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

Management of Electric Shock

Immediately ensure scene safety by turning off the power source before approaching the victim; if impossible, use a non-conducting object to separate the victim from the electrical source, then begin standard CPR with the C-A-B sequence if the patient is unresponsive and not breathing, attaching an AED as soon as available. 1, 2

Immediate Scene Safety and Initial Assessment

• Never approach or touch an electrocution victim while power remains on, as this places rescuers at risk of becoming secondary victims 1, 2
• Turn off the power at its source; at home the switch is usually near the fuse box 1
• If power cannot be immediately turned off, use a non-conducting object to separate the victim from the electrical source 1, 2
• Assess the victim's responsiveness by talking to them and gently shaking their shoulders once the scene is safe 1

Cardiopulmonary Resuscitation Protocol

• Begin standard CPR using the C-A-B sequence immediately if the victim is unresponsive and not breathing, as ventricular fibrillation is the most common cause of immediate death from electrocution 2, 3
• Attach an automated external defibrillator (AED) as soon as available 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 2, 3
• When multiple victims are struck simultaneously by lightning, prioritize patients in respiratory or cardiac arrest (reverse normal triage priorities) 1
• Continue prolonged resuscitation efforts, as young victims without underlying cardiac disease may have better outcomes than typical cardiac arrest patients, even after extended CPR duration 4, 5

Defibrillation and Arrhythmia Management

• For ventricular fibrillation or pulseless ventricular tachycardia, deliver unsynchronized shocks at 200 J, 200 J, then 360 J in rapid sequence within 30-45 seconds 2, 3
• If VF/pulseless VT is refractory to electrical shock, administer amiodarone 300 mg (or 5 mg/kg) IV bolus followed by repeat defibrillation 3
• For unstable monomorphic ventricular tachycardia with a pulse, use synchronized cardioversion starting at 100 J, with stepwise energy increases if initial attempts fail 1, 2, 3
• Follow standard ACLS protocols without modification for electrical injury victims, except maintain attention to possible cervical spine injury 1
• Place defibrillator patches at least 8 cm from ICD generator position if present 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 2, 3
• Use caution with airway control measures due to potential soft-tissue swelling 1
• If vomiting occurs during resuscitation, turn the victim to the side and remove vomitus; logroll the victim if spinal cord injury is suspected 1
• Maintain spinal motion restriction by manually stabilizing the head to minimize motion of head, neck, and spine 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, 2, 3
• Continue continuous cardiac telemetry monitoring for at least 24 hours, as delayed arrhythmias can occur even after initial stability 1, 2, 3, 6
• Monitor for cardiac arrhythmias including ventricular fibrillation, ventricular asystole, and ventricular tachycardia which may result from both low and high-voltage current 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, 2, 3
• Administer fluid boluses of 250-1000 mL with reassessment after each bolus to ensure adequate resuscitation while preventing fluid overload 2
• Monitor electrolyte concentrations and keep at low normal in comatose patients 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, 2, 3
• Measure blood glucose concentrations urgently; infuse glucose only for documented hypoglycemia 1
• Perform regular blood gas analysis 1
• Use pulse oximetry to assess oxygen saturation non-invasively 1
• Document total body surface area (TBSA) affected using the Lund-Browder method, which is more accurate than other assessment methods 2, 3

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 2, 3
• Selected patients with low voltage injuries, absence of syncope, and a normal ECG may be discharged home from the emergency room 6

Additional Management Considerations

• Control seizures with anticonvulsants such as diazepam, phenytoin, or barbiturates 1
• Consider multimodal analgesia combining non-opioid analgesics, antihyperalgesic drugs (ketamine), and opioids during surgical management to prevent prolonged pain 2
• Avoid direct application of ice to burns, as it can produce tissue ischemia 1

Critical Pitfalls to Avoid

• Never delay resuscitation to obtain blood samples or perform non-essential assessments 1, 2
• Do not underestimate injury severity based on visible skin damage, as internal tissue destruction is often far more extensive than external appearance suggests 2
• Do not fail to monitor cardiac function continuously, as arrhythmias are a significant cause of mortality and can occur in a delayed fashion 2
• Do not approach the victim while power is still on 1, 2