for occult trauma, as approximately 15% of electrical burn victims sustain traumatic injuries from falls or being thrown 2, 5

Monitoring for Compartment Syndrome

• Continuously assess peripheral perfusion and compartment pressures, as damaged muscle swelling within investing fascia can cause compartment syndrome requiring escharotomy 2, 5
• Consider early escharotomy within 48 hours if compartment syndrome develops, ideally performed at a burn center 3
• Tetanic muscle contractions from electrical current cause imbalance favoring flexor groups, which can result in bone fractures and compartment syndrome 5

Surgical Consultation and Transfer

• Obtain immediate surgical consultation for significant burns requiring escharotomy or debridement, suspected compartment syndrome, deep tissue injury requiring exploration, and potential need for amputation 2
• Major amputations were required in 71.42% of patients with musculoskeletal complications in one series 7

Admission Criteria

Admit all patients with:

• High-voltage exposure (>1000V) 2
• Abnormal initial ECG 2
• Cardiac arrest requiring resuscitation 2
• Burns >10% TBSA 2
• Deep tissue injury 2
• Concomitant traumatic injuries 2

Critical Pitfalls to Avoid

• Never underestimate injury severity based on visible skin damage alone, as electrical burns have extensive deep tissue damage not apparent on surface examination 3, 2, 4
• Do not use hypotonic solutions like lactated Ringer's for initial resuscitation, as they increase tissue edema 3
• Do not delay cardiac monitoring, as failure to detect arrhythmias is a significant cause of mortality 1
• Do not apply standard thermal burn fluid resuscitation formulas, as they underestimate fluid needs in electrical injuries 2, 5
• Neurologic and psychological symptoms may not appear until several months after injury, requiring long-term follow-up 5