What is the management approach for a patient who has suffered electrocution?

Management of Electrocution

Immediate Scene Safety and Initial Assessment

The first priority in electrocution management is ensuring scene safety by turning off the power source before approaching the victim; if this is impossible, use a non-conducting object to separate the victim from the electrical source. 1, 2, 3

Scene Safety Protocol

• Never approach or touch an electrocution victim while power remains on 1, 2
• Turn off power at its source (typically near the fuse box in home settings) 2
• Use non-conducting objects to separate victim from electrical source if power cannot be immediately disabled 2, 3

Immediate Assessment

• Assess responsiveness by talking to the victim and gently shaking their shoulders 2
• Check for cardiopulmonary arrest immediately, as this is the primary cause of death from electrocution 2, 3
• Begin standard CPR with C-A-B sequence if victim is unresponsive and not breathing 2, 3
• Attach an AED as soon as possible, as ventricular fibrillation is a common consequence of electrical injury 3

Cardiac Management

Follow standard ACLS protocols without modification for electrical injury victims, using synchronized cardioversion at 100 J for unstable monomorphic ventricular tachycardia with pulses, and unsynchronized high-energy shocks for pulseless ventricular tachycardia or ventricular fibrillation. 1, 2

Arrhythmia Management

• Obtain a 12-lead ECG within 10 minutes of first medical contact to assess for arrhythmias and cardiac injury 2
• Continue cardiac monitoring for at least 24 hours to detect potential arrhythmias 2
• Use intravenous amiodarone to facilitate defibrillation and prevent VT/VF recurrences in acute situations 1
• Start defibrillation at maximum output for in-hospital cardiac arrests 1
• Place defibrillator patches at least 8 cm from ICD generator position if present 1

Special Cardiac Considerations

• Cardiopulmonary arrest is the primary cause of immediate death, with ventricular fibrillation, ventricular asystole, and ventricular tachycardia being the most common arrhythmias 2
• 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 2
• Lightning strike victims may experience spontaneous return of cardiac activity but continued respiratory arrest, requiring ventilatory support to prevent secondary hypoxic cardiac arrest 2, 3

Airway and Respiratory Management

Consider early intubation for patients with extensive burns involving the face, mouth, or anterior neck due to potential soft-tissue swelling. 2, 3

Respiratory Support

• For victims with respiratory arrest but maintained cardiac function, provide rescue breathing immediately 2, 3
• Respiratory arrest may result from electric injury to the respiratory center in the brain or from tetanic contractions/paralysis of respiratory muscles 2
• Use caution with airway control measures due to potential soft-tissue swelling 2, 3
• If vomiting occurs during resuscitation, turn the victim to the side and remove vomitus; logroll the victim if spinal cord injury is suspected 2, 3

Fluid Resuscitation

Initiate aggressive IV fluid resuscitation with crystalloid isotonic fluids (0.9% saline) as first-line treatment, using boluses of 250-1000 ml with reevaluation after each bolus. 2, 3, 4

Fluid Management Protocol

• Rapid IV fluid administration is indicated for victims with significant tissue destruction to counteract shock and facilitate excretion of myoglobin, potassium, and other byproducts of tissue destruction 2, 3
• Use fluid challenge technique with boluses of 250-1000 ml and reevaluation after each bolus 3
• Monitor for signs of fluid overload such as pulmonary edema, especially in patients with limited access to mechanical ventilation 3
• Peripheral venous access via antecubital vein is the site of choice, with external jugular vein as an alternative 1
• Propel drug delivery from peripheral veins with a fluid flush of 20 ml or more to expedite entry to circulation 1

Temperature Control and Burn Management

Active cooling prevents coagulum formation and reduces ongoing thermal injury at the tissue level, while avoiding hyperthermia is crucial as elevated temperature accelerates tissue destruction. 4

Temperature Management

• Temperature control is the intervention that decreases the zone of stasis in electrical burn injuries 4
• Avoid hyperthermia in the post-injury period, as it accelerates tissue destruction and metabolic dysfunction 4
• Do not apply ice directly to burns, as it can produce tissue ischemia 1

Burn Assessment

• Document total body surface area (TBSA) affected using the Lund-Browder method, which is more accurate than other assessment methods 3

Multiple Casualty Management

When multiple victims are struck simultaneously by lightning, give highest priority to patients in respiratory or cardiac arrest—this reverses normal triage priorities. 2, 3

• This unique triage approach is necessary because lightning strike victims may have spontaneous return of cardiac activity but continued respiratory arrest 2
• Victims who appear dead may have better prognosis than those who appear less severely injured 2

Laboratory and Monitoring

Essential Laboratory Tests

• Obtain routine laboratory tests including complete blood count, electrolytes, renal function, coagulation studies, and capillary glucose level 2
• Monitor electrolyte concentrations and keep at low normal in comatose patients 1
• Measure blood glucose concentrations urgently; infuse glucose only for documented hypoglycemia 1

Ongoing Monitoring

• Regular blood gas analysis should be performed 1
• Pulse oximetry may be used to assess oxygen saturation non-invasively 1
• Continue cardiac monitoring for at least 24 hours or until alternative diagnosis is made 2

Additional Considerations

Spinal Precautions

• Maintain spinal motion restriction by manually stabilizing the head to minimize motion of head, neck, and spine 1
• No modifications to standard ACLS protocols are required except attention to possible cervical spine injury 2

Pain Management

• Consider multimodal analgesia combining non-opioid analgesics, antihyperalgesic drugs (ketamine), and opioids during surgical management 3
• Control seizures with anticonvulsants such as diazepam, phenytoin, or barbiturates 1

Critical Pitfalls to Avoid

• Never delay resuscitation to obtain blood samples or perform non-essential assessments 2
• Do not underestimate injury severity based on visible skin damage alone, as this can lead to delayed recognition of serious complications 3
• Failure to monitor cardiac function can result in missed arrhythmias, which are a significant cause of mortality 3
• Do not neglect pressure ulcer prevention measures in patients with spinal cord injuries, including early mobilization once spine is stabilized 3