What is the appropriate treatment and management for a patient with electric shock burns?

Management of Electric Shock Burns

Electric shock burns require immediate referral to a specialized burn center with aggressive fluid resuscitation, continuous cardiac monitoring, and early cooling within 30 minutes of injury. 1, 2

Immediate Scene Safety and Initial Assessment

• Ensure scene safety first by turning off the power source before approaching the victim to prevent rescuer injury 1
• Once power is disconnected, assess for cardiopulmonary arrest and initiate CPR and defibrillation if needed, as cardiac arrest is the primary cause of immediate death from electrocution 1
• All electrical burns are classified as severe burns requiring immediate specialist consultation, regardless of visible surface damage 1

Critical Early Interventions (First Hour)

Cooling Protocol

• Initiate cooling with tap water (15-25°C) within 30 minutes of injury for burns with <20% TBSA in adults or <10% TBSA in children without shock 2
• Continue cooling for at least until pain is relieved, but limit to less than 40 minutes to significantly reduce need for skin grafting (P < 0.001) 2
• Avoid cooling large burns without core temperature monitoring due to hypothermia risk 2

Fluid Resuscitation

• Administer 20 mL/kg of balanced crystalloid solution (Ringer's Lactate preferred) within the first hour for adults with burns and pediatric patients 3
• Use 0.9% saline as first-line isotonic fluid for patients showing signs of shock 1
• Avoid hypotonic solutions like lactated Ringer's as they can increase tissue edema in electrical injuries 2
• Target urine output of 100 mL/hour in electrical burn patients due to extensive deep tissue destruction 2
• Obtain IV access in unburned areas; use intraosseous route if IV access cannot be rapidly obtained 3

Cardiac Monitoring

• Initiate continuous cardiac monitoring immediately due to risk of ventricular fibrillation, ventricular asystole, and ventricular tachycardia from both low and high-voltage current 1
• High-voltage injuries carry significantly higher risk of cardiac arrest (20% vs. 3.6% in low-voltage) and loss of consciousness (69.1% vs. 23.6%) 4

Airway Management

• Consider early intubation for patients with extensive burns involving the face, mouth, or anterior neck to prevent airway compromise 1

Specialist Referral and Transfer

• Contact a burn specialist immediately to determine need for burns center admission, as this improves survival, facilitates rehabilitation, and reduces complications 3
• Use telemedicine when specialists are not readily available to improve TBSA measurement and prevent both overtriage and undertriage that increases morbidity and mortality 3
• Arrange direct admission to a burns center rather than secondary transfer, as this reduces time to excision, duration of mechanical ventilation, and improves survival 1
• Burns involving face, hands, feet, flexure lines, genitals, or perineum require specialist evaluation 3

Burn Assessment

• Use the Lund-Browder chart for accurate TBSA measurement as it is the reference method that prevents both overtriage and undertriage 3, 1
• The open hand (palm and fingers) represents 1% TBSA and is a practical alternative that limits overvaluation 3, 1
• Smartphone applications (e.g., E-Burn) can facilitate TBSA assessment 1

Surgical Considerations: Escharotomy

• Perform escharotomy if deep burns induce compartment syndrome in limbs or trunk that compromises airways, respiration, and/or circulation 3
• Escharotomy is rarely indicated immediately; the only urgent indication is compromised airway movement and/or ventilation 3
• Patients with intra-abdominal hypertension or circulatory impairment should undergo escharotomy within 48 hours of emergence of these conditions 3
• Escharotomy should ideally be performed at a burns center by an experienced provider due to risks of hemorrhage, infection, and increased morbidity from poorly performed procedures 3, 1
• If immediate transfer is impossible, obtain specialist advice before performing escharotomy 3

Pain Management

• Administer over-the-counter analgesics such as acetaminophen or NSAIDs for burn pain as first-line agents 1
• Consider multimodal analgesia with titrated intravenous ketamine combined with other analgesics for severe burn-induced pain 1
• Titrate all analgesic medications based on validated comfort and analgesia assessment scales 1

Critical Pitfalls to Avoid

• Do not underestimate injury severity based on visible skin damage alone, as electrical burns often have extensive deep tissue damage not apparent on surface examination that does not correlate with visible injury 1, 2
• Do not fail to monitor cardiac function, as missed arrhythmias are a significant cause of mortality 1
• Do not delay fluid resuscitation, as early administration (within 2 hours) reduces morbidity and mortality 3
• High-voltage injuries have significantly higher amputation rates (23.6% vs. 5.5% in low-voltage) 4
• Neurological deficits occur in 16.7% of electrical injury patients; 48.2% recover, but 33.3% persist long-term 4