What is the primary diagnosis for a patient with an electrical burn to the forearm?

Primary Diagnosis for Electrical Burn to the Forearm

The primary diagnosis for a patient with an electrical burn to the forearm is "Electrical Burn Injury" with specification of voltage level (high-voltage ≥1000V or low-voltage <1000V) and affected anatomical location. 1

Diagnostic Classification Framework

Voltage-Based Classification

• High-voltage electrical burn (≥1000 volts): Results in extensive subcutaneous fat, muscle, and potentially bone injury with significant deep tissue destruction not apparent on surface examination 2
• Low-voltage electrical burn (<1000 volts): May present with lesser injuries but still requires specialized burn center evaluation 2
• All electrical burns are automatically classified as severe burns requiring immediate referral to a specialized burn center, regardless of voltage 1

Essential Diagnostic Documentation

Document the following components in your diagnosis:

• Voltage exposure level (if known): High vs. low voltage determines injury severity and management intensity 2
• Total Body Surface Area (TBSA): Use the Lund-Browder chart for accurate measurement, as it prevents both overtriage and undertriage that increase morbidity and mortality 1
• Entry and exit points: Electrical burns cause extensive local tissue destruction at contact points 3
• Depth assessment: Third-degree circumferential burns can cause compartment syndrome requiring escharotomy 1

Critical Associated Diagnoses to Rule Out

Immediate Life-Threatening Complications

Cardiac complications must be documented if present:

• Cardiac arrhythmias (ventricular fibrillation, ventricular asystole, ventricular tachycardia) can result from both low and high-voltage exposure 1
• Cardiopulmonary arrest is the primary cause of immediate death from electrocution 1
• Continuous cardiac monitoring is mandatory due to arrhythmia risk 4

Compartment syndrome in the forearm:

• Circumferential third-degree burns can cause acute limb ischemia with neurological disorders 1
• High-voltage injuries to extremities are particularly prone to compartment syndrome requiring fasciotomy 5, 6
• Document if escharotomy is indicated within 48 hours 4

Hidden Deep Tissue Injury

Critical pitfall: Never underestimate injury severity based on visible skin damage alone, as electrical burns have extensive deep tissue damage not apparent on surface examination 4, 2

• Muscle necrosis with myoglobin release: Document presence of heme pigments in urine, as this indicates risk for acute renal failure 2
• Vascular injury: Bilateral upper extremity vascular injury can occur, resulting in limb-threatening ischemia 6
• Nerve injury: Neurologic complications can present immediately or up to 2 years after injury 2

Severity Criteria for Documentation

For adults: Electrical burns meet severe burn criteria when involving:

• High-voltage electricity, OR
• Low-voltage electricity combined with TBSA >10% or deep burns 3-5% 1

For children: Any electrical burn automatically qualifies as severe 1

Additional Diagnostic Considerations

Traumatic Injuries

• Approximately 15% of electrical burn victims sustain concurrent traumatic injuries from falls or being thrown against objects 2
• Tetanic muscle contractions can cause bone fractures from prolonged muscular contracture 2
• Document any associated fractures or traumatic injuries in the diagnosis

Organ System Assessment

• Renal: Myoglobinuria from muscle breakdown 2, 3
• Ocular: Cataracts may develop over time following electrical injury 2
• Neurologic: Full neurologic examination findings should be documented on admission 2

Example Diagnostic Statement

"High-voltage electrical burn injury to right forearm with [X]% TBSA third-degree burns, entry wound at [location], exit wound at [location], with/without compartment syndrome, with/without cardiac arrhythmia, with/without myoglobinuria"

This comprehensive diagnostic approach ensures appropriate triage to a specialized burn center, which reduces time to excision, duration of mechanical ventilation, and improves survival 1.