What is the management of a patient who has suffered an electric shock?

Management of Electric Shock

Immediate Scene Safety and Victim Extrication

Before approaching any electric shock victim, the power source must be turned off at its source—attempting rescue while power remains active can be fatal to rescuers. 1, 2, 3 If the power cannot be immediately disconnected, use a non-conducting object (such as a wooden pole or dry rope) to separate the victim from the electrical source. 1, 3 Never touch a victim who remains in contact with an active electrical source. 4

Initial Resuscitation

Cardiopulmonary Assessment and CPR

• Assess for cardiac arrest immediately upon safe access to the victim—if unresponsive and not breathing, begin standard CPR using the C-A-B sequence (compressions-airway-breathing) without delay. 1, 2, 3
• Attach an automated external defibrillator (AED) as soon as available, as ventricular fibrillation is the most common cause of immediate death from electrocution. 1, 2, 3
• For victims with isolated respiratory arrest but maintained cardiac function, provide rescue breathing immediately—this is particularly critical in lightning strike victims who may have spontaneous cardiac recovery but persistent respiratory failure requiring ventilatory support to prevent secondary hypoxic cardiac arrest. 1, 2, 3

Defibrillation Protocol

• For ventricular fibrillation or pulseless ventricular tachycardia, deliver unsynchronized shocks at 200 J, 200 J, then 360 J (for monophasic defibrillators) in rapid sequence within 30-45 seconds. 5
• For unstable monomorphic ventricular tachycardia with a pulse, use synchronized cardioversion starting at 100 J. 5, 1
• Standard ACLS protocols apply without modification for electrical injury victims, except maintain awareness of possible cervical spine injury. 3

Multiple Casualty Triage

• When multiple victims are struck simultaneously (as in lightning strikes), prioritize patients in respiratory or cardiac arrest first—this reverses normal triage principles because these patients have the highest survival potential with immediate intervention. 1, 2, 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, 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—if vomiting occurs, logroll the victim to the side while maintaining spinal alignment. 1, 3

Cardiac Monitoring

• Obtain a 12-lead ECG within 10 minutes of first medical contact to assess for arrhythmias and cardiac injury. 2, 3
• Continue continuous cardiac telemetry monitoring for at least 24 hours, as delayed arrhythmias can occur—ventricular fibrillation, asystole, and ventricular tachycardia are primary causes of immediate death. 1, 2, 3, 6

Fluid Resuscitation

• Initiate aggressive IV crystalloid resuscitation immediately with 0.9% normal saline as first-line therapy—this counteracts shock and facilitates excretion of myoglobin, potassium, and other tissue breakdown products. 1, 2, 3
• Administer fluid boluses of 250-1000 mL with reassessment after each bolus to ensure adequate resuscitation while preventing fluid overload. 1, 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, as external skin appearance grossly underestimates internal tissue damage—extensive deep tissue necrosis may exist beneath minimal skin changes. 1, 2, 3

Comprehensive Assessment

Laboratory Evaluation

• Obtain comprehensive laboratory panel immediately including complete blood count, comprehensive metabolic panel with electrolytes, renal function tests, coagulation studies, and capillary glucose. 2, 3
• Monitor for myoglobin release and rhabdomyolysis complications. 1

Burn Assessment

• Document total body surface area (TBSA) affected using the Lund-Browder method, which is more accurate than other assessment methods. 1, 2
• Always look for two external wounds (entry and exit points) and cover with dry dressings. 4

Imaging

• Obtain CT imaging based on mechanism and clinical findings—high-energy mechanisms warrant evaluation for occult trauma and internal injuries. 2

Surgical Consultation

• Obtain immediate surgical consultation for: 2
  • Significant burns requiring escharotomy or debridement
  • Suspected compartment syndrome
  • Deep tissue injury requiring exploration
  • Potential need for amputation

Admission Criteria

Admit all patients with the following: 2

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

Selected patients with low-voltage injuries, absence of syncope, and normal ECG may be considered for discharge from the emergency department, though this requires careful clinical judgment. 6

Pain Management

• Consider multimodal analgesia combining non-opioid analgesics, antihyperalgesic drugs (ketamine), and opioids during surgical management to prevent prolonged pain. 1

Critical Pitfalls to Avoid

• Never delay resuscitation to obtain blood samples or perform non-essential assessments. 3
• Do not underestimate injury severity based on visible skin damage—internal tissue destruction is often far more extensive than external appearance suggests. 1, 2
• Do not fail to monitor cardiac function continuously—arrhythmias are a significant cause of mortality and can occur in a delayed fashion. 1, 6
• Do not neglect spinal precautions when mechanism suggests trauma or loss of consciousness. 2, 3