What are the clinical practice guidelines (CPG) for managing patients with electrocution injuries?

Management of Electrocution Injuries

Ensure scene safety first 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 leading cause of immediate death from electrocution. 1, 2, 3

Immediate Scene Safety and Initial Assessment

• Never approach or touch an electrocution victim while the power source remains active, as this places responders at risk of injury 1, 2, 3
• Turn off power at its source (typically near the fuse box in home settings) or use a non-conducting object to separate the victim from the electrical source if power cannot be immediately disconnected 3
• Once scene is safe, rapidly assess for responsiveness by talking to the victim and gently shaking their shoulders 3

Resuscitation and Cardiac Management

Cardiopulmonary Arrest

• Begin standard CPR immediately using the C-A-B sequence (compressions-airway-breathing) if the victim is unresponsive and not breathing 2, 3
• Attach an AED or defibrillator as soon as possible, as ventricular fibrillation, asystole, and ventricular tachycardia are primary causes of death 2, 3
• No modifications to standard ACLS protocols are required for electrical injury victims, except maintaining awareness of possible cervical spine injury 3
• For unstable monomorphic ventricular tachycardia with pulses, use synchronized cardioversion starting at 100 J 3
• For pulseless ventricular tachycardia or ventricular fibrillation, deliver unsynchronized high-energy shocks 3

Isolated Respiratory Arrest

• Provide rescue breathing immediately for patients 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 2, 3
• This is particularly critical in lightning strike victims, where respiratory arrest may outlast the cardiac arrest 3

Multiple Casualty Scenarios

• Reverse normal triage priorities when managing multiple lightning strike victims by giving highest priority to patients in respiratory or cardiac arrest, as these patients have better survival potential than in other mass casualty scenarios 3

Cardiac Monitoring

• Obtain a 12-lead ECG within 10 minutes of first medical contact to assess for arrhythmias, ST-segment changes, and evidence of cardiac injury 2, 3
• Continue telemetry monitoring for at least 24 hours or until an alternative diagnosis is made to detect potential delayed arrhythmias 2, 3
• Alternating current (AC) is more dangerous than direct current (DC) because it causes tetanic muscle contractions that "lock" victims to the electrical source and increases likelihood of ventricular fibrillation during the cardiac relative refractory period 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 2, 3
• Use caution with airway manipulation due to potential cervical spine injury and progressive edema 2
• Maintain spinal precautions if the mechanism suggests trauma or loss of consciousness occurred 2
• If vomiting occurs during resuscitation, turn the victim to the side and remove vomitus; use logrolling technique if spinal cord injury is suspected 3

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 2, 4, 3
• Administer fluid boluses of 250-1000 mL with reassessment after each bolus to ensure adequate resuscitation while preventing fluid overload 2
• Target lactate reduction of 20% in the first hour as a marker of adequate tissue perfusion 2
• Rapid fluid administration is critical because external skin appearance grossly underestimates internal tissue damage in electrical injuries 2

Laboratory and Imaging Assessment

• Obtain comprehensive laboratory panel immediately including complete blood count, comprehensive metabolic panel with electrolytes, coagulation studies, and capillary glucose 2, 3
• Never delay resuscitation to obtain blood samples or perform non-essential assessments 3
• Obtain CT imaging based on mechanism and clinical findings, as high-energy mechanisms warrant evaluation for occult trauma 2

Burn and Wound 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, as extensive deep tissue necrosis may exist beneath minimal skin changes 2
• Assess for compartment syndrome and deep tissue injury requiring surgical exploration 2

Continuous Monitoring Parameters

Monitor the following continuously to detect complications:

• Cardiac rhythm via telemetry 2
• Urine output 2
• Vital signs including blood pressure and respiratory rate 2
• Neurological status 2
• Peripheral perfusion and compartment assessment 2

Surgical Consultation

Obtain immediate surgical consultation for:

• Significant burns requiring escharotomy or debridement 2
• Suspected compartment syndrome 2
• Deep tissue injury requiring exploration 2
• Potential need for amputation 2

Admission Criteria

Admit all patients with the following:

• 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

Discharge Considerations

Selected patients with low-voltage injuries, absence of syncope, and a normal ECG may be reasonable candidates for discharge from the emergency department 5

Key Pathophysiology Considerations

• AC causes tetanic skeletal muscle contractions that can "lock" victims to the electrical source, leading to prolonged exposure and more severe injury 3
• Lightning strikes act as an instantaneous, massive direct-current shock that simultaneously depolarizes the entire myocardium 3
• Respiratory arrest may result from electric injury to the respiratory center in the brain or from tetanic contractions or paralysis of respiratory muscles 3
• Cardiac arrhythmias including ventricular fibrillation, ventricular asystole, and ventricular tachycardia may result from exposure to both low and high-voltage current 3

Common Pitfalls to Avoid

• Do not place ice directly on burns, as it can produce tissue ischemia 1
• Do not underestimate internal tissue damage based on external appearance 2
• Do not delay resuscitation for non-essential assessments 3
• Do not approach the victim while power remains on 1, 3