What is the management approach for a patient who has experienced an electric shock?

Management of Electric Shock

Immediate Scene Safety and Victim Extrication

Do not approach or touch the victim while they remain in contact with an electrical source—first ensure the power is turned off at its source, typically near the fuse box, before attempting any rescue. 1, 2

• Use a non-conducting object to separate the victim from the electrical source only if power cannot be immediately disconnected. 1
• Once scene safety is confirmed and power is disconnected, immediately assess the victim for responsiveness and signs of life. 1, 3

Immediate Resuscitation Protocol

Begin standard CPR using the C-A-B sequence immediately if the victim is unresponsive and not breathing, and attach an AED as soon as available, as ventricular fibrillation is the most common cause of immediate death from electrocution. 1, 4, 3

Cardiac Arrest Management

• For ventricular fibrillation or pulseless ventricular tachycardia, deliver unsynchronized shocks at 200 J initially; if unsuccessful, give a second shock at 200-300 J, then 360 J if necessary. 5, 4
• If VF/pulseless VT is refractory to electrical shock, administer amiodarone 300 mg (or 5 mg/kg) IV bolus followed by repeat defibrillation. 5
• For unstable monomorphic ventricular tachycardia with a pulse, use synchronized cardioversion starting at 100 J, with stepwise energy increases if initial attempts fail. 5, 4

Respiratory Arrest Without Cardiac Arrest

• Provide immediate rescue breathing for victims with isolated respiratory arrest but maintained cardiac function—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, 4, 3

Multiple Casualty Triage (Lightning Strikes)

• When multiple victims are struck simultaneously by lightning, reverse normal triage priorities and give highest priority to patients in respiratory or cardiac arrest, as these patients have the greatest chance of survival with immediate intervention. 1

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, 4, 3

• Use caution with all airway manipulation due to potential cervical spine injury from falls or tetanic muscle contractions. 1, 3
• Maintain spinal precautions if the mechanism suggests trauma or loss of consciousness occurred. 3
• If vomiting occurs during resuscitation, logroll the victim to the side if spinal injury is suspected. 1

Cardiac Monitoring and Assessment

Obtain a 12-lead ECG within 10 minutes of first medical contact to assess for arrhythmias and evidence of cardiac injury. 1, 4, 3

• Continue continuous cardiac telemetry monitoring for at least 24 hours, as delayed arrhythmias can occur even after initial stability. 1, 4, 3
• No modifications to standard ACLS protocols are required for electrical injury victims, except attention to possible cervical spine injury. 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. 1, 4, 3

• Administer fluid boluses of 250-1000 mL with reassessment after each bolus to ensure adequate resuscitation while preventing fluid overload. 4, 3
• Target lactate reduction of 20% in the first hour as a marker of adequate tissue perfusion. 3
• Rapid IV fluid administration is particularly critical for victims with significant tissue destruction. 1

Laboratory and Diagnostic Assessment

• Obtain comprehensive laboratory panel immediately including complete blood count, comprehensive metabolic panel with electrolytes, renal function tests, coagulation studies, and capillary glucose. 1, 4, 3
• Document total body surface area (TBSA) affected using the Lund-Browder method, which is more accurate than other assessment methods. 4, 3

Critical Pitfalls to Avoid

• Never delay resuscitation to obtain blood samples or perform non-essential assessments. 1, 4
• Do not underestimate injury severity based on visible skin damage—internal tissue destruction is often far more extensive than external appearance suggests, as electrical current follows paths of least resistance through deep tissues. 4, 3
• Do not fail to monitor cardiac function continuously, as arrhythmias are a significant cause of mortality and can occur in a delayed fashion. 4

Admission Criteria

Admit all patients with high-voltage exposure (>1000V), abnormal initial ECG, cardiac arrest requiring resuscitation, burns >10% TBSA, deep tissue injury, or concomitant traumatic injuries. 4, 3

• Selected patients with low-voltage injuries, absence of syncope, and normal ECG may be considered for discharge from the emergency department after appropriate observation. 6

Surgical Consultation

• Obtain immediate surgical consultation for significant burns requiring escharotomy or debridement, suspected compartment syndrome, deep tissue injury requiring exploration, or potential need for amputation. 3