What is the management approach for electrocution burns?

Management of Electrocution Burns

Electrocution burns require immediate early cooling (within 30 minutes), aggressive fluid resuscitation with isotonic crystalloids targeting urine output of 100 ml/hour, continuous cardiac monitoring for arrhythmias, and urgent referral to a specialized burn center for definitive care. 1, 2

Immediate Initial Management

Scene Safety and Primary Survey

• Turn off the power source before approaching the victim to prevent additional injuries 2
• Initiate CPR and defibrillation immediately if needed, as cardiopulmonary arrest is the primary cause of immediate death from electrocution 2
• Assess for thermal burns and shock once the scene is safe 2

Early Cooling Protocol (Critical Time-Sensitive Intervention)

• Cool the burn with tap water at 15-25°C for at least until pain is relieved, ideally within 30 minutes of injury for burns with total body surface area <20% in adults and <10% in children without shock 1, 3
• Cooling times of less than 40 minutes significantly reduce the need for skin grafting (P < 0.001) by limiting progressive tissue destruction, decreasing inflammation and capillary leakage 1, 3
• Never apply ice directly, as this causes tissue ischemia and increases tissue damage 3
• Avoid cooling large burns without ability to monitor core temperature due to hypothermia risk 1, 3

Fluid Resuscitation

Aggressive Crystalloid Administration

• Initiate therapy with crystalloid isotonic fluids (0.9% saline solution) as first-line treatment for patients showing signs of shock 1, 2
• Target urine output of 100 ml/hour to maintain normal vital signs, as electrical burns cause significant tissue destruction requiring more aggressive resuscitation than thermal burns 1, 3
• Administer fluids using a fluid challenge technique with boluses of 250-1000 ml, reevaluating after each bolus 2
• Avoid hypotonic solutions like lactated Ringer's, as they can increase tissue edema in electrical injuries 1, 2

Monitoring Resuscitation Response

• Measure lactate levels, aiming for a 20% reduction in the first hour 2
• Monitor clinical signs of tissue perfusion continuously 2
• Consider vasopressors (such as norepinephrine) if hypotension persists despite adequate fluid resuscitation 2
• Watch for signs of fluid overload, particularly pulmonary edema 2

Cardiac Monitoring and Management

Continuous Cardiac Surveillance

• Continuous cardiac monitoring is mandatory due to risk of arrhythmias including ventricular fibrillation, ventricular asystole, and ventricular tachycardia from both low and high-voltage current 1, 2, 3
• The frequency of alternating current increases the likelihood of current flow through the heart during the vulnerable period of the cardiac cycle, potentially precipitating ventricular fibrillation 2
• Failure to monitor cardiac function can result in missed arrhythmias, which are a significant cause of mortality 2

Airway Management

• Consider early intubation for patients with evidence of extensive burns, particularly those involving the face, mouth, or anterior neck 2
• This prevents airway compromise from progressive edema in the acute phase 2

Burn Assessment

Accurate TBSA Measurement

• Use the Lund-Browder chart for TBSA measurement, as it is the most accurate method and prevents both overtriage and undertriage that can increase morbidity and mortality 4, 2
• The Wallace rule of nines significantly overestimates TBSA and is not suitable for children 4
• The open hand (palm and fingers) represents approximately 1% TBSA and is a practical alternative that limits overvaluation 4
• Smartphone applications (e.g., E-Burn) can facilitate assessment 4

Specialist Referral and Transfer

Urgent Burn Center Consultation

• Referral to a burn specialist should be sought immediately to determine whether the patient should be admitted to a burns center 4
• Telemedicine should be used to improve initial assessment when no burns specialists are readily available, as it reliably improves TBSA measurement and prevents inappropriate transfers 4
• Direct admission to a burns center should be preferred if hospitalization is indicated, as this reduces time to excision, duration of mechanical ventilation, and improves survival 4
• Multidisciplinary management at specialized centers is associated with better survival, facilitates rehabilitation, and reduces complications, length of hospital stay, and costs 4

Surgical Considerations

Escharotomy

• Escharotomy should be performed if deep burns induce compartment syndrome in the limbs or trunk that compromises airways, respiration, and/or circulation 4
• Early consideration for escharotomy within 48 hours is recommended if compartment syndrome develops 1
• Ideally, escharotomy should be performed in a burns center by an experienced provider 4, 1
• Circumferential third-degree burns can cause acute limb ischemia with neurological disorders, thoracic/abdominal compartment syndrome with decreased cardiac output and pulmonary compliance, hypoxia, hypercapnia, acute renal failure, and mesenteric ischemia 4

Critical Pitfalls to Avoid

Assessment Errors

• Do not underestimate injury severity based on visible skin damage alone, as electrical burns often have extensive deep tissue damage not apparent on surface examination 1, 2, 3
• The extent of injury often does not correlate with visible skin damage in electrical injuries 2

Treatment Delays

• Do not delay cooling—it must be initiated within 30 minutes of injury for maximum benefit, as delayed intervention loses the protective effect on the zone of stasis 1, 3
• Delayed recognition of serious complications can occur when severity is underestimated 2

Fluid Management Errors

• Avoid using hypotonic solutions for initial resuscitation, as they worsen tissue edema 1, 2
• Do not cool large burns without core temperature monitoring capability 1, 3