What is the treatment for electric burns?

Treatment for Electric Burns

Electric burn injuries require immediate scene safety, aggressive fluid resuscitation with isotonic crystalloid, cardiac monitoring for arrhythmias, early surgical debridement of nonviable tissue, and transfer to a specialized burn center for definitive care. 1

Immediate Scene Safety and Initial Assessment

• Turn off the power source before approaching the victim to prevent rescuer injury 1, 2
• Once power is disconnected, assess for cardiopulmonary arrest and initiate CPR with standard C-A-B sequence if the victim is unresponsive and not breathing 2
• Attach an AED as soon as possible, as ventricular fibrillation and ventricular asystole are common causes of immediate death from electrocution 1, 2
• Obtain a 12-lead ECG within 10 minutes of first medical contact to assess for arrhythmias and cardiac injury 2

Cardiac Monitoring and Management

• Continue cardiac monitoring for at least 24 hours due to risk of delayed arrhythmias, which are a primary cause of mortality 1, 2
• The severity of electrical injury often does not correlate with visible skin damage, making cardiac surveillance essential even with minimal external burns 1
• Use standard ACLS protocols for arrhythmias: synchronized cardioversion starting at 100 J for unstable monomorphic ventricular tachycardia with pulses, and unsynchronized high-energy shocks for pulseless ventricular tachycardia or ventricular fibrillation 2
• No modifications to standard ACLS are required except attention to possible cervical spine injury 2

Airway Management

• Consider early intubation for patients with extensive burns involving the face, mouth, or anterior neck before airway swelling develops 1, 2
• Use caution with airway control measures due to potential soft-tissue swelling 2
• If vomiting occurs during resuscitation, turn the victim to the side and remove vomitus; logroll if spinal cord injury is suspected 2

Fluid Resuscitation

• Initiate aggressive IV fluid resuscitation with isotonic crystalloid (0.9% saline solution) as first-line therapy for patients showing signs of shock 1, 3
• Administer rapid IV fluids to counteract shock and facilitate excretion of myoglobin, potassium, and other tissue breakdown products 1, 3, 2
• Use a fluid challenge technique with boluses of 250-1000 ml, reevaluating after each bolus 1
• Target urine output of 100 ml per hour to overcome the destructive renal tubular effects of myoglobin and hemoglobin products 4
• Evaluate response to fluid resuscitation by measuring lactate levels (aiming for 20% reduction in the first hour) and clinical signs of tissue perfusion 1
• Consider vasopressors (such as norepinephrine) if hypotension persists despite adequate fluid resuscitation 1
• Monitor for signs of fluid overload such as pulmonary edema 1

The aggressive fluid requirements for electrical burns exceed those for thermal burns of similar surface area because electrical injury causes extensive deep tissue destruction not apparent from surface examination 5, 4.

Wound Assessment and Management

• Use the Lund-Browder chart to document total body surface area (TBSA) affected, as it is the most accurate method 1
• The open hand (palm and fingers) represents approximately 1% TBSA and is a practical alternative 1
• Smartphone applications (e.g., E-Burn) can facilitate TBSA assessment 1
• Perform aggressive debridement of nonviable tissue, particularly periosseous muscle, as electrical injury causes progressive tissue destruction through small vessel occlusion 5, 4
• Apply silver sulfadiazine cream 1% once to twice daily to a thickness of approximately one-sixteenth of an inch to all burn areas 6
• Reapply silver sulfadiazine immediately after hydrotherapy and whenever removed by patient activity 6
• Continue treatment until satisfactory healing has occurred or until the burn site is ready for grafting 6

Surgical Considerations

• Perform escharotomy if deep circumferential burns induce compartment syndrome in the limbs or trunk that compromises airways, respiration, and/or circulation 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 1
• Ideally, escharotomy should be performed in a burns center by an experienced provider 1
• Early surgical excision and debridement are critical, as the modern trend toward early intervention has decreased amputation rates and reduced disability 5

Transfer to Specialized Care

• Refer to a burn specialist immediately to determine whether the patient should be admitted to a burns center 1
• 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 1
• Use telemedicine to improve initial assessment when no burns specialists are readily available, as it reliably improves TBSA measurement and prevents inappropriate transfers 1
• Burns involving the face, hands, feet, and genitals may require surgical intervention to prevent permanent disability and should be treated in a specialized burn center 7

Laboratory Investigations

• Obtain routine laboratory tests including complete blood count, electrolytes, renal function, coagulation studies, and capillary glucose level 2
• Monitor CPK levels as elevated levels correlate with prolonged hospital stay 8
• Never delay resuscitation to obtain blood samples or perform non-essential assessments 2

Pain Management

• Administer over-the-counter analgesics such as acetaminophen or NSAIDs for burn pain, as they are well tolerated and generally recommended 7
• Consider multimodal analgesia with titrated intravenous ketamine combined with other analgesics for severe burn-induced pain 7
• All analgesic medications must be titrated based on validated comfort and analgesia assessment scales 7

Critical Pitfalls to Avoid

• Do not underestimate injury severity based on visible skin damage alone, as electrical burns cause extensive deep tissue destruction that may not be apparent externally 1, 4
• Do not use hypotonic solutions like lactated Ringer's, which can increase tissue edema in electrical injury patients; use 0.9% saline instead 1
• Do not delay cardiac monitoring, as arrhythmias can occur with both low and high-voltage exposures 1
• Avoid inadequate fluid resuscitation, as electrical injury causes more extensive tissue destruction than thermal burns of similar surface area 5, 4
• When multiple victims are struck simultaneously by lightning, prioritize patients in respiratory or cardiac arrest, as they have the best chance of survival with immediate intervention 2