What is the immediate management for a patient with electrocution?

Immediate Management of Electrocution

Ensure scene safety by confirming the power source is disconnected before approaching the victim, then immediately initiate standard ACLS protocols if cardiac arrest is present, as cardiopulmonary arrest is the primary cause of immediate death from electrocution. 1, 2

Scene Safety and Initial Approach

• Do not approach the victim while power is still on - turn off power at its source (typically near the fuse box in homes) before any patient contact 1
• Use a non-conducting object to separate the victim from the electrical source if power cannot be immediately turned off 1
• Verify scene safety is confirmed before patient transport to prevent injury to responders 2

Immediate Resuscitation

Cardiac Arrest Management

• Initiate standard ACLS protocols immediately using the C-A-B sequence (compressions-airway-breathing) if the patient is unresponsive and not breathing 1, 2
• Attach an AED or defibrillator as soon as possible, as ventricular fibrillation and ventricular asystole are common causes of immediate death 1, 2
• No modifications to standard ACLS protocols are required for electrical injury victims, except attention to possible cervical spine injury 1
• Use unsynchronized high-energy shocks for pulseless ventricular tachycardia or ventricular fibrillation 1
• For unstable monomorphic ventricular tachycardia with pulses, use synchronized cardioversion starting at 100 J 1

Respiratory Arrest Management

• Provide immediate rescue breathing for victims with respiratory arrest but maintained cardiac function, as lightning victims may have spontaneous cardiac recovery but persistent respiratory failure requiring ventilatory support to prevent secondary hypoxic arrest 1, 2
• This is particularly critical because respiratory arrest may result from electric injury to the respiratory center in the brain or from tetanic contractions of respiratory muscles 1

Multiple Casualty Situations

• When multiple victims are struck simultaneously by lightning, prioritize patients in respiratory or cardiac arrest - this reverses normal triage priorities 1, 3

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
• Use caution with airway manipulation due to potential cervical spine injury and progressive edema 2
• Maintain spinal precautions with logrolling technique if mechanism suggests trauma or loss of consciousness occurred 1, 2
• If vomiting occurs during resuscitation, turn the victim to the side and remove vomitus (logroll if spinal injury suspected) 1

Cardiac Monitoring

• Obtain a 12-lead ECG within 10 minutes of first medical contact to assess for arrhythmias and evidence of cardiac injury 1, 2
• Continue telemetry monitoring for at least 24 hours or until alternative diagnosis is made to detect potential delayed arrhythmias 1, 2
• Monitor continuously for ventricular fibrillation, ventricular tachycardia, and asystole, which may result from both low and high-voltage exposure 1

Fluid Resuscitation

• Initiate aggressive IV crystalloid resuscitation immediately with 0.9% normal saline as first-line therapy to counteract shock and facilitate excretion of myoglobin, potassium, and other tissue breakdown products 4, 2
• Administer fluid boluses of 250-1000 mL with reassessment after each bolus to ensure adequate resuscitation and prevent fluid overload 2
• Target lactate reduction of 20% in the first hour as a marker of adequate tissue perfusion 2
• Rapid IV fluid administration is particularly critical for victims with significant tissue destruction 4, 1

Laboratory Assessment

• Obtain comprehensive laboratory panel immediately including complete blood count, comprehensive metabolic panel with electrolytes, renal function tests, coagulation studies, and capillary glucose 1, 2
• These tests assess for electrolyte imbalances, rhabdomyolysis, coagulopathy, and metabolic derangements 2

Burn and Tissue Injury Assessment

• Document total body surface area (TBSA) using the Lund-Browder method, which is more accurate than other assessment methods 2
• Recognize that external skin appearance grossly underestimates internal tissue damage - extensive deep tissue necrosis may exist beneath minimal skin changes 2
• Assess for compartment syndrome and deep tissue injury requiring surgical consultation 2

Temperature Control

• Avoid hyperthermia in the post-injury period, as elevated temperature accelerates tissue destruction and worsens outcomes 4
• Active cooling prevents coagulum formation and reduces ongoing thermal injury at the tissue level 4

Admission Criteria

Admit all patients with: 2

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

Critical Pitfalls to Avoid

• Never delay resuscitation to obtain blood samples or perform non-essential assessments 1
• Do not underestimate internal injury based on benign external appearance - electrical injuries cause extensive deep tissue damage 2, 5
• Do not discharge patients with high-voltage injuries, syncope, or abnormal ECG without at least 24 hours of monitoring 5
• Early hospitalization is highly required for successful treatment, even in cases that appear mild initially 6